Do you know about the birth? I’m often asked, sitting with some new mother in her pajamas. I go see them as soon as possible. I bring food, fold laundry, do dishes. I want them to feel seen, heard, human. Sometimes they’re bright-eyed, centered, fine, but too often they’re hollowed out, haunted, hurting. When they talk about giving birth, they sigh or shrug or burst into tears. Whatever, they say, shaking it off. My baby is here. My baby is alive. That’s what matters.

Bullshit! I never dare say. You matter. What happened to you matters.

It’s been a grade-schooler’s lifetime since Ricki Lake and Abby Epstein’s documentary The Business of Being Born shone a bright light on mainstream assumptions about birth. It followed on the heels of Jennifer Block’s masterful book Pushed, which came a few years after Naomi Wolf’s controversial Misconceptions. Now, Lake and Epstein are executive producers of Brigid Maher’s The Mama Sherpas, a hopeful film about collaborative care between midwives and obstetricians. Thanks to these and many other books and films, there is a heightened awareness of the issues surrounding childbearing, and the C-section pandemic has become dinner-party conversation.

It’s become fashionable to obscure the question of how we give birth as a matter of personal preference rather than a systemic problem with real public-health consequences. Which is a sophisticated tool of silence, because to press the issue is considered, oh dear, impolite. The unfortunate consequence is a pervasive lack of familiarity with the physiology of healthy childbirth. Last summer, a 7-year-old girl proudly informed me that babies are born when the doctor decides it’s time to cut open the mother’s stomach.

To be clear: A number of otherwise healthy women legitimately require and are grateful for medical intervention in childbirth. We are not talking here about that minority. Besides, the issue is more complex than surgical versus vaginal, doctors versus midwives, medicated versus unmedicated, everyone versus hippies.

“Whether or not you have or want children,” says Cristen Pascucci, founder of Birth Monopoly and vice-president of Improving Birth, “please don’t ignore the reality it is still permissible, in 21st-century America, to tell a grown woman to shut up, lie back, and not question what’s done to her body.”

Reproductive rights are all the rage. The existence of the female orgasm is no longer in question. Rape is no longer culturally acceptable. We seem, finally, to have begun to understand that women’s bodies are sacrosanct. But obstetric violence is the last culturally acceptable form of violence against women.

I’m outraged by what’s happening to all these women, which is starting to seem weird, given how few of them seem outraged. So I write a novel about a woman in the wake of birth gone awry, hoping it will quell my fixation on birth gone awry. It doesn’t. So I teach an M.F.A. seminar about the literature of the childbearing body, hoping it will exhaust my obsession with the cultural treatment of the childbearing body. It doesn’t. So I sign up to become a doula. Why not make it official? Give it a name. Put this energy to use.

We are 18 women training in a 600-square-foot tenement apartment in Harlem for three days. My fellow future doulas are a nurse, a personal trainer, a college senior at work on her thesis, a dozen moms of small children, a Jehovah’s Witness, and my friend Rebecca. Several gave birth via routine intervention, were treated questionably by caregivers, and got mad. Many admit to being obsessed with birth. One refers to doula work as a “calling.” Amen. I want to link arms, take to the streets, storm the maternity wards.

Obstetric violence is the last culturally acceptable form of violence against women.

Our trainer is Leah, the Bronx’s own Venus of Willendorf. She asks us to introduce ourselves and our maternal lines as far back as we can. Females are born with all our eggs (unlike males, who manufacture sperm on demand), so we actually somewhat existed within our maternal grandmothers and great-grandmothers, Matrushka dolls back to the start of time. I am Elisa, daughter of Elaine, granddaughter of Bea, great-granddaughter of Dora.

Dora had eight babies under the care of a midwife, four boys and four girls. All the boys were stillborn, or died within hours, because of a genetic blood disorder that is easily fixable today. Bea had difficulty getting pregnant. I have no idea how she gave birth, but given obstetric protocol from the 1940s, she was likely unconscious, tied to a bed, shaved, given a routine enema and an episiotomy. Elaine had three routine epidurals, episiotomies, and forceps deliveries. Her OB was very handsome and refused to answer any of her questions. “You don’t want to know,” he’d say flirtatiously. There are a lot of ways to be mistreated in birth. I gave birth just fine at home with a doula, though my careless midwife was absent for most of my labor. Thereafter I was a raw nerve, a frayed wire. Childbirth politics crackled through me and zapped everyone who came close. I reject the predictable categorization. Postpartum depression, my ass. It has the ring of a ghetto. A female thing: Sweep it under the rug, fix it with pills, shut it up. Postpartum doesn’t begin to hack it. The lack of lyricism!

