While childbirth is a profoundly personal experience, it is deeply embedded within larger social contexts of family, community, and institutions of power. In early America, childbirth took place in the home and was managed exclusively by midwives and female family members (Wertz & Wertz, 1977). The mid-eighteenth century ushered in the medicalization of childbirth as part of the increasing emphasis on science and pathology. As a consequence, a female-controlled experience transitioned to a male-controlled one. Since then, the United States culture of maternity care has portrayed pregnancy and childbirth as pathological conditions in need of medical interventions from healthcare professionals (Dye,1980). There is no doubt that when medical interventions are used appropriately they can be life-saving, but when unnecessary they can have a profoundly negative effect on the birth process, turning a natural physiological event into an unnecessary and dangerous surgical procedure (Jansen, Gibson, Bowles, Leach, 2013).
Until recently, the magnitude of the harm caused by medical interventions in the United States maternal healthcare system has gone largely unacknowledged. While the concept of “obstetric violence” is widely used when discussing the coercion of non-evidence based interventions outside of the United States, scholars of reproductive healthcare have been reluctant to apply this term when discussing the same practices within the United States. I offer this paper as part of a broader intervention initiated by legal scholars Diaz-Tello (2016) and Borges (2018). Both have argued for the introduction of ‘obstetric violence’ as a legal framework that will allow women to redress instances of coerced unnecessary interventions within the context of the American civil justice system. As a scholar of communication, a feminist scholar, and a scholar concerned with reproductive healthcare, I would like to extend the argument of Diaz-Tello (2016) and Borges (2018) beyond it’s the legal context in the realm of American mainstream cultural understanding. I suggest that the first step in this process is for scholars of reproductive healthcare to use the term ‘obstetric violence’ in lieu of “unnecessary non-evidence based interventions” or even “routine interventions” when writing about or discussing, the routine practices that cause harm and trauma to laboring women in the United States. It is a necessary and appropriate term which grants women a way to identify their own experiences, allows space for healing, and opens the possibility for more critical conversations.
The Power of Language
Notably, the perspectives of women are largely absent from historical accounts of childbirth in America. Dye (1980) laments “…the history of childbirth could more accurately be termed the history of obstetrics…a handful of dedicated men in the late eighteenth and nineteenth centuries brought birth out of the realm of ignorance and superstition and laid the foundation for a scientific understanding of the birth process” (p.97). In other words, as the landscape of childbirth shifted from home to the hospital and became more isolated, medicalized and physician-centered it is difficult to ascertain the basic facts of women’s own perspectives simply because their perspectives were rarely recorded. Instead, we have the historical account of men. Feminist scholars have long noted the power of language to suppress the voices of women. Cameron (1985, 1986) determines that while many inherit the view that language is deployed to sustain dominant ideologies by upholding meanings that serve those in power, there is no reason why language cannot be appropriated by the oppressed as part of the struggle against alienation.
Naming
Granting meaning, or naming is done to project a certain interpretation or definition. Likewise, to refuse to name is a refusal of acknowledgment. It is to obscure, to ignore, and to dismiss. It is my contention that this point is further exemplified in the reluctance of scholars to identify ‘obstetric violence’ in the United States as ‘obstetric violence’. By refusing to call violence what it is, we aid in the oppression of women through language. When the problem is not named it remains invisible and therefore almost impossible to solve. Cameron (1986) asserts that while language is part of patriarchy, “the problem for feminists is to uncover the ways in which this is done, to create alternative meanings and make them stick” (p.84). Thus, a key goal of this essay is to underscore ‘obstetric violence’ as an appropriate name for coerced non-evidence based interventions during childbirth. Of course, there is no one correct way for women to name their own experiences, but women should not be suppressed by the inadequacy of words. I argue that naming obstetric violence in the United States maternal healthcare system fills a gap in terminology, and is one small yet powerful intervention in the struggle against women’s oppression through language.
‘Obstetric Violence’ as a legal term
Over the past thirty years, countries outside of the United States have mobilized to address excessive use of routine non-evidence based interventions during childbirth as ‘obstetric violence’ (Chadwick, 2016; Diniz, de Oliveira Salgado, de Aguiar Andrezzo, 2015). A 2007 Venezuelan law introduced “Obstetric violence” as a new legal term defined as :
The appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, abuse of medication, and to convert the natural processes into pathological ones, bringing with it the loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women (D’Gregorio, 2010, p. 201).
