I was contacted by a lawyer who is working on a law review article about birthrape… she found me via my blog. A couple of days ago, she presented me with a list of questions that have come up as she is writing her paper. As I answered her, I thought my comments would make a great stand-alone post, so here I present the information I have given to the brave lawyer who is poised to stand strong against the storm that is sure to come after her piece is read and digested. She is already our hero, just for taking on the legal aspects of this fight.
Addendum: Patricia Shepard, the lawyer I referenced above, has asked that I share her information with you all. She says, "I'm particularly interested in hearing from women who have attempted to find counsel to take their cases in civil court, or attempted to press criminal charges, but have been denied." Patricia's email is: patricia DOT s DOT shepard AT gmail DOT com
This piece is rife with definitions and commentary. Each topic can be stand-alone and deserves its own space in our discussions.
What About the Baby?
Let us just get this out of the way now. The baby is important, but not more important than the mother. Equally important. I discuss emergency procedures below, but lest you think, “The mother’s feelings be damned! Doctors, nurses and midwives can do anything to save the baby,” that is not what we are talking about. We are speaking about non-emergent issues, experiences that have zero to do with aid, but everything to do with Power and control.
It hardly needs saying, but this piece is filled with possible triggers for women who have been birth abused. Some of the links contain photographs or videos of extremely graphic procedures, so click links with caution if you are watching for triggers. While I respect and honor your processes and truly desire not to hit those painful buttons, with this issue, in this situation, I feel the more graphic the information, the better lawyers and law enforcement will understand; comprehension can come from the nuances. If you find yourself being pulled into the pain, please attend to yourself kindly, calling a friend if you need to. And always remember: you are not alone.
Because there are no legal definitions of what we are going to be talking about, I have attempted to define the different aspects of Birth Abuse, breaking them down into their basest forms and outlining the actions that make up the violation. I am using the term Birth Abuse as the umbrella term. I do this not to discount or soften the blow of the word Birthrape, but to give a definition that encompasses Birth Violation, Birth Dehumanization (which includes Humiliation), Birth Violence, and Birthrape. Note that terms may (and often do) overlap in each incident a woman experiences. I have struggled with always capitalizing the words to create a deeper sense of urgency and emotion, but also know it can be disconcerting when reading and might detract from the message. So, I have chosen to capitalize when defining or using a word as a noun. For example, the term informed consent is different than Informed Consent; Informed Consent is the formal process of questions and answers and the signed contract between a client and her care providers –the complete package. I use the words informed consent to mean individual parts to the complete package of Informed Consents. This is my personal distinction which, to anyone else, might mean nothing, and, as we know, what we sign in the hospital is not even called Informed Consent, but merely Consent Forms. Part of what we are looking for here is the Informed part, right?
When I first heard the term Birthrape (sometimes written Birth Rape or birth rape) in 2004, I was horrified someone would be as arrogant or blind as to equate anything done at birth, even atrocious things, with rape. As a rape survivor, it was beyond insulting that anyone could use the word birth and rape in the same context. And then I started talking to the birthrape survivors and was humbled by what I heard. In the ensuing seven years, I have talked to hundreds of women who have identified as birthrape survivors… women who have had physician, obstetrician, nurse, nurse midwife and non-nurse midwife perpetrators.
Because there are no legal definitions of any birth abuse terms, but there are women who have been birth abused, it is imperative for these women to join together, in their pain, and come up with a consensus of verbiage to use when talking about their own experiences. I am unsure whether this will happen in support groups, in online support forums such as Solace for Mothers, in a specific Terminology Facebook page or through comments to this piece, but somehow, it has come time to create the language the law will use when prosecuting our cases. While I have not been birth abused, I was certainly birth disrespected and painful as it is to say, I have witnessed accounts of birth abuse (including birthrape) and have also been a perpetrator early in my midwifery training. It is in that light that I try to define experiences that I have not personally had, but have participated in. This in no way allows me to define another woman’s experiences; women define their own and if I define birthrape one way and a birth abused woman defines it another, she is correct; not me. Some might even find extreme arrogance in my attempting to define these terms as a former perpetrator, but I am humbly offering my services and if it is offensive to you, I do apologize. Yes, I am sure there are serious overtones of mea culpa in why I write about birthrape; it is the least I can do for my past.
So, here I go.