A good doula has a warm heart, Leah says by way of opening. A doula — Greek for “female servant” — is not a healthcare provider like a midwife, but can offer physical, emotional, spiritual, and practical support, in addition to generally normalizing healthy pregnancy, birth, and life with a newborn. Problem is, I’m short on warmth since I took up the cause, or it took up me. I get sarcastic, I lose my cool, I bust up dinner parties, I roll my eyes. Mainstream birth talk gets real old real fast.

In order to birth well, Leah tells us, a woman must turn off her mind. Fundamentally, birth works. The process has a rhythm all its own. It can go on safely for quite a while as the cervix softens and opens. If she has scar tissue (from overzealous Pap smears, HPV treatment, abortion, previous surgery), it can take longer. If she is immobilized or numb, it can take longer. If she is anxious or fearful, it can take longer. If she is in unfamiliar surroundings, it can take longer. Once her cervix is fully open, there is the urge to push. Restitution, delivery of baby, delivery of placenta. An efficient and complex progression, never exactly the same, tied inextricably to a woman’s feelings about her body, sexuality, history, family, self (see also: the mind).

Yeah, the mind. What to do about the mind? Loyal to a toxic heritage, forged by Hollywood, by every birth scene ever staged, shaped by vague inherited myths and horrific it-happened-to-mes. The mind believes birth to be narrowly averted tragedy with a haunting Kate Bush soundtrack (remember John Hughes’s She’s Having a Baby?). The mind believes Nora Ephron’s Heartburn, wherein Streep is frantically rushed to the hospital in early labor, shrieking, gasping, terrified. Soon she’s on her back, oxygen mask over her face. Guy in a lab coat reads a printout from a machine: “There’s something wrong! We need to operate now!” When she awakes, her husband is grinning and the terror is depicted as having zero fallout. The mind believes a particularly moronic episode of Girls in which a wacky character, herself purportedly a doula, attempts a critically premature unassisted home birth and is carried, protesting, to the hospital, where she is surgically delivered of a child who goes immediately to the NICU. Then two characters break up while holding hands over the incubator, while the mother is shown serene, her arms empty, hopped up on painkillers, no big. The mind believes a recent piece on cosmopolitan.com that purports to be about the author’s mother-friendly, doula-assisted C-section, but repeats on no fewer than three occasions how happy she is that she didn’t have to rip her vagina “to shreds.” To change the way we approach birth, we must begin to change the stories we tell about birth.

Leah walks us through basic hospital regulation: induction, triage, rotating nurses, hospital gowns, nothing to eat or drink, timed labor. How to outwit them? How to avoid interference, sneak in some crackers or juice or soup, get out of bed and move around, indulge all the healthy, normal impulses of the body? Decent birth under regulatory control would seem to call for a combination of espionage and luck. Don’t get on the nurses’ bad side, Leah advises. Make friends with the nurses.

Two trainees realize they had the same OB at the same Manhattan hospital, and giggle about how she’s known for marching into the room literally swinging her forceps.

Oh, and what about Dr. R---? He comes in and stands there while you’re pushing and goes, “Don’t make me cut you.”

I would have liked to have given birth at home, another says, but my husband wasn’t okay with it. Others nod: Of course your husband has final say.

I get a sinking feeling. This is not my beautiful roomful of furious radicals.

Listen, say my fellow future doulas. Women are afraid of childbirth. Everyone’s afraid of childbirth. Fear of childbirth is in our water, in our air, in our genes. What can you do?

I don’t know, I say. Educate? Empower? Revolt?

Be practical, they say. This is the way things are. We must work within the system.

I don’t want to work within the system, I whine. I want to dismantle the system.

Look, Leah concedes. The first intervention is leaving your house. The next intervention is putting on a hospital gown. With her first child, a daughter, she had commonplace complications caused by routine intervention. She says what everyone says: I didn’t know any better. I did what they told me. She’s quick to clarify: I am not here to talk smack about obstetrics. She goes on to say, however, that after doula service at a hundred births over five years all over Manhattan, Brooklyn, Queens, and the Bronx, she no longer attends planned hospital births: I saw enough, she says quietly. I aspire to be like her: reasonable, level, kind. She is exactly who you want as your doula. She knows what’s up, but she’s not full of rage. Rage just corrodes the vessel. No one wants a corroded doula.

