The Neuro-Affirming Midwife

The Invisible Intersection You probably became a midwife because you care. Deeply. You wanted to support people during one of the most intense, vulnerable, and incredible times of their lives. You're good at reading the room, offering a steady hand, and navigating the unpredictable nature of birth. You know how to connect. But what happens when the person you are trying to connect with experiences the world in a fundamentally different way? What if the standard ways you show care-making eye contact, using a soft voice, offering a reassuring touch-actually cause distress? Think about a recent shift. Maybe you had a client who seemed distant, almost cold. She avoided eye contact, flinched when the blood pressure cuff inflated, and gave one-word answers to your questions. You might have thought she was anxious, or perhaps just difficult. You tried harder, talked more, maybe even moved closer. And she shut down completely. Or perhaps you cared for someone who couldn't sit still during a prenatal appointment. She interrupted you constantly, asked a million questions about things that seemed irrelevant, and probably forgot half of what you told her by the time she reached the parking lot. You might have felt frustrated, rushed, and worried she wasn't taking things seriously. Here's the deal. These aren't examples of difficult patients. These are often examples of unsupported neurodivergence. We are standing at an invisible intersection. It's where the established practices of midwifery meet the rapidly growing understanding of the human brain. For too long, we've designed maternity services for the "neurotypical" majority-those whose brains process information and sensory input in the way society expects. And in doing so, we have unintentionally marginalized a significant portion of the people giving birth. This book is about making that intersection visible. It's about changing our practices so that every parent, regardless of their neurology, receives safe, respectful, and affirming care. The numbers demand our attention Let's look at the reality on the ground. When we talk about neurodiversity, we're talking about a substantial part of the population. The term neurodiversity includes conditions like Autism, ADHD (Attention Deficit Hyperactivity Disorder), dyslexia, dyspraxia, and others. These aren't rare occurrences. Current estimates suggest that up to 15% of the population is neurodiverse (British Journal of Midwifery, 2024). Think about that for a second. Fifteen percent. Let's break down what that means for your daily work. If you work in a busy unit seeing 20 clients in a day, statistically, three of those clients are likely neurodivergent. If your service delivers 5,000 babies a year, around 750 of those parents might be Autistic, have ADHD, or another neurodivergent condition. These numbers are huge. And honestly? They are probably underestimated. For decades, Autism and ADHD were seen primarily as conditions affecting young boys. The diagnostic criteria were based on how males present. This means countless women and assigned female at birth (AFAB) individuals have slipped through the net. They learned to "mask"-to hide their traits, suppress their natural responses, and try to fit into a neurotypical world. It's exhausting. Truly exhausting. And it often leads to severe anxiety, depression, and burnout. Here's where it gets really interesting for us as midwives. Many people don't realize they are neurodivergent until they become pregnant (Maternal Mental Health Alliance, 2025). Why? Well, pregnancy changes everything. The hormonal shifts, the sensory intensity of the physical changes, the overwhelming demands of planning and appointments-it can crack the mask wide open. The coping mechanisms that worked before suddenly fail. The structure they relied on disappears. So, when you meet a client for the first time, you are often meeting someone who is not only navigating the massive transition to parenthood but also grappling with a new understanding of their own brain. Or, they might not have a diagnosis at all. They just know they feel overwhelmed, misunderstood, and terrified of the birth experience. The implication for midwifery is clear. This is not a niche issue. It's a mainstream issue. We can no longer treat neurodiversity-affirming care as an optional extra or something only specialists do. It must be woven into the fabric of everything we do. We have a critical need and a call to action The profession is waking up to this reality. The leadership knows we need to do better. In 2024, the Royal College of Midwives (RCM) issued new guidance highlighting the critical need for specialized support for neurodivergent parents (Royal College of Midwives, 2024). And this isn't just happening in one country; the conversation is global. This guidance isn't just a quiet suggestion. It's a mandate for change. It recognizes that the current system is failing these parents and that midwives are on the front line of making the necessary adjustments. The professional guidance emphasizes several key areas:

1. Recognition: We need to get better at recognizing the signs of neurodivergence, even without a formal diagnosis. It's about observing needs, not diagnosing conditions.
2. Communication: We must adapt how we communicate information, moving away from abstract language and ensuring clarity and processing time.
3. Environment: The sensory environment of maternity units is often hostile to neurodivergent people. The lights, the sounds, the textures-we need to address this urgently.
4. Choice and Control: Neurodivergent individuals need genuine choice and control over their care, which requires predictable pathways and personalized support.

Research echoes this urgency. Studies have shown a "critical need for neurodiversity-affirming practices" in maternity care (Hampton et al., 2022). This research highlights that when we don't adapt our care, we risk causing significant harm. Why now? The convergence of increased awareness, better diagnostic tools (though still imperfect), and a powerful self-advocacy movement driven by neurodivergent adults means we can no longer ignore the issue. People are speaking up about their experiences. They are demanding better. And frankly, it's about basic human rights and legal obligations. Laws like the Americans with Disabilities Act (ADA) in the US, or the Equality Act in the UK, require public services to make "reasonable accommodations" or adjustments for disabled people. Autism and ADHD are recognized disabilities. So, providing adapted care isn't just good practice; it's often a legal requirement. Think of it like this: If a patient needed a wheelchair, you wouldn't ask them to try harder to walk up the stairs. You would find a ramp. Neurodiversity-affirming care is the ramp. It's about providing the necessary adjustments so everyone can access the care they deserve. But let's put the legal stuff aside for a moment. It's about our professional ethics. As midwives, we are committed to providing individualized, person-centered care. How can we claim to do that if we are ignoring the fundamental neurology of 15% of our clients? We can't. The mandate is clear. We have the guidance. We have the evidence. Now we need the practical skills. The cost of getting it wrong is high Let's talk about what happens when we don't adapt our care. The consequences of unsupported care are severe and long-lasting. This isn't just about making people feel comfortable, although that is very important. It's about safety, engagement, and equity. Trauma is the biggest risk. The birth experience is inherently intense. For someone with sensory processing differences, the standard birth environment can be agonizing. The bright fluorescent lights, the constant beeping of machines, the unfamiliar smells, the intrusion of strangers, the feeling of the fetal monitor straps-it can be overwhelming. When a neurodivergent person is overwhelmed, they can enter a state of sensory overload. This isn't just stress. It can lead to a meltdown or a shutdown. A meltdown might look like extreme distress, crying, yelling, or even aggression. It's an outward expression of "I can't cope." It is not a tantrum. It is an involuntary response to distress. A shutdown is often quieter but just as serious. The person might become non-verbal, retreat inward, and be unable to process information or make decisions. They might look compliant, but they are actually frozen in fear. When this happens during labor, the consequences are profound. The physiological process of labor can stall. The need for interventions increases. And the experience is coded in the brain as trauma. Consider Sarah's story. Sarah is Autistic, though she didn't know it when she had her first baby. She arrived at the hospital in labor and was immediately put into a bright triage room. The midwife, rushed and distracted (we've all been there), asked her questions rapidly while attaching monitors. Sarah felt the walls closing in. She tried to explain she needed the lights dimmed, but the midwife said it was policy to keep them on for observation. When the midwife performed a vaginal examination without explicit warning, Sarah experienced it as an assault. She shut down. She couldn't communicate her pain levels or her needs. Her labor stalled, leading to a...