Throughout, I use the term perpetrator, again, struggling whether to capitalize it and give it an uglier, we-see-you aspect or lowercase because they are doing despicable things to women and to keep them in a place of derision. I’m choosing the latter.
Perpetrators come in many guises including doctors, nurses, certified nurse midwives and non-nurse midwives. While it might be shocking to some that one or the other has the possibility to birth assault a woman, I promise, there are a dozen more that can attest to their abilities.
I have gone back and forth on whether to call the umbrella term Birth Abuse or Obstetric Abuse. The word “obstetric” is so clinical, devoid of emotion and almost always takes the mind immediately to a doctor, an obstetrician, and, I would guess, for many of us, a male obstetrician. Later, we bring in the word “rape” and that word is almost exclusively centered on male perpetrators. Because I am hyper-aware that perpetrators come in different identities, I really wanted to use a term that did not automatically conjure up a male in a white coat; therefore I chose the words Birth Abuse.
Birth abuse covers all aspects of abuse a woman might encounter during her pregnancy, labor, birth or postpartum. There is a gray area when, if the woman is pregnant, abuse occurs during a Pap test or during a breast exam, but this can be sorted out later. For the moment, this specific piece speaks to a woman’s experience during labor, birth and the immediate postpartum period, which I would consider during the first week after the birth or so; the most vulnerable time for women, as well as the time when perpetrators have the highest access to women.
We come to our births full of hope and expectation. We hope to have a healthy baby and be able to mother our child fully. Beyond that, we also trust we will be treated with respect and to maintain our dignity as a human being. When this does not occur, our trust has been violated. Violations can take on many guises including:
- Ignoring our birth plans
- Ignoring our demands to stop
- Ignoring our requests
- Any touching without permission
All of the following definitions are included in birth violations, too.
Much has been written about the dehumanization of women in birth… whole books and even research papers have explored this topic. But in the birth abuse context, re-visiting the list of the “normal” events that are dehumanizing is important. I think noting that depending on a woman’s emotional or physical history, she might construe dehumanization as birth violence. Again, her perception is the right one.
- Being required to wear the hospital gown when she says she wants to wear her own clothes
- Being required to wear the hospital gown open to the back without being given another gown when she expresses concern about modesty
- People entering her room without knocking
- People entering the room without introductions
- People watching her without her consent
- Strangers touching her without her consent
- People touching her baby without consent
- Her baby’s condition not being revealed to her when she asks
- Not being given her healthy baby when she asks
- Being addressed as “mommy” instead of using her name
Moving on to birth violence, these now become the more physical of the violations, although not all are physical, but violent, nevertheless.
- Intimidating the woman, either in labor or even in the pregnancy (i.e. telling a woman she hasn't been to medical school and s/he has so s/he knows better or, the most classic of all intimidation tactics, what we've come to call the Dead Baby Card) In fact, you can see the enormous amount of intimidation tactics on the My OB Said What?!? site.
- Forcing a woman to have an IV when she expressly refuses
- Forcing a woman to have no food or drink during labor
- Giving the woman sedatives, narcotics, pitocin, magnesium sulfate or any other medication, prescription or otherwise, without express informed consent
- Physically restraining a woman who is trying to change positions
- Physically moving a woman against her will (i.e. pushing her from hands and knees to on her back during pushing)
- Yelling at the woman (i.e. belittling her ability to cope with pain or demanding certain behaviors)
- Negating her experience (i.e. "It hasn't even begun to hurt yet," or "Just wait until you start having real contractions")
- Doing aggressive perineal stretching in the guise of perineal massage or support (perineal stretching often causes physical damage to the mother; perineal massage and support are extremely gentle procedures)
- Abandoning a woman (I had one client delivering and the doctor stood across the room, refusing to come catch the baby, punishing her for trying to have a homebirth)
- Pulling aggressively on the umbilical cord to get the placenta out before it has detached (this is very different than the Active Management of Third Stage in that it physically hurts the birthing woman especially if she does not have an epidural, and can cause severe hemorrhage)
- Aggressively and painfully "massaging" the uterus after the delivery of the placenta (I learned to "touch the newly postpartum woman's spine" with my balled up fist... I've since learned that the only thing most women need is a quick and gentle feel for if the uterus has remained contracted and if it has not, gentle massage will "rub up" a contraction.)
