Forcing pregnant people who request a C-section to see a psychiatrist is obstetric violence

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It’s one of the oldest tricks in the misogynist playbook: declare that any woman who tells inconvenient truths is mentally ill. Physicians of the 19th and early 20th Century even had a name for the purported mental illness: hysteria.

That’s why it is the bitterest irony that Australian midwives have declared that women who request C-sections should be seen by psychiatrists.

The only thing more disrespectful than telling pregnant people how to give birth is declaring them mentally ill because of their choices.

Aussie docs slam mental health screening of C-section women:

Australian obstetricians have vowed to fight any move to send pregnant women booked for a C-section to a psychiatrist, as the extreme move to slash caesarean rates …

However, the Australian College of Midwives supports efforts to reduce unnecessary C-sections and believes women should have access to a psychiatrist to discuss their de-cision …

Apparently, Australian midwives believe that women who request C-sections are “hysterical” and require mental health evaluation.

In the paper The Race of Hysteria: “Overcivilization” and the “Savage” Woman in Late Nineteenth-Century Obstetrics and Gynecology, Laura Briggs explains how the mental health diagnoses were weaponized to control women:

Hysteria, we learned from feminist historical scholarship in the 1970s, was never just a disease. It was also the way nineteenth century U.S. and European cultures made sense of women’s changing roles. Industrialization and urbanization wrought one set of changes, while the women’s rights movement brought another. Together, these included higher education for women, their increasing participation in a (rapidly changing) public sphere, paid employment, and declining fertility. These cultural changes were accompanied by a virtual epidemic of “nervous weakness” largely among women, causing feminist historians to begin asking whether the diagnostic category of hysteria was simply a way of keeping women in the home…

To punish women who refused to be enslaved by their biology, misogynist physicians declared these women’s choices to be symptoms of mental illness.

Similarly, to punish pregnant people who refused to be enslaved by their biology, misogynist midwives declare these people’s choice of C-section to be symptoms of mental illness, requiring evaluation by mental health professionals. This how radical midwifery ideology makes sense of women’s effort for greater bodily autonomy in choosing how they will give birth. As in the case of hysteria, it tells us more about the prejudices of those making the diagnosis than the health of the pregnant people being diagnosed.

Moreover, requiring women who choose C-section to see a psychiatrist isn’t merely misogynistic; it is obstetric violence.

Obstetric violence is defined as:

…[T]he appropriation of women’s body and reproductive processes by health personnel, which is expressed by a dehumanizing treatment, an abuse of medicalization and pathologization of natural processes, resulting in a loss of autonomy and ability to decide freely about their bodies and sexuality, negatively impacting their quality of life.

It is supremely disrespectful to tell pregnant people how they ought to give birth and ignoring what they might want (pain relief, interventions, maternal request C-section) in labor. Telling a woman she must undergo a vaginal birth simply because it is natural is no different from telling a woman she must continue an unwanted pregnancy because that is natural. It results in a loss of autonomy, ability to decide freely about their bodies and sexuality, negatively impacting their quality of life.

The only thing more disrespectful is to label them as mentally ill and force them to be evaluated by a psychiatrist. Not only does that compound the loss of a pregnant person’s autonomy, it is an abuse of the mental health system. As in a totalitarian state, it turns the mental health system into an expression of state power. Second, it reduces access for people who actually have mental illness to the mental health services they need by diverting those services to ideological ends.

It is fundamentally unethical — and probably also illegal — to force pregnant people into psychiatric evaluation that they do not want and do not need in an effort to deprive them of autonomy to choose a C-section.

And it is a particularly egregious form of obstetric violence.

  • kelen

    I had a maternal request c-section (MRCS) five years ago. When I first registered my request at my preconception appointment, I was told ‘no, we don’t do that in Canada,’ and I was referred to a psychologist who told me that my letter explaining my reasons, which I had brought to the appointment, was extremely eloquent and well-written, but it was obvious that I was ‘using my anxiety to get what I wanted.’ He told me I was going to have to ‘prove to him that I wanted to “get better.”‘ I sat in my car and ugly cried for an hour, and from there I developed panic attacks and insomnia that plagued me for over a year until well into my pregnancy. It’s funny how a woman’s health will deteriorate if you take away her bodily autonomy and label her as manipulative if she tries to speak for herself. Maybe the midwives are right. Psych help will be needed by the time they’re done shaming the women in their care for their preferences and threatening to take away control over their bodies.
    Dr Tuteur, your blog was a lifeline to me during that time. I probably read every single post on here and every single comment. It helped me learn how to advocate for myself. Every post you make about maternal request c-sections is incredibly validating to me.

  • DrRadium

    I’m a psychiatrist and I agree completely with Dr. Tuteur . Not only is this obstetrical violence, it is a gross abuse of the mental health system. First, in most places outside of large cities, there is a shortage of psychiatrists. Even in cities, it can be very difficult to quickly access psychiatric care for people who need it. This is even true for people with life threatening conditions including severe psychosis and who are severely suicidal. Even more so in the setting of he COVID pandemic. The situation may be better in Australia than the US, but there is still a shortage of psychiatrists and psych inpatient beds that is only getting worse. Now midwives want women seeking elective C-sections to further tax the system? How many deaths of severely mentally ill people is an avoided C-section worth? They should figure it out because are advocating making that exact trade.