Studies in the United States reveal a long history of laboring women subjected to treatment which falls under the definition of ‘obstetric violence’ (Borges, 2018; Diaz-Tello, 2016; Sadler et al., 2016; Roth et al., 2014). In one cross-national survey in the United States and Canada, it was found that over 50 percent of professional healthcare workers report witnessing a physician engage in a procedure against a woman’s will or without giving the mother time or choice to consent (Roth et al., 2014). Human Rights attorney, Diaz-Tello (2016) takes an important step in positing that in the context of the United States legal system, such practices must be recognized as ‘obstetric violence’. Diaz-Tello (2016) argues that forced or coerced procedures are a form of gender-based violence which takes place in a setting where women have less power than doctors and in a “society where women’s capacity for pregnancy has been historically used to sanction their exclusion from full citizenship…” (p.5). Similarly, Borges (2018) advocates for the introduction of “obstetric violence” as a legal framework which would allow women in the United States to redress experiences of abuse and coercion by healthcare professionals. Borges (2018) notes: “This innovation is important because abuse in obstetric and gynecological care is a type of violence often left out of the conversation about violence against women…” (p.830). Research by Sadler et al. (2016) bolsters the argument offered by Diaz-Tello (2016) and Borges (2018) stating “…it is a feminist issue, a case of gender violence; laboring women are generally healthy and not pathological; and labor and birth can be framed as sexual events, with obstetric violence being frequently experienced and interpreted as rape” (p.50). Scholars of reproductive healthcare must extend upon the call initiated by Diaz-Tello (2016) and Borges (2018) and name unnecessary routine interventions as ‘obstetric violence’, thus underscoring it as a systematic structural problem in need of redress. Healthcare professionals will be compelled to have new conversations and reexamine traditional practices. Additionally, giving the problem a name will provide women a means of healing by rendering their own experiences visible and definable.
Unnecessary Interventions are Violent
Studies show that the use of medical interventions during childbirth is driven by organizational culture, common beliefs about childbirth, and the personal preference of the
physician (Sadler, et al. 2016). It is not driven by any medical evidence that justifies the use of such procedures. Furthermore, the consequent effect of such interventions on the laboring mother is not taken into account by physicians and healthcare professionals. Many unnecessary birth interventions result in pain and trauma, which undoubtedly plays a role in the woman’s perception of the birth experience. Non-evidence based routine procedures include: placing the mother in the supine position, electronic fetal monitoring (EFM), frequent vaginal exams, routine episiotomy, withholding food and drink, cesarean sections, and catheterization.
Placing the Mother in the Supine Position
For centuries laboring women followed the cues of her body, remaining upright and mobile during childbirth (DiFranco & Curl, 2014). Getting down on hands and knees, kneeling, squatting, leaning forward, standing, and swaying, are all positions shown to increase the effectiveness of contractions, reduce pain, and aid in natural deliveries (Dudding et al., 2008, Zwelling, 2010). Yet, placing the laboring woman on her back in the supine position is usually the first unnecessary intervention encountered upon admission to the hospital (Jansen, et al., 2013). This position can result in low-quality contractions, prolonged labor, increased rate of episiotomy, slow dilation and failure of the fetus to descend (Zwelling, 2010; Jansen et. al. 2013). Most concerning, forcing a laboring woman into this position causes much more pain, resulting in greater maternal and fetal distress which, in turn, increases the likelihood of cesarean surgery (Zwelling, 2010).