- Grabbing a woman's breast and shoving it into the baby's mouth without warning or without consent to do so ("I found my experience with the hospital nurses and breastfeeding to be frustrating. They were very pushy and grabbed my breast and the baby’s head and made her cry and she wouldn’t latch on while they were doing that.").
I cannot talk about Birth Violence without mentioning that Venezuela, in 2007, coined the term Obstetric Violence. Many of us did not catch it until the “Special Editorial” in the International Journal of Gynecology and Obstetrics entitled “Obstetric Violence: A new legal term introduced in Venezuela” in December, 2010. (I have the original article in .pdf; if you want it, please email me: Navel gazing Midwife AT g mail DOT com.)
“In Article 15, 19 forms of violence are described, including obstetric violence, which is defined as: the appropriation of the body and reproductive processes of women by health personnel, which is
expressed as dehumanized treatment, an abuse of medication, and to convert the natural processes into pathological ones, bringing with it loss of autonomy and the ability to decide freely about their bodies and
sexuality, negatively impacting the quality of life of women.”
While this is somewhat encompassing the topic here, I feel as some do, that it is woefully lacking not only not describing what women who have been birth abused have experienced, but also leaving the descriptive words too broad, allowing perpetrators too much leeway in believing that what they are doing/did could not possibly be considered birth abuse/obstetric violence.
I definitely think the term obstetric violence has potential as the term to use for all of these segments of birth abuse, but I did want to weigh in on why I chose differently.
The hottest button word of them all. Birthrape is, for many women, an all-encompassing term and, as I have said before, the woman defines her experience. But, as I have listened and talked to women over the years, I have come to distinguish birthrape as having actual penetration involved. All of the below scenarios include being done either without warning, without full informed consent, if the woman withdraws consent and/or if she is actively forbidding the procedure. The perpetrator might even restrain or use force, or ask for help in restraining, the woman in order to continue with the procedure. For example, if a woman is refusing a vaginal procedure and the perpetrator physically pushes her legs apart in order to continue; this is force being used.
- Vaginal exams (more specifically, cervical exams)
- Inserting fetal scalp electrodes
- Inserting IUPCs (Intra-Uterine Pressure Catheter)
- Inserting Foley or straight catheters
- Rupturing (or releasing) membranes
- Stripping (or sweeping) membranes
- Manually dilating a cervix
- Cutting an episiotomy
- Manual removal of the placenta
- Checking the uterus for dehiscence postpartum and rectal exams (rectal exams are rarely done now, but used to be a preferred method of checking cervical dilation, supposedly limiting infection; it didn't work)
- Cesarean Section – there are women who have been forced into cesarean sections and consider that birthrape even though there was no vaginal penetration
- Bimanual compression is another vaginally "invasive" procedure, but is typically only used for an uncontrolled postpartum hemorrhage, but I can see how a woman might consider this birthrape; I have not ever heard a woman do so, however.
Much is said about the Consent Forms a woman signs when she checks into the hospital, but as anyone who has been to court knows, Consent Forms mean nothing if they are not adhered to. And a woman always has a right to withdraw consent. Some believe reading the consents and crossing off what they do and do not want to consent to makes a difference, but the ultimate argument in doing those procedures crossed off is: it was to save the mother’s/baby’s life. Even if it was not, who is to say for sure? (That is the courtroom argument, anyway.)
So what do we do with Consent Forms? Do we simply not sign them at all? Do we ask to be informed every step of the way? What would happen if we did not sign the forms? How can it even be legal to have a woman in the throes of labor sign forms she cannot take the time to read and digest? But, then we face the “a woman in labor is not in her right mind and can’t make a decision about anything, so we get to make all the decisions for her” argument and that is not acceptable, either. I do not have the perfect answer for that yet and really hope the courts are able to figure out the answer to this one, even if it is, ultimately, the Supreme Court. Of course, I am with many of you, feeling our litigious society needs to stop the madness, but our legal system is there for a reason and birth abuse seems like a pretty damn good reason to me.