    And this isn’t just a case of bad priorities. This is a misuse of psychiatry to commit a serous human rights abuse, Much as powerful people could once get rid of troublesome relatives by having a pliant psychiatrist commit them, Psychiatry has an unfortunate history of being co-opted by repressive states and societies for social control. This is yet another attempt to commit such a crime, and it is critical that psychiatrists recognize it a such. It demeans women and degrades our profession to take part in such activities. I can only hope that the Royal Australian and New Zealand College of Psychiatrists recognizes that failing to oppose this proposal is a step on a path to dark chapters in the history of psychiatry.

    There is nothing in the choice to elect a C-section that in any way suggests mental illness or any psychiatric diagnosis at all. Perhaps the midwives will go the classic soviet route and invent one, like ‘slow schizophrenia’, the primary symptom of which was the persistent inability to recognize one lived in the workers paradise. May I suggest a new diagnosis: “Anyone Birthing Using Surgery Instead of Vagmental Extremism.” The acronym speaks for itself,

  • Heidi

    If a woman did have an irrational fear of vaginal birth, so what? What good could come out of forcing her to give birth vaginally when we have a relatively safe alternative? I don’t even know what would constitute an irrational fear anyway. Childbirth is scary, I’d argue. I did it and nothing went wrong and I never want to do it again.

    • The Bofa on the Sofa

      I agree, Heidi!

      If someone has an irrational fear of high places, do we insist that they have to go to high places when they don’t have to?

      I sure as heck hope not.

    • MaineJen

      Amen! I’d say a fear of natural birth is a very healthy and rational response to an insanely painful and difficult event. I don’t even know what an “irrational” fear would be. When you get to a certain stage of labor, you wish for death, and that’s scary!

  • J. R.

    ….pregnant people?

    • MaineJen

      Yes this blog does discuss human pregnancy

  • demodocus

    Wow. That makes as much sense as a 2yo’s drawing.

  • Who?

    I hadn’t heard about this, but I’m sorry to say it doesn’t surprise me.

    Our ‘conservative’ party at both state and federal levels is increasingly under the control of religious extremists, who are little by little doing damage to all kinds of rights, including rights around reproduction.

  • mabelcruet

    Its similar to termination of pregnancy law in the UK. A termination is the only medical procedure that requires two doctors to agree to it. Everything else, major invasive life threatening brain surgery for example, only needs one doctors signature on the form. But a simple early termination, requiring a couple of pills, needs two independent doctors before its allowed. In Northern Ireland, the termination of pregnancy laws were among the strictest in the world, and only permitted if the mothers health was in imminent danger. But the interpretation of case law was altered such that it was no longer up to the obstetrician to decide whether the pregnancy was endangering the mothers mental health, she was supposed to be referred to a specialist perinatal psychiatrist for that assessment. Except we didn’t have a full time perinatal psychiatrist in the region, only part time, which essentially had the effect of banning virtually every termination on any grounds.

    With regard to Australian midwifery, this ridiculous suggestion is utter nonsense and highly offensive to women, but what do you expect when a whackjob like Hannah Darlen is in charge?

  • Kim Thomas

    What you tend to find is generally that women who ask for a planned caesarean either have tokophobia (ie they are terrified of giving birth vaginally, sometimes because they have had a previous traumatic birth) or they have done their research, weighed up the risks and benefits and have worked out that a planned caesarean is the safest option for them. Much of the risk attached to caesareans comes from multiple caesareans; if you know that you’re only intending to have one or two children you may well conclude that a planned caesarean is the right choice, particularly if you have other risk factors, such as a big baby. Treating women who have made a rational assessment of the risks as if they have a mental illness is patronising in the extreme and, as you say, arguably abusive.

    • Daleth

      Yes… and tokophobia, even if it were a “mental illness,” has no cure. So WTF is the point of requiring anyone to undergo a mental health assessment?

  • Lee McCain MD

    think I have said this before but if a patient request a primary section and you convince her otherwise to a perfect SVD then you have only broken even. Anything less you are a horrid terrible doctor who will be ripped on social media! A cesarean section is one of the safest procedures performed in our country. I generally tell patients that a section takes out all the variables. Just last week I convinced a patient wanting a TOLAC who was post dates to give it up to a repeat C-section. My partner did it and she had an placental accreta on an accessory lobe. In our state psych services are difficult to find with excellent insurance coverage and with Medicaid non existent. Just do the damn section. Scheduled. 20 minutes. Everyone will be happy. I do resent the misogyny comment. I have known plenty of female OBs who fall prey to transference and think all women should have the perfect vaginal delivery they had. I had a female attending who savaged me over getting epidurals or givng pain medicine because she had all her deliveries natural. My response always was that I thought delivering a baby looks like it hurts and called her out. Maybe both sexes technically can be misogynistic but think that is a nuance you don’t explain. I have no such predilections other than to make my patient happy with her experience.

