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.

  • rational thinker

    Most stories I have heard about abuse or mistreatment has involved nurses or midwives.

    I am pretty sure this story took place in the late 1930’s. My grandmother came from a catholic family and when she was about 13 she got pregnant. Her parents sent her to one of those mothers homes run by nun’s for pregnant young girls. Thankfully this was in the US and not someplace like Ireland where they were abused and enslaved and imprisoned- some were imprisoned for decades. I dont know how she was treated during her time there in the convent but she did tell me about when she was in labor. She said the nuns would yell demeaning things at her about not keeping her legs closed and this was her punishment for falling from grace, and they would hit you with a whip every time you screamed during labor. One interesting thing she told me was that sometimes the girl in the bed next to you in labor was a nun herself. So this was where they sent all the pregnant nuns too.
    Most of those women were forced to give the baby up for adoption and the church would make money from that. My grandmother was kind of lucky because her parents let her keep the baby on one condition. Her parents would adopt him and she would be his sister instead of his mother. This secret was kept for about 48 years until one night my grandmother had a few beers and told everyone.

    So I would say if you look at history women in labor were always most often abused by other women.

  • mabelcruet

    As a medical student 30 years ago, I witnessed the treatment of women in labour. We were required to observe 10 vaginal births (staying with the woman throughout the whole labour, even though the midwifery staff came and went) and then deliver 20 babies under supervision.

    I can still remember some of the treatment these women got-I haven’t done any obstetrics since then so I don’t know if things have improved, but I witnessed women being called names and spoken to harshly (‘silly girl’, ‘don’t be a little cry-baby’, ‘do what you’re told’, ‘you can walk around when I tell you you can walk around’). One birth I recall very clearly was a baby with a midline cleft palate-at the time, ultrasound scans were still not widely used and this hadn’t been diagnosed antenatally. The mum started to cry and the midwife told her to stop crying, the baby was alive and it could be treated. I also witnessed a mum trying to push the midwife’s hands away when she was attempting to do a vaginal examination-the midwife slapped her hands and got another midwife to hold them out of the way. As a student its really hard to know what to do, and it was made very clear to us as students that we were only there at the grace and professional courtesy of the midwives (some of my student colleagues had sat with their women all day and night leading up to the delivery, only to be shoved out of the way to make room for a student midwife to come and do the delivery, so if you created any fuss or made a complaint, your life would have been made hell and you wouldn’t have got signed off). I spoke to the medical registrar (middle grade doctor) who was nominally supervising us and he said ‘There’s nothing I can do’.

    For balance and fairness, I also witnessed some poor behaviour from medical staff-the one incident I remember most clearly was a woman with a retained placenta, and the midwife called the obstetrician, who barely introduced himself, then shoved his hand up to grab the placenta. The poor woman was in tears and in agony.

    I work fairly closely with midwives (although not in the clinical arena so I don’t see how they talk about and to their women during delivery), but certainly the language now used in clinical meetings, and in discussions about baby loss, stillbirths, bereavement etc, seems to be more respectful and sounds more like a partnership than a patient vs medical professional scenario.

    • guest

      I started working in Labor & Delivery about twenty years ago and have seen the working culture change radically since then. Patient rights were barely talked about then, now they are at the forefront of most discussions.

      May I ask where you were a student?

      • mabelcruet

        In the UK (started training in 1986 so it was a very long time ago). Theres been massive changes in the medical profession since then, and we certainly pay far more attention to patients wishes than we used to, medical paternalism doesn’t really exist any more, which is definitely for the better.