Continued discussions about birth abuse entail talking about the perpetrator’s intention in the scenarios, but I believe birth abuse, violations, violence and rape are defined/named by the victim; the perpetrators’ intent is completely irrelevant. When comparing birthrape to the typical understanding of what rape is (which, to me, is a separate issue altogether, but if we were to do so), just as there are birthrapists who do not intend to harm, there are also rapists who do not intend to hurt their victims. Perhaps the rapist intends to teach a girl or woman how to have sex or to help her understand what a great lover he is. Rape is not always intended to intimidate or harm the woman… from the perpetrators’ viewpoint. Again, it is totally irrelevant what the perpetrator believes is his/her intent. Whether the doctor, nurse or midwife intended to hurt, scare or intimidate the woman does not matter… it is how the woman experiences the behavior or procedure that defines the event.
Looking at the examples and definitions I have given, you can imagine how prevalent birth abuse is. I do understand most women would never consider calling the same experiences birth abuse, but that might be because they have not been able to name the feelings at the time or after the birth. Perhaps if the terms became more common, more women will name the offenses. I know that women have developed Postpartum Depression (PPD) or Post-Traumatic Stress Disorder (PTSD) after traumatic births they could not name birth abuse because they were not aware of the terms. For many women, learning the terms and naming the actions or events that involved the perpetrator/s became a significant step in the healing of the experience.
The most common types of abuse I have seen are dehumanization and intimidation, but I have either witnessed or participated in all of them. Detractors might argue, if so many women experience even one of the above behaviors, perhaps what I am calling Birth Abuse, really is merely a random interpretation and that, instead of what we consider despicable, really is not only typical behavior, but even normal? That what I am naming Birth Abuse is so common, it is my own perception that is skewed, perhaps even wrong? Might my own abuse history or my own guilt at (what I would call) Birth Abuse be coloring the acts themselves? Might I be giving women an idea that really does not exist at all? These are all great questions that, I am sure, will soon be debated.
Future Topics That Must Be Addressed
Birth Abuse & Emergency Procedures
I find this a challenging aspect because when the emergency is a true and honest emergency, I have not found women to be angry about any of the listed violations that are emergency-driven. I have known women (many, in fact) who initially were grateful the actions were taken, but upon reflection and with time, reframed their experiences to one of birth abuse. Women, especially ones who were told one thing and then later read very different stories in their medical charts are wont to reframe their births. But when women feel the emergency actions were justified, I have not seen them in anger. Shock, yes, but anger, no. I think we need to hear more stories than just mine, though.
Witnessing Birth Abuse
What happens when a doula (or nurse or doctor or midwife... or family member, phlebotomist, etc.) witnesses birth abuse? Does s/he say anything right then? Is there a place to let the client know later that what she experienced was birth abuse? Is it another person’s place to name the trauma or abuse? Or are those of us in birth work merely reflections for women, acknowledging and validating their experiences.
I believe many birth trauma feelings are caused by birth abuse. However, that does not mean all the women identify it as such. Over the years, when women shared emotions with me, they often stumbled over the right words to use. I have given them words other women have used, but I have been very careful not to preemptively name the abuse or trauma for women. It can take months or even years for women to come to terms with their birth experiences. If a doula (or support person) sees a woman struggling, is it her moral imperative to assist her with information? Up until now, I have tended to wait for them to question what happened. But is this the right thing to do? If I identify an action or behavior as abuse, but the woman does not, is it abuse? If a battered woman believes she deserves the punishments, is she being abused? In other situations that lead to PTSD, it can be a race to see who names the abuse first – television, magazines, books, relatives, physicians, therapists, etc. When a molested child is rescued, one of the first things that happens in therapy is naming the abuse, seeing it as abuse, reframing the experience in the light our culture requires. But, what if our culture does not see the trauma like we do? Whose barometer do we use?
And what of the witnesses’ mental state? How will we attend to our hearts and minds as we are required to watch the abuse happen again and again. I know birth abuse is the main reason for burn out of doulas. How can we support witnesses so they/we are able to keep going, so we are able to be there for the women who need/want us with them?
Power & Convenience
I think birth abuse happen for distinct reasons and addressing these will be required.
- It is easier to have each woman behave exactly the same, variations take more time and energy for providers.
- Women who want to/demand to be treated as an individual can provoke anger in frustrated nurses.
- Being in control of most aspects of the birthing environment, doctors, nurses and midwives can feel a sense of entitlement and react negatively when their Power is questioned.
- Hospital staff 100% believes they have the women’s and babies’ best interests in mind and when their care is questioned, they take it personally.
- Even as most hospital staff understands many protocols are made because of insurance companies and not based on scientific evidence, they support the protocols, even if they believe they harm women, knowing they could lose their jobs if they buck the system… it is easier to intimidate women into compliance than to fight The Establishment.