Electronic Fetal Monitoring
Electronic Fetal Monitoring (EFM) further prohibits a woman’s movements by requiring her to be immobile (Healen, 2013). During continuous EFM, straps are placed around the woman’s abdomen to monitor the fetus’s heart rate. Continuous monitoring is associated with a significant increase in complications including cesarean section and maternal infection (Alfirevic et al., 2006). EFM restricts a laboring woman’s ability to move around and change positions, thus adding to the overall anxiety of the birthing process (Alfirevic, Devane, & Gyte, 2006). Although women suffering from preeclampsia, type 1 diabetes, and preterm birth should be monitored with EFM, but there are no proven benefits for healthy women with low-risk pregnancies. Studies prove that continuous EFM puts healthy women at risk (Healen, 2013)
Frequent Vaginal Exams
Vaginal examines are done to assess dilation of the cervix, how much it has thinned, and the position of the fetus. Aside from being invasive and uncomfortable, Downe et al. (2013) could find no evidence which supported or rejected the routine use of vaginal exams to improve labor outcomes, while other studies found that frequent vaginal exams can introduce bacteria and put women at risk for infections (Maharaj, 2007; Sebitloane, Moodley, & Esterhuizen, 2008).
Routine Episiotomy
Routine episiotomy can result in severe pain and perineal/vaginal trauma (Sadler et al, 2016; Jiang, Qian, Carroli, & Garner 2017; Hartmann, Viswanathan, Palmierir, Gartlehner, Thorp & Lohr, 2005) and anal sphincter lacerations (Dudding, Vaizey & Kamm, 2008; Kudish, Sokol & Kruger, 2008). Routine episiotomy is further associated with an abundance of risks including damage to muscle tissue, urinary incontinence, painful sexual intercourse and increased recovery time. Some clinicians believe that an episiotomy is necessary to prevent more severe tearing (Sadler et al. 2016, Jiang, Qian, Carroli & Garner, 2017). Jiang, et al., (2017) conducted a study comparing health care providers who performed routine episiotomies with health care providers who performed selective episiotomies. The study concluded that selective episiotomy policies result in fewer women experiencing severe perineal and or vaginal trauma. This verifies previous findings (Hartman, et al, 2005) that evidence does not support any maternal benefits to routine episiotomy.
Withholding Food and Drink
The practice of withholding nutritional intake was developed in 1946 when Dr. Curtis Mendelson argued that the risk of incurring an anesthesia-related complication during a cesarean could be avoided if food and drink were restricted (Sperling, Dahlke, Sibai, 2016). This direction is upheld in obstetric guidelines published by the American Society of Anesthesiologists which states “the oral intake of solids during labor increases maternal complications”(2007), yet studies prove there is no basis for this guideline. On the contrary, the lack of nutritional intake during labor can result in “maternal dehydration, ketosis, hyponatremia, and increased maternal stress” (Jansen et al. , 2013). At the minimum, refusing food and drink to a woman in labor may contribute to feelings of fear and intimidation and unnecessarily contribute to an overall negative birth experience (Sperling, Dahlke, Sibai, 2016).
Cesarean Surgery
Cesarean surgery is performed on one in three women in America, making it the most common operating room procedure in the United States (Kozhimannil, Arcaya, & Subramanian, 2014). A cesarean section is a major surgical procedure, which carries many side effects including pain, increased risk of hemorrhage and uterine rupture, blood clots, infection at the surgical site, a spontaneous hysterectomy, longer recovery time and risk of death (Jansen et al., 2013). Ideally, cesarean surgery is only performed when a vaginal birth would endanger the life of the mother or infant, however, Harasim (2012) finds that cesarean surgeries are often performed for the convenience of the physician or at the request of the patient. Overuse of cesarean section among low-risk women increases the likelihood of potential harms for both mothers and infants with minimal likelihood of benefit.
Catheterization
Women undergoing cesarean surgery are routinely catheterized without assessment of need (Nasr, ElBigaway, Abdelamid, Alkhulaidi, Al-inany, Sayed, 2009). Catheterization entails a thin metal tube into the woman’s urethra for the purpose of emptying the bladder. Catheterization results in increased pain, longer hospital stays and puts the mother at increased risk for developing a urinary tract infection (Nasr et al, 2009). Most significantly, a study done by Pandey, Mehta, Grover, and Goel (2015) concluded that routine catheterization performed preoperatively for cesarean section was not justified by any scientific evidence.
Perceptions of Trauma
In any other context, unnecessarily inflicting pain, forcing surgery, restricting movement, withholding nourishment and endangering someone’s life would be considered acts of violence. Yet women in the United States are acculturated into accepting painful, unnecessary, harmful, and potentially deadly interventions as part of routine procedures. Similarly, healthcare professionals are not motivated to reexamine their own protocols because obstetric violence remains obscured in the United States. This isn’t to say that obstetricians maliciously engage in routine non-evidence based childbirth interventions, but simply do not recognize their own practices as violent. Naming provides a new frame of understanding for healthcare professionals as well as patients.