Anthropologist Robbie Davis-Floyd, in her monumental Birth As an American Rite of Passage, suggests women will find comfort in the rituals of their belief system. If she has been raised to fear birth, to see her body as dangerous and the doctor as safety, then the rituals of medical birth (machines, bright lights, air conditioning, restrictions, invasive tests, lack of privacy, steel instruments, narcotics, gowns, needles, numbness, surgery) will be reassuring. If, on the other hand, she is taught to think of birth as normal and safe and to think of herself as fully capable, she’s more likely to feel safe and fully capable.

I get a sinking feeling. This is not my beautiful roomful of furious radicals.

We watch a childbirth-education film from the 1950s. Pack a suitcase … drones a male voice. A woman with a blank face carefully does so. Bring makeup … to make you pretty. The blank woman is escorted to the hospital, where the husband waves her off and takes a seat. Everything is absolutely sterile. Rows of gleaming metal tools. In the next shot, birth is presumably over and done: A nurse wheels an occupied bassinet into a nursery. What happened?! Are we are too delicate or dumb to handle our own realities or be trusted with our own bodies?

“When I arrive at the hospital, I want a glass of whiskey, I want the epidural in my back, and I want to be hit in the face with a baseball bat. And just wake me up when it’s over, because I’ve seen the videos, and it looks terrifying,” actress Kristen Bell said on the Ellen DeGeneres Show in 2013.

In Susan Sontag’s notebooks, she writes only that her son’s birth was “difficult,” and that she “wanted to be knocked out, not to know anything.” She was 19 years old. She was put under. Imagine Sontag, the most voracious intellect of her era, wanting not to know.

This apartment is not suitable for a group our size. I feel caged. In another video, famed elder doula Penny Simkin helps a woman find her rhythm. Rhythm is key. Labor is dance. Labor is effort. Labor is active. We examine a study in which respect and affection in labor equals higher postpartum self-esteem. Leah phrases it more poetically: How will she remember this? I’ve lost count of all the accomplished people I know with awful birth stories—women who can build bookshelves, make meringue, helm companies, toss around academic jargon, sew a dress. When I say awful, I mean she doesn’t understand what happened or why. Awful meaning someone else was in charge. Awful meaning she will not discuss it ever again. Awful meaning she wishes she could do it over. Awful meaning she can’t stop thinking about it, can’t sleep at night, can’t relax with her baby. Awful meaning she wonders if it had to be that way.

We segue into a discussion about the word advocate, which one woman says makes her uncomfortable because it sounds too much like adversary.

It’s your job to support the woman in whatever she wants, someone says.

Even her ignorance? In her terror? No.

Legal advocacy is crucial, says Hermine Hayes-Klein, lawyer and founder of Human Rights in Childbirth (HRiC). “Most feminist movements began with a small, fringe group of women fighting for the rights of all. Think of the suffragists. Most women wanted nothing to do with the vote. They’d say, ‘Why would I need to vote? My husband votes for me!’” HRiC works to create first-of-their-kind legal protections for childbearing women, including informed consent and the right to refuse treatment. Basic rights, neither of which are yet guaranteed to childbearing women in American hospitals.

Maybe you should be a midwife, someone tells me. You’re so, like, passionate.

The undergrad chimes in: I’m not a feminist or anything, but …

Are you fucking kidding me? Rebecca says. Leah excuses us for lunch.

We watch a video of a woman in Mexico giving birth surrounded by her friends with a pan-flute soundtrack. In early labor, they go for a walk down to a stream. When they return, she’s ravenous, eats lunch. Then labor gets intense, and she dances unself-consciously around the house with her husband and kids. After hours of good, hard, celebratory work, it’s time to climb into the bath, where she delivers her little girl. Everyone is laughing and crying, intact and well.

To change the way we approach birth, we must begin to change the stories we tell about birth.

Now a C-section video. The patient has severe fibroids. Hallelujah for surgical birth in such cases. Incision through layers of skin and muscle tissue, into the uterus itself, cauterizing blood vessels along the way. A burning smell, we’re told. Takes 20 minutes. Then five minutes of yanking and pushing and pulling and two pairs of hands holding the woman’s body down and finally: a baby. They replace her internal organs and begin to sew up the layers of skin and muscle. For this woman it was lifesaving; not so for the majority who undergo it. I had a C-section and it was no big deal and I love my baby and all is well and it’s my body and I’m fine and it doesn’t matter so fuck off, people often say in public, but I have never, not once, heard anything like it in private.

