The Reality of Obstetric Violence

Increasingly, we are hearing more and more women speak out about abuse and violence that have happened to them at the hands of their childbirth care provider. The video of a woman having a forced episiotomy reached far beyond the usual ‘birth junkie’ circles. Another woman’s experience of being physically wrestled onto her back causing long-term pelvic injury made the local papers. These voices have become loud enough that the term ‘obstetric violence’ has entered our vocabulary.

What Does Obstetric Violence Look Like?
Obstetric violence or abuse can take on many aspects, but the core element is a blatant disrespect for, and abusive treatment of, a woman during labor, birth and/or postpartum. Looking at the general categories of abusive tactics (as articulated by domestic & relationship abuse prevention) we have- Emotional Abuse, Verbal Abuse, Physical Abuse, Economic Abuse & Sexual Abuse. Here’s how those manifest in an childbirth setting:

Emotional Abuse
Emotional abuse manifests as bullying and using scare tactics towards the mother- often with the implication that, being pregnant, she is not entirely mentally competent to make decisions, and cares more about herself than for the baby. Phrases like “I’m the doctor here, where did you get your medical degree?”, “I won’t be held responsible if something happens.”, “If your baby dies, it’ll upset the staff.” “You must not want a healthy baby.” These fear based proclamations and undermining of the mother’s wants & needs are common enough that labor support people often call it playing the dead baby card.

Verbal Abuse
Verbal abuse is found in demeaning, aggressive language towards the mother, often targeting her choices, actions and behavior during labor. “Stop yelling, you’ll upset the other moms.”, “Just get the epidural, stop trying to be a hero.” “Quit making those noises, you sound stupid.” “You’re embarrassing”. “Just do what the doctor tells you, why do you have to be so difficult?” “If you don’t hurry it up, we’re going to have to do a cesarean”. “You can’t be pregnant forever, so schedule your induction.”

Note that this language is not at all limited to the care providers, other people present at the birth may use demeaning language, especially when confronted with a laboring woman that does not meet their expected standards of behavior.

Physical Abuse
We find physical abuse when women are:

  • Denied freedom of movement during labor & birth- attached to monitors & machines confining them to bed, confined to small rooms for safety/convenience, denied access to labor/birth support tools (birth balls, birth stools, squat bars, hydrotherapy, etc), restricted to birthing in provider-approved position.
  • Denied access to nutrition & hydration- iv ‘just in case’, no food allowed, ice chips only, long hours without being able to intake any ‘fuel’.
  • Subjected to physical procedures without fully informed consent- monitoring, episiotomies, vaginal exams, amniotomy, stripped membranes, etc.
  • Denied access to their healthy newborn immediately following birth- lack of skin/skin contact, delayed breastfeeding, etc.
  • Economic Abuse
    Economic abuse exists through the systemic limitations of the US healthcare system. Women are regularly constrained in their choice of care provider and birth location to that which is approved by her insurance company. Even if she desires a different provider, or a different location, those options are denied to her unless she has the financial resources to pay out of pocket. If a woman finds herself actively in conflict with, or uncomfortable with her care provider, changing to another may be economically difficult.

    Comprehensive childbirth education and trained labor support (doulas) are likewise considered luxuries (instead of the money saving, outcome improving tools they are), and are primarily accessible only to those families in economically advantaged populations with financial resources.

    Sexual Abuse
    Discussing obstetric sexual abuse or ‘birth rape’ is often where people are the most uncomfortable. The idea that a woman’s body can be sexually violated while giving birth does not fit what most people think of as ‘rape’. However, childbirth is absolutely a sexual act that involves all of a woman’s primary sexual organs & hormones. Violation of those areas during birth will have a profound impact on a woman’s sexuality postpartum and beyond, especially if the woman (like so many) has been the victim of sexual assault previously.