In some cases, obstetricians act in what they perceive to be the best interests of the fetus. Due to prevailing cultural attitudes about women, her safety, and right to self-autonomy are not considered. In an article focusing on obstetricians use of courts to order medical treatment, Charles (2011), describes a situation where an obstetrician recommended that a patient, after going into premature labor, remain on bedrest for the remainder of her pregnancy. When the woman expressed a desire to leave the hospital for a second opinion, her obstetrician called the State Attorney who ordered the woman to not only remain the hospital but to consent to any procedures her physician found necessary. Three days later a cesarean section was performed that resulted in a stillbirth. Likewise, in a 2016 article, Diaz-Tello presents a small sample of case studies in which obstetricians used threats of law enforcement and Child Protective Services to compel women toward unnecessary interventions and forced cesarean sections. In one example, a mother of five was told during a routine ultrasound that she needed to report to the hospital immediately for cesarean surgery. Because she had the only family car and was accompanied by her two-year-old, she elected to return home for the time being. She then received an email threatening to have law enforcement arrest her and forcibly bring her in. As a result, the mother went into hiding. In another example, a laboring mother who initially refused cesarean surgery was threatened with having child protective services called to take her baby away. The mother consented to the surgery, only to have the hospital call Child Protective Services anyway, due to her initial refusal. As a result, the mother was denied immediate access to her newborn.
While using court orders to force women into accepting unwanted procedures is possibly the most egregious method of obstetric coercion, it is thankfully the rarest (Charles, 2011). In Reed, Sharman & Inglis’s (2017) study the majority of descriptions involve forced interventions, physical and verbal abuse, lies and threats. One woman reported that her obstetrician performed cesarean surgery because “he was ready to go home” (p.4). Other women reported being threatened that their baby could be taken away from them if they did not consent to cesarean. Women describe having their own embodied knowledge of the birth process disregarded in favor of the perception of the healthcare professional. The women used words such as ‘humiliating’, ‘belittled,’ ‘brutal and barbaric’ and ‘being treated like a piece of meat, or an ‘animal’” (p.6).
Such communicative acts of bullying and intimidation disempower mothers and contribute to perceptions of a traumatic birth experience. A traumatic birth experience causes overall mental distress for the mother, altering her sense of self, disrupting family relationships, and stifling her ability to bond with the infant. Consequently, difficulties with forming a mother-infant bond can dramatically impact a child’s emotional, social and mental development (Reed, Sharman &Inglis, 2017). Women’s experiences of birth trauma are undoubtedly a consequence of obstetric violence.
Conclusion
The United States culture of medicine and motherhood upholds a model of care which places a low priority on a woman’s own innate abilities to give birth. Women in labor often find themselves at the mercy of caregivers who prioritize their own cultural beliefs, personal preferences, and traditional organizational practices to impose non-evidence based interventions through tactics of coercion, intimidation, and bullying. Legal scholars Borges (2018) and Diaz-Tello (2016) make a powerful case that this term must be introduced as a legal framework, and I aim to extend their call by suggesting that feminist scholars of reproductive healthcare begin using this term when discussing the coercion involved in the so-called “routine” practice of non-evidence based interventions in the context of United States maternal healthcare. Naming obstetric violence as ‘obstetric violence’ holds healthcare professionals accountable. Naming offers a frame for a different cultural understanding and a vehicle for a different conversation. Furthermore, naming offers women a means to illuminate their own experiences while also challenging the structural sanctioning of these practices. The ultimate hope is that obstetricians and healthcare professionals may be motivated to reexamine their own practices and cultivate a model of care which upholds a collaborative communicative relationship with the mother, centers her in the birthing process, and respects her right to dignity and bodily autonomy. Thus, while introducing ‘obstetric violence’ as a legal framework is one step in addressing the problem systematically, I find that until then it is incumbent for scholars of reproductive healthcare to adopt this framing, and name unnecessary coerced interventions what they are: acts of obstetric violence.
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