Accidental Birth Abuse
I was asked if there were accidental cases of birthrape or birth violence, but to me, the distinguishing factor in birth abuse is it is always associated with Power and/or control. Along with the emergency issues above, I believe if women understand the person did not mean to hurt them and sincerely apologizes, I think women are able to process the experience in a non-birth abuse way. Again, others might feel differently and we will need to hear from them.
I have found that even in the most dire of situations, one can ask permission to help at least assign one person to explain to mom what is happening and why. It can be a short statement: “I need to get your baby out now,” or “You’re bleeding. I need to help.” It takes a second of time and I know seconds count, but that doesn’t mean the life-saving procedures are abandoned in order to converse with the woman! One particularly gnarly shoulder dystocia I had, I was getting a laboring woman out of the tub as I asked, “May I help?” She says that quick and simple question helped her to not be so traumatized by the birth even though her hip was dislocated trying to get the baby out. (We did; she’s fine.) In the hospital, there are many people associated with emergencies, so I feel someone needs to be assigned to talk to the woman and, during drills, they need to practice what to say to the laboring and birthing woman. I believe this can help women in a myriad of ways, the least of which is they are part of the team… and they most definitely are.
Reporting Birth Abuse
I know several women who have filed complaints to medical and midwifery boards, but the complaints are addressed half-heartedly, if at all. I filed one against a doctor, several nurses and a hospital and during the review, of which neither I nor the parents were permitted to speak, the hospital staff refuted our claims and the hospital received a glowing review anyway. One governing board did fine the hospital, but the parents, who divorced because the birth abuse affected the marriage, had no recourse. No lawyer would take the case; they would not even meet with the parents if there was no “permanent damage.” Apparently, sexual dysfunction, PTSD and terror of anything medical does not count as permanent. This is only my experience; there are many, many (too many) others.
Somehow, we have to find lawyers that will talk to women and judges that will hear the cases.
We have to get the point across that, if a normal person in a normal situation experienced these behaviors or procedures, would they consider them abusive? Most assuredly so.
We have to create medical and midwifery boards that are not made up of peers that are also friends we socialize with. Incestuous midwifery communities must be required to parcel out the complaints so a woman is able to be heard fairly. National organizations should be required to study and implement a method of impartiality in order to serve women, not themselves. If we have to, midwifery board reviews need to occur outside the state of the complaint in order to find an impartial group of midwives to hear the case. The onus should not be on the woman to create fairness, nor should she have to suffer through hearings where she sees "sister midwives" blatantly supporting each other. It disgusts us when physicians do the Good Ol’ Boy network; the Yeah, Gal network is just as indecent.
End of Tolerance for Abuse
It is baffling how women are expected to lie back and take the abuse from doctors, nurses and midwives. People would never tolerate being treated thusly from a lawyer, accountant or teacher! Can you imagine a lawyer shoving a woman’s legs apart? Or a lawyer mocking a client (picture a male client!) saying, “What law school did you go to?” I just can’t see us sitting quietly if our accountant went to our home, rifling through our personal things, saying, “If you don’t let me look through your underwear drawer, you’re going to go to prison for tax fraud.” And yet, these lame examples do not even come close to the massive violation slapped across women every single day in the name of medical and midwifery care. It has to stop. It. Simply. Has. To. Stop.
I look forward to hearing others’ thoughts and I would love to see us create a list of demands so all women and babies are treated with respect and dignity, something far more comprehensive than the Pregnant Patient’s Bill of Rights. And legally binding.
I dream of women calling the police during labor, reporting birth abuse, and being heard and action taken.
I dream of women sitting in their therapists’ offices, learning how to report their perpetrators and knowing… knowing… they will be heard.
I dream of medical and midwifery boards that are truly impartial.
My ultimate dream is that medical and midwifery establishments “get” it and understand their behaviors as abusive and they take a collective vow to never cross the abuse lines again.
I dream of Informed Consent… real informed consent.
I dream that medical and midwifery professions learn to manage and control their own through workshops, seminars, research studies and peer pressure.
I dream of medical and midwifery care providers asking women, always asking women, how they can avoid smashing their senses of Self.
For it is the women themselves… we women ourselves… who are the determining factor in how we birth.
It is our birthright.