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COVID-19: a watershed moment for women’s rights in childbirth

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Fleur van Leeuwen at Bogazici University
Fleur van Leeuwen
Daniela Drandic at University of Dundee
Daniela Drandic
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COVID-19: a watershed moment for women’s rights in childbirth
By Daniela Drandić & Fleur van Leeuwen
“People — and their rights — must be front and center,” said the UN Secretary-General on 23 April 2020. Since the start of the
COVID-19 pandemic, drastic measures have been taken by public bodies and health authorities to contain the spread of the virus.
Many of these have had serious repercussions for internationally recognized human rights.
The position of the rights of women in childbirth is in this context a precarious one. Stories have emerged in mainstream media –
supported by personal accounts received by global and European birthrights organizations – of women having their labor induced,
being forced to have cesarean sections, giving birth alone, and being separated from their babies immediately after birth. For
Human Rights in Childbirth (HRiC), Drandić (co-author of this piece) collected data on global experiences of childbirth during
COVID-19. In this essay, we focus on accounts received by HRiC and reports in mainstream media coming from Europe that warn
of serious infringements of women’s rights in childbirth.
By and large, the measures taken in maternal healthcare settings in response to COVID-19 are attributed to the need to “flatten the
curve,” such as by protecting healthcare professionals, women in labour, and their newborn babies from the risk of contagion in
hospital settings. Although they are presented as temporary – necessitated by and lasting only for the duration of the current
pandemic – they follow decades of institutionalization of childbirth, deeply rooted structural inequality, patriarchy, and neoliberal
austerity measures. Even prior to the pandemic, this had resulted in a situation in which disrespect and abuse in childbirth were
common. This includes, for example, brutal or inexperienced vaginal palpation, episiotomies carried out without consent, fundal
pressure, membrane stripping, condescending remarks, and refusal to allow women to choose how they want to give birth.
Current responses to the pandemic in maternal healthcare and the acceptance of these measures on the basis of “necessity” not
only imply serious infringements of human rights but also present a serious risk that the precarious status of women’s rights in
childbirth will become the new normal.
Reports on measures taken in response to COVID-19 indicate a closure of midwifery and community services in several European
countries. These moves provide an impetus for a further institutionalization of childbirth. Since the 1950s, European countries
have witnessed a shift in childbirth practices, from a traditionally female-led model that considers pregnancy and childbirth to be
normal, physiological life events (known as “the midwifery model of care”), to typically male-led models of care in which the
underlying presumption is that birth events are inherently pathological and need to be medically managed in specialized,
centralized facilities (“the obstetric model of care”). As Johanson, Newburn and Macfarlane point out, obstetrician involvement
and medical interventions have become routine in normal childbirth in most developed countries. Although it is in the best
interest of expectant families that these models of care complement each other, respecting the differences in approach and
necessity, this has often not been the case.
The shift from midwifery models of care to the obstetric model typically led to over-medicalization of pregnancy, childbirth and
postpartum, characterized by the “active management of labour.” The practice is reflected in highly elevated cesarean rates and the
use of medical interventions that are not based on evidence. Notably, as Oja and Yamin observe, over-medicalization can reduce
women to objects of interventions without agency, just as neglect of women’s differential needs in pregnancy and delivery can
harm them.
Following the 2008 financial crisis, many European governments drastically reduced public expenditures on health. Cuts in
healthcare budgets have been associated with understaffing, high patient volume, low salaries, long hours, and lack of
infrastructure. A study of the effects of austerity measures in European Union countries linked austerity measures to a likely
increase in maternal deaths. A side-effect of austerity was the strengthening of existing systems, for better or worse, and decrease
in the chances that new programs like midwifery-led services could be implemented or gain traction.
The measures taken in maternal healthcare settings in response to COVID-19, moreover, did not happen in a gender-neutral
vacuum. Blasko and colleagues, for example, point to how the lack of gender balance in COVID-19 decision-making in Europe
impacts the degree to which women’s specific needs are taken into consideration. And Sadler and colleagues reiterate that rather
than being an effective response to COVID-19, many of the measures currently taken in maternal healthcare settings are a “cloaked
manifestation of structural gender discrimination.”