The labor room isn’t the place for politics, Leah says. Of course not. But everywhere else sure is.

At last, Leah disseminates birth-support strategy. Watch the woman, not the clock. Watch the woman, not the calendar. Watch the woman, not the monitor. Birth generally responds well to trust. Negative thoughts and words are dangerous: The laboring woman is psychic. Fear and excitement are hormonally identical. Keep your voice low. Breathe with her. Model calm. Be her mirror. Follow her lead. Be consistent. Be quiet. The laboring woman is not polite. Don’t take anything personally. Take off your shoes. Respect cultural differences. Make eye contact. Go with the flow. Anticipate her needs. Remind her to keep her jaw loose, her noises low. Beauty secret: Grab a little of the baby’s vernix, the best moisturizer ever. A vast wealth of evidence points to the physiological benefit of having sympathetic women close at hand in relaxed, familiar surroundings. Physiological birth requires encouragement, stamina, and calm, continuous support. It’s helpful if the lights are low. A relaxed body can open. The fearful mind is noise. Beyond thought, a primal wisdom exists.

My doula told me to imagine I was standing on a shore with waves crashing over me. Duck under the wave, she advised. Go into it. I held on to her for dear life. Don’t let it crash into you, she said, see it coming and dive under it. The power of her words!

I don’t want to do this, I said. I can’t do this. I understand why people don’t want to do this. Please don’t make me do this.

You are doing it, she said. This is it. You’re doing it. And I was doing it. I did do it. Where would I have been without her? If I’d been alone with the standing offer of a sweet spinal, the “just in case” surgical team, the vague threat of my baby’s dying, a sea of impatient, furrowed-browed strangers, I am quite certain I would not have been “able” to do it.

When training is over, Leah gives us each a starfish and an allegory about a boy on a starfish-strewn beach. He spends all his time walking up and down the shore, tossing starfish back into the ocean so they won’t dry up and die. What are you doing? asks an old man. You’ll never be able to get all these starfish back into the sea. You can’t make a difference to them all. Yeah, says the boy, picking up another, throwing it. But I made a difference to that one.

It’s awesome what happens when I begin to identify myself as a doula: Women of all stripes light up and lean over to confide about miscarriages, birth, fertility, abortions, breast-feeding, sorrow, triumph. I’m privy to so much. They find me via word of mouth, one after another. I do three, four, five births. All VBACs (vaginal births after cesarean), two at home, each uniquely transcendent and humbling.

I wanted doula training to be a balm for my outrage. How ridiculously naïve. Outrage can be motivating, inspiring, and energizing. It’s a kind of passion. But it can tilt into fervor, zealotry, fury, ire. The truth is that sometimes you’ve got to dial it down if you want to get anything done. And there’s always more to do. Text a woman who’s due soon about how hard it is to wait. Bring food to a woman with a newborn. Fold laundry for a woman with a toddler and an infant and the flu. Make a woman in early labor laugh. Walk laps around the labor and delivery unit as she’s wondering how much longer she can keep on keeping on. Hold a woman’s hand in the middle of the night when the nurses are changing shifts. Gather resources for a woman who wants to get off hormonal birth control. Text a woman in her fourth month, remind her it’s okay to take it easy.

I have to decide whether or not I want a C-section, a woman tells me at a party. My husband cracks up, backs away. That’s a big decision, I say. What are your thoughts? And then, when it’s clear she doesn’t intend to give it much thought and doesn’t want to talk about it, I say: Hey, have you tried this hummus? It’s really good.

I don’t want them to cut my taint, and I don’t want them to cut me open, and I don’t want to poop in front of strangers, a nervous young pregnant woman confesses to me one bright fall morning.

I nod. So, maybe you want to think about giving birth in an environment where those things are less likely to happen?

I really like my doctor, she says before changing the subject. So invite your doctor out for coffee! But I wish her well, and try not to worry about her.

We are different after we give birth, different than before, and too often not for the better. Did I take up the cause, or did it take up me? Elisa, daughter of Elaine, daughter of Bea, daughter of Dora, daughter of I don’t know, daughter of I don’t know, daughter of I don’t know.