The dirty secret about obstetric violence: midwives are responsible for a lot of it.

Middle age senior nurse doctor woman over isolated background angry and mad raising fist frustrated and furious while shouting with anger. Rage and aggressive concept.

The term birthrape didn’t work out so well for the natural childbirth industry.

It was in vogue for several years, but generated not the outrage at obstetricians that midwives and doulas were hoping for, but rather revulsion at their appropriation of the suffering of rape victims to publicize their cause.

The new term is obstetric violence.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Campaigns against obstetric violence aren’t about protecting women; they’re about promoting midwives.[/pullquote]

But there’s a dirty little secret at the heart of campaigns against obstetric violence: they rarely mention midwives, a major group of perpetrators. How do I know that midwives are a significant source of obstetric violence? Because that’s what the scientific literature shows.

A new study in The Lancet, How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys, raises the alarm:

We prospectively recruited women aged at least 15 years in twelve health facilities (three per country) in Ghana, Guinea, Myanmar, and Nigeria between Sept 19, 2016, and Jan 18, 2018. Continuous observations of labour and childbirth were done from admission up to 2 h post partum. Surveys were administered by interviewers in the community to women up to 8 weeks post partum. Labour observations were not done in Myanmar. Data were collected on sociodemographics, obstetric history, and experiences of mistreatment.

What did they find?

2016 labour observations and 2672 surveys were done. 838 (41·6%) of 2016 observed women and 945 (35·4%) of 2672 surveyed women experienced physical or verbal abuse, or stigma or discrimination. Physical and verbal abuse peaked 30 min before birth until 15 min after birth (observation). Many women did not consent for episiotomy (observation: 190 [75·1%] of 253; survey: 295 [56·1%] of 526) or caesarean section (observation: 35 [13·4%] of 261; survey: 52 [10·8%] of 483), despite receiving these procedures. 133 (5·0%) of 2672 women or their babies were detained in the facility because they were unable to pay the bill (survey). Younger age (15–19 years) and lack of education were the primary determinants of mistreatment (survey). For example, younger women with no education (odds ratio [OR] 3·6, 95% CI 1·6–8·0) and younger women with some education (OR 1·6, 1·1–2·3) were more likely to experience verbal abuse, compared with older women (≥30 years), adjusting for marital status and parity.

The study itself has generated mainstream press and has been highlighted by midwives and their advocates. But here’s the kicker: there are very few obstetricians in these facilities; much of the violence was committed by midwives.

If those complaining loudest about obstetric violence actually cared about women, they’d acknowledge that midwives are perpetrators. Perhaps some of them do, but I haven’t seen it yet. That doesn’t surprise me because complaints about obstetric violence aren’t about improving birth for women; they’re about demonizing obstetricians, midwives’ chief economic competitors.

Ironically, midwives have institutionalized perhaps the largest category of obstetric violence: campaigns for “normal birth.” Denying women epidurals, trying to talk them out of them, delaying them or failing to call for the anesthesiologists who can perform them is emblematic of obstetric violence. There is not much that is more brutalizing in a healthcare setting than deny relief for excruciating pain.

That’s merely one aspect of abusive campaigns for “normal birth.”

Consider activist Amie Newman’s definition of obstetric violence:

It is an umbrella term that includes disrespectful attitudes, coercion, bullying, and discrimination from care providers, lack of consent for examinations or treatment, forced procedures like C-section by court order, and also physical abuse.

It’s hard to imagine anything more disrespectful than telling a woman how she ought to give birth and ignoring what she might want (pain relief, interventions, maternal request C-section), yet this is precisely what campaigns for normal birth do. By campaigning on behalf of a process instead of for patients themselves, proponents of unmedicated vaginal birth are explicitly ignoring the needs and wishes of those patients.

A good rule of thumb for respectful care is: “Nothing about me without me.”

Declaring that unmedicated vaginal birth is an institutionally supported goal instead of one choice among many possible choices, midwifery organizations are most definitely making policy and determining practice WITHOUT the input of women.

When will campaigns against obstetric violence take midwives to task for their role in perpetuating it? Not any time soon. Why? Because campaigns about obstetric violence aren’t about protecting women; they’re about promoting midwives.