Crucially, the developments in maternity services over the past few decades happened within a system of structural gender
inequality, discrimination, and patriarchy. Feminist literature on childbirth points to patriarchy, where women are instructed that
their suffering during labour has a purpose, and that their very existence is intrinsically linked to that purpose. Simonovic observes
in this regard that “Women are told to be happy about a healthy baby – their own physical and emotional health is not valued.”
And Blondin finds that gynecological and obstetric violence is “the result of the continued existence of a patriarchal culture within
the medical sector, particularly in the training given to health care staff, and of persistent gender stereotypes in society.” Studies in
this respect also focuses on the notion that the primary threat to fetal health comes from its “maternal environment.”
The institutionalization of childbirth and the erosion of maternal health and midwifery care, coupled with patriarchy and
discrimination, have led to serious impacts on women’s rights in childbirth. COVID-19 has deepened this problematic situation.
Since the beginning of 2020, the international NGO HRiC has been collecting data on the changes in care provided to pregnant,
birthing, and postpartum women and their newborns. These data reinforce the stories in mainstream media. Reports from the
United Kingdom, Germany and Slovenia – for example – point to the (further) closure and limitation of community and midwifery
care and to midwives being removed from their duties in maternity units to work with COVID patients. In Malta, patients are
allegedly discouraged from having home births. These measures not only indicate a further restriction to the already limited
availability of midwifery-led care but also severely restrict women’s rights to decide how and where to give birth. These measures
may furthermore impose risks to women’s access to high quality maternal healthcare and thereby affect women’s right to life and
health. Early models estimate significant increases in mortality due to reduced availability of maternal healthcare services
resulting from COVID-19.
As noted above, institutionalization of childbirth led to an increase in medical interventions. Reports received by HRiC of practices
in Europe during COVID-19 signal that in a number of medical institutions, these interventions, undertaken without medical
indication, are becoming the norm, thereby directly infringing upon women’s agency and integrity in childbirth. Croatian
obstetricians, for example, called for compulsory cesarean sections in all (suspected) cases of COVID-19, and in Spain, women are
subjected to inductions, instrumental births, and caesareans regardless of their infection status in order to minimize the risk of
potential COVID-19 infection. Similarly, women in Poland that had travelled abroad and were therefore in self-isolation, reported
that they were required to give birth by cesarean without any medical indication.
Finally, there has been widespread coverage of COVID-19 being used in as rationale for removing birth companions from delivery
rooms. HRiC received reports on this practice from Lithuania, Portugal, Poland, and Germany. The WHO, recognizing that
disrespectful and undignified care is prevalent in many facility settings globally, particularly for underprivileged populations, and
that the prevailing model of maternity care in many parts of the world enables the healthcare provider to control the birthing
process, recommends a companion of choice for all women throughout labor and childbirth. A Cochrane review of interventions by
Bohren and colleagues, concluded that having a labor companion of choice improves outcomes for women and babies and is
regarded as an important aspect of improving quality of care during labor and childbirth. WHO recommendations and research
shows that having a birth companion can drastically decrease the chances that members of marginalized groups will develop
severe complications or even die during childbirth.
The notion that these newly restrictive measures in maternal healthcare are necessary in light of the pandemic offers a false
understanding that they are isolated responses to COVID-19, which will only last for the duration of the pandemic. This narrative
overlooks the context in which women’s rights in childbirth have – gradually – been undermined in the past decades and also
brings with it a serious risk that this precarious status of women’s rights in childbirth will become the new normal post-pandemic.
COVID-19 is a watershed moment for birth rights. It will either magnify the existing harmful policies around maternity care and
create an important impetus for a radical rethinking of the way maternity care is delivered or result in a further degradation of
women’s rights in childbirth. We must strive for the former.
Daniela Drandić is a Croatian maternal and newborn health advocate and a board member of the international NGO Human
Rights in Childbirth. She is one of the authors of the Report on Rights Violations in Maternity Care during COVID-19. Ms. Drandić
is currently working on the second edition of this report.
Fleur van Leeuwen, LL.M., Ph.D. is a lecturer in law at Bogaziçi University, Istanbul, Turkey and a senior affiliated researcher at
Atria – Institute on Gender Equality and Women’s History in Amsterdam, the Netherlands. She is the managing editor of
Tijdschrift voor Genderstudies (Journal of Gender Studies).