    • MaineJen

      It does, in fact, hurt! Thank you for understanding that. 🙂

      Women who think like the OB you describe blow my mind; just because you endured the pain, you think everyone else should have to, as well? I’m willing to bet my great grandmother would have given her left eye for an epidural.

      • The Bofa on the Sofa

        3000 years ago, the pain of childbirth was clearly so bad that it was attributed to being a punishment from God. If someone finds it to be “not too bad” then good on them, but don’t pretend for a minute that it should be that way for everyone. All evidence is to the otherwise.

    • demodocus

      My ob’s partner definitely became a better ob after her own harder than average delivery. (Honestly, I think it may have been traumatizing for her from the bits and fragments I did hear about.) I did see her a few times in both pregnancies. My regular ob is a guy, and a solid sort of doc.

    • E.C.

      I asked every gynecologist I ever saw from the time I was a teenager until my late-thirties about elective c-sections. They all said no. They were all women. One told me that she’d been scared of childbirth, but then she had a great delivery and I would too. I told another my concerns about things that could go wrong, and she condescendingly said that none of that would happen to me. No reason why it wouldn’t happen, just the blithe certainty.

      Fortunately, I was able to find an obstetrician who favors patient choice. He happened to be male. A good friend in another state who also wanted an elective c-section also found a male OB who would honor her wishes. I’d been wondering if anyone else noticed the pattern. Though, we’re on Dr. Amy’s page and she’s a woman OB who supports elective c-sections.

      My elective c-section was absolutely perfect, everything I ever wanted. If I’m fortunate enough for IVF (in 2022, after everyone is vaccinated) to work a second time, I’ll hope the birth will go exactly the same way.

      • Mel

        I had my son at 26 weeks due to a rare, scary pregnancy complication. He was born by CS because 1) they didn’t have a few days to mess around with starting labor, 2) he was decidedly breech, and 3) CS delivery prior to 34 is correlated with greatly reduced risk of brain bleeds.

        My OB comes in to discuss the CS and gently informs me that because the CS is happening so early in the pregnancy, she’ll need to use a vertical incision to deliver Spawn so I’ll never be a candidate for a vaginal birth.

        I looked at her and said “So there’s no storm cloud so dark it doesn’t have a silver lining, huh? That’s a get-out-of-jail free card for me.”

        My OB was not expecting that response.

        I explained that I was well aware of the multiple pelvic floor surgeries needed by my grandmother, maternal aunts and mother to recreate a semi-functional pelvic floor after menopause thanks to vaginal births. I was, IMHO, trading one surgery that was better for my son and I right now in exchange for skipping an average of 2 (range 1-4) pelvic floor surgeries in my sixties and beyond.

    • kelen

      Misogyny is simply the hatred of or prejudice against women. Both men and women can be misogynists. Think of women who slut shame each other, for example. Thank you for being an awesome OB 🙂

  • Alia

    Meanwhile over here you cannot get a maternal request C-section, at least not in a public (eg. free) hospital – because apparently it’s a medical decision and cannot be decided “on a whim” (yeah, right). As a result, many women go to see a psychiatrist to get a diagnosis of tocophobia, which is reason enough for a C-section.

  • fiftyfifty1

    Thank you for this. There are already long wait lists for psychiatrists in most areas. What could the psychiatrist add anyway? I’m pretty sure there is no DSM-V diagnosis for preferring the risks of planned C-section over the risks of trial of labor.

    • demodocus

      The wait-list for my new psychiatrist was long enough that you could easily have gone from just beginning to suspect to baby in your arms, and I only talk to her for 10 or 15 minutes every 3 months.* Fortunately, my old doc had given me enough refills to see me through the transition.

      *my regular therapist is a social worker and the only not overbooked LPN sees my husband

    • Sarah

      What the psychiatrist can do is move the recommendation from a matter of preference to a medical indication in certain circumstances (e.g. tokophobia or PTSD from a sexual assault). It is not afaik to establish whether the person is competent to make the decision but rather to provide medical indication.

      • Mel

        Why, though?

        Women can want a CS birth for reasons unrelated to mental illness.

        My maternal relatives have fairly easy vaginal births. They also need multiple pelvic floor repairs after menopause. My assumption is that the vaginal births were pretty easy because our pelvic floor muscles have the strength of paper towels while in childbearing years and become as weak as wet tissue paper after menopause after the rigors of vaginal birth.

        I had my son at an advanced maternal age. We were not going to have a large family – like 2 or 3 kids total. Having a CS at age 35 to preserve my pelvic floor makes a ton of sense – and can’t be classed as a form of mental illness.

      • DrRadium

        The fact that one can imagine a mental illness contributing to a decision says nothing about whether that decision justifies triggering an automatic evaluation. If in a particular persons case there is a real concern, there is nothing stopping the referral now, Likewise, unless there is a reason to suspect lack of decisional capacity, no automatic evaluation is warranted.

        I do see the point I think you are trying to raise, that a psych eval could be used to change the c-section fro being merely elective (and perhaps not paid for by insurance) to indicated due to harm to patients mental health. I can see that, and fortunately there is nothing stopping such referrals now.

        All problems with getting psychiatrists involved arise from the mandatory nature of the midwives proposal.