    Examples of sexually violating behavior can include:

  • Exposure of genitals & body to unknown/unfamiliar people.
  • Repeated exams & touching of genitals by multiple providers.
  • Unexpected and/or ungentle touch around genitals.
  • Alteration of genital area without consent (episiotomy).
  • Comments and/or commentary about genitals, sexual acts, sexual performance/ability (“We’ll just stitch you up nice and tight for your hubby, hmm?” “Looks like you’ve got plenty of room for breastmilk in there, your husband/partner will have to share those, now!”).
  • Responding To Obstetric Violence

    Although it is not a new phenomenon, the increased voices means that the reality that obstetric violence happens, and that women legitimately can experience PTSD symptoms postpartum (and beyond) because of their birth experiences is coming out of the hush-hush shadows where “You have a healthy baby!” was a valid reason to ignore what had happened to the mother. Sadly, this has not meant (yet!) that providers are ebing held legally accountable. The woman with the pelvic injury is in litigation with the hospital, but the woman who’s assault was caught on video is representing herself in court, after being told by hundreds of lawyers she didn’t have a case- “The problem is, you don’t have any damages. Your baby is fine and you are alive.”

    It is important to acknowledge that the vast majority of providers, from OBGYNs, to Family Practitioners, to Midwives of all types, are thoughtful, respectful people who have a positive intention of supporting & serving women during birth. We must not, in pursuing a culture of openness and raw honesty about obstetric violence paint anyone, or any profession with broad brushes- even while we acknowledge the systemic issues of training, environment and mindset that can lead to condoning obstetric violence. AKA, it isn’t just “those” providers, or “that” location where obstetric violence happens.

    But, unlike domestic abuse, there’s no roadmap for helping women recognize when abuse is happening to them, or how to know that they are ‘at risk’ for obstetric violence. Because the abuse often happens in a contained time period of a few hours, even the women who are abused may brush off their experience as unimportant, or even tell themselves it didn’t really happen that way, that she’s misremembering.

    A study in 2005 found that oxytocin, the hormone in full swing during labor, increases trust levels in humans. A laboring woman flooded with oxytocin is vunerable in a way she never is anywhere else, and she may belive that what’s being done to her is correct, or in her best interests, or not abusive, because she is chemically encouraged to be trusting. Once that oxytocin glow wears off, she may feel confused and even betrayed by herself and her response to what was happening. It is vitally important that we give women a way to tell the deep, heart-true stories of their birth, not just the social contract birth story she’ll tell family and playgroup moms, but the core essence of her birth story, and have it be truly listened to. Birthing From Within offers this through their Birth Story Listening– but that’s a whole blog entry of its own!

    For Labor Day 2014, the consumer group Improving Birth created the hashtag #breakthesilence, that made a safe space for people to begin speaking out about their experiences, things they’ve witnessed, how they’ve stepped up to being working against obstetric violence. I have no doubt it’ll happen again for 2015, 2016 and further, until the cycle of obstetric violence, and societal acceptance of such as a ‘normal’ part of birth, ends.

    For more information:

    Caught on Video: Improving Birth Breaks the Silence on Abuse of Women in Maternity Care

    Forced Episiotomy: Kelly’s Story

    Telling the Truth About Childbirth

    Pain Happens, Suffering Doesn’t Need To

    There’s a lovely article out right now: “Denying the Pain of Labour Is Like Denying the Pain of Life”. In it she talks about how “pain-free birth” has become a holy grail, even among people going for a ‘natural’ birth. If you just do XYZ, your birth will be painless, or orgasmic, or some other enlightened, empowering phrase. And for the women who don’t find that enlightenment, even if they do XYZ, there’s feelings of disappointment or failure.

    The flip side of this is the people who look at the suggestion that pain is inevitable in labor, and think how HORRIBLE and CRUEL it is to make a woman go through such misery. This viewpoint is especially prevalent in some feminist circles, who find the idea of experiencing pain in childbirth as a barbaric throwback to the days when easing pain in childbirth was actually illegal because of the “punishment of Eve”. It also occurs in traditional care provider circles because they have been taught that pain is the enemy, something to be defeated.