© 2020 Medical Anthropology Quarterly. All Rights Reserved.
... Such practices, along with early pandemic restrictive policies in maternity wards (e.g. denial of birth companion), 13,14 have caused concerns among human rights advocates and associations of care professionals who were prompt to warn healthcare facilities against potential negative impacts on birth experiences and outcomes. 15,16 The need to prioritize evidenced-based care has since been made clear in professional guidelines and recommendations, which noted the importance of upholding women's rights when implementing COVID-19 pandemic-related measures. ...
... 9 Additionally, most studies on medicalization of birth have investigated its determinants only at the micro (individual) level, focusing on women's sociodemographic characteristics, provider characteristics, type of hospitals, and other aspects of case management. [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] However, a country's more general context, its health system, care culture, and social norms can also influence the provision of care. 21 Different approaches to maternity care are embedded within wider discourses on childbirth risks and medicalization of birth. ...
Individual and country‐level variables associated with the medicalization of birth: Multilevel analyses of IMAgiNE EURO data from 15 countries in the WHO European region
Article
Full-text available
  • Dec 2022
Objective: To investigate potential associations between individual and country-level factors and medicalization of birth in 15 European countries during the COVID-19 pandemic. Methods: Online anonymous survey of women who gave birth in 2020-2021. Multivariable multilevel logistic regression models estimating associations between indicators of medicalization (cesarean, instrumental vaginal birth [IVB], episiotomy, fundal pressure) and proxy variables related to care culture and contextual factors at the individual and country level. Results: Among 27 173 women, 24.4% (n = 6650) had a cesarean and 8.8% (n = 2380) an IVB. Among women with IVB, 41.9% (n = 998) reported receiving fundal pressure. Among women with spontaneous vaginal births, 22.3% (n = 4048) had an episiotomy. Less respectful care, as perceived by the women, was associated with higher levels of medicalization. For example, women who reported having a cesarean, IVB, or episiotomy reported not feeling treated with dignity more frequently than women who did not have those interventions (odds ratio [OR] 1.37; OR 1.61; OR 1.51, respectively; all: P < 0.001). Country-level variables contributed to explaining some of the variance between countries. Conclusion: We recommend a greater emphasis in health policies on promotion of respectful and patient-centered care approaches to birth to enhance women's experiences of care, and the development of a European-level indicator to monitor medicalization of reproductive care.
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... Especially at the beginning of the pandemic, some of the measures and changes in the organisation and delivery of maternity care have threatened rights to respectful maternity care. This led civil societies globally and international organizations (e.g., World Health Organization, International Confederation of Midwives) to call for less restrictive measures [36][37][38] with a particular emphasis on allowing birth partners, avoiding unnecessary interventions, and guaranteeing opportunity for postpartum bonding between the newborn and their mother. Such infringements of basic birth rights are visible in our data, as illustrated by the experiences of several women, who shared that they had given birth "alone", which was perceived as traumatising and impacted their wellbeing negatively. ...
Experiences of giving birth during the COVID-19 pandemic: a qualitative analysis of social media comments through the lens of birth integrity
Article
Full-text available
  • Jan 2023
Background Social media offer women a space to discuss birth-related fears and experiences. This is particularly the case during the COVID-19 pandemic when measures to contain the spread of the virus and high rates of infection have had an impact on the delivery of care, potentially restricting women’s rights and increasing the risk of experiencing different forms of mistreatment or violence. Through the lens of birth integrity, we focused on the experiences of women giving birth in Germany as shared on social media, and on what may have sheltered or violated their integrity during birth. Methods Using thematic analysis, we identified key themes in 127 comments and associated reactions (i.e. “likes”, emojis) posted on a Facebook public page in response to the dissemination of a research survey on maternity care in the first year of the COVID-19 pandemic. Results Women contributing to the dataset gave birth during March and December 2020. They were most negatively affected by own mask-wearing –especially during the active phase of labour, not being allowed a birth companion of choice, lack of supportive care, and exclusion of their partner from the hospital. Those topics generated the most reactions, revealing compassion from other women and mixed feelings about health measures, from acceptation to anger. Many women explicitly formulated how inhumane or disrespectful the care was. While some women felt restricted by the tight visiting rules, those were seen as positive by others, who benefited from the relative quiet of maternity wards and opportunities for postpartum healing and bonding. Conclusion Exceptional pandemic circumstances have introduced new parameters in maternity care, some of which appear acceptable, necessary, or beneficial to women, and some of which can be considered violations of birth integrity. Our research calls for the investigation of the long-term impact of those violations and the reassessment of the optimal conditions of the delivery of respectful maternity during the pandemic and beyond.
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... Under the initial epidemiological pressure, emergency measures reshaped the birth carepath in ways that highlighted the delicate balance between safeguarding public health and guaranteeing reproductive rights (Yuill, 2020). In this sense, COVID-19 might be recalled as "a watershed moment for birth rights" (Drandić and Van Leeuwen, 2020). ...
The Global Impact of COVID-19 on Maternity Care Practices and Childbearing Experiences
Book
Full-text available
  • May 2021
The global impact of COVID-19 and SARS-CoV-2 on Maternity Care Practices and Childbearing, including newborn and maternal health outcomes.
View
... Under the initial epidemiological pressure, emergency measures reshaped the birth carepath in ways that highlighted the delicate balance between safeguarding public health and guaranteeing reproductive rights (Yuill, 2020). In this sense, COVID-19 might be recalled as "a watershed moment for birth rights" (Drandić and Van Leeuwen, 2020). ...
“They Would Have Stopped Births, if They Only Could have”: Short-and Long-Term Impacts of the COVID-19 Pandemic—a Case Study From Bologna, Italy
Article
Full-text available
  • Apr 2021
This article addresses the short-term impacts of the COVID-19 pandemic in Italy and hints at its potential long-term effects. Though many might want it to, birth does not stop during a pandemic. In emergency times, birth practices need to be adjusted to safeguard the health of birthing mothers, babies, birth providers, and the general population. In Bologna, Italy, one of the emergency measures employed by local hospitals in response to COVID-19 was to suspend women’s right to be accompanied by a person of their choice for the whole duration of labor and childbirth. In this work, we look at how this measure was disputed by the local activist birth community. Through the analysis of a social campaign empowered by Voci di Nascita—an association of parents, birth providers, and activists—we examine how social actors negotiated the balance between public health and reproductive rights in a time of crisis. We argue that this process unveils several structural issues that characterize maternity care at the local and national levels, including the (re)medicalization of birth, the discourse on risk and safety, the internal fragmentation of Italian midwifery, and the fragility of reproductive rights. The Covidian experience forced the reshaping of the birth carepath during the peak of the emergency. We suggest that it also offered an opportunity to rethink how birth is conceived, experienced, and accompanied in times of unprecedented global uncertainty—and beyond.
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... Many of these have resulted in unnecessary deviations from timely, evidence-based, respectful care (for example, routine separation of newborns from COVID-19 positive mothers, lack of support for breastfeeding, denial of abortion care, suspension of reproductive cancer screening activities). 3 These negative impacts have been documented across different health systems and a broad range of country income levels, exposing the underlying lack of prioritisation, attention and funding to these critical areas of health, exacerbated by a global pandemic. ...
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Becoming a Mother During COVID-19: Adjustments in Performing Motherhood
Article
Full-text available
  • Apr 2022
Based on online semi-structured interviews with middle-class women who were pregnant or had recently given birth in Western Europe (France, Spain, the United Kingdom, and Switzerland), this study analyses how motherhood has been experienced and performed during the COVID-19 pandemic. The article reflects on the specific new risk assessments and responsibilities that emerged during the pandemic by showing women’s coping strategies concerning lockdowns and other public health measures. Using a COVID-19 lens also allows a broader analysis of middle-class families’ concerns about performing ‘good motherhood’. By highlighting the discrepancies between women’s expected and actual experiences, the prescriptive aspects of pregnancy, delivery, and the postpartum phase are revealed and analysed, prompting us to consider parenting as a form of doing and proving. By underlining the importance attached to the expectant mother’s wellbeing, the partner’s involvement, the support of relatives, and the future socialisation of the baby, we argue that women face a myriad of imperatives to ensure a meaningful experience of motherhood.
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