    But what they are talking about, what they and every single birth professional, be they in home, hospital or birth center, is rightly against is not pain, but suffering.

    Suffering is when the experience of pain overwhelms us, when we start telling ourselves negative stories about what the experience is, when our coping skills are overwhelmed.
    We have, all of us, experienced pain without suffering. How many of us have cut ourselves shaving, and it didn’t start hurting until we saw the blood? Or the bruise on some body part that you discover later, but you have no idea when or how it happened? It’s a bruise, pain signals from the damaged area had to go from there to the brain, but you weren’t aware of them. What about smacking your thumb with a hammer? The ‘coping skills’ people use for that (yelling swearing, hopping up and down, grabbing the affected hand) are so common, they’re used in cartoon and comedy. We’ve gotten through broken bones, bruised shins, cuts, bumps, scrapes, scraps and other painful mayhem by drawing on our own, inborn coping skills, and our body’s natural response to pain.

    Take, for example, getting a tattoo. It hurts, right? Getting little needles poked into your skin at high speed is not going to be without pain. And yet people do it all the time, sometimes in amazingly intense hours-long sessions. How? If you watch someone getting a tattoo, you often see the same coping skills that women use in labor; deep or naturally patterned breathing, eyes closed inward focus or eyes focused on a specific point, external distractions. And if you talk to someone after a tattoo, they may describe feeling “euphoric” or “floaty” or even “orgasmic”. That’s because they were able to use their body’s natural response to pain,endorphins, to get through.

    Or what about a marathon runner? Labor is often compared to marathon running- lots of hard physical work, ups and downs and breaks, and an exhausting but exhilarating finish. No one denies that marathon runners go through physical pain when running, and yet, no one suggest that they should take medication at the soonest opportunity, or that they are suffering for ‘no reason’ or are ‘trying to be a hero” or just out to ‘win a medal’. In fact, their perseverance, focus and drive are often lauded and celebrated.

    So how do those runners get through their marathons without suffering? Training and education. They’ve done things to help their body prepare physically for the marathon, they know how their body is going to respond to the challenges of the event, and they’ve learned skills that will help them meet each challenge as it comes. And they, too, rely on endorphins to get up and over the pain.

    Fear leads to Suffering

    Quotes from Master Yoda aside, one thing both the tattooee and the marathoner have been able to do is overcome fear. Remember when we talked about all the things that have caused pain, but we’ve not noticed them or ignored them or powered through? Part of the reason we coped with those experiences is because we were not afraid.

    When we experience fear (even when we know we are ‘safe’, like watching a horror movie), our body floods us with hormones that get is ready to either run like heck, or put up a fight. And those hormones override endorphins, because if we’re going to be running or fighting, we need to not be loopy on natural painkillers.

    In labor, that Fight or Flight response directly interferes with the birth process (In a whole lot of complex ways, that’s a complete blog post of its own!) and increases pain. Increased pain when someone is experiencing fear, increases the fear, increasing the pain, until the coping skills are overwhelmed, and suffering sets in.

    So a key element to childbirth preparation is learning how to recognize and face potential fear triggers in labor, learning what your own reflexive, already existing coping skills and resources are, and learning to draw on those coping skills at any point during labor.

    By educating women about labor and birth, by validating their concerns and helping them recognize their coping skills and resources, by giving them tools to respond to the pain of labor without fear, by giving them skilled support in labor (and not expecting partners to be professional Coaches, and allowing partners to be supported in what is their birth, too!), we set women up for experiencing labor and birth without suffering.

    Through giving all birthing women these resources we make it so that, if or when medical supports become a part of birth, or a woman reaches a point where she feels she’s tapped out her coping skills and requests medication, she’s done so in complete awareness of her body and her choices, and she can make decisions without doubt or fear of ‘failure’.