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Abstract

'Medical iatrogenesis' was first defined by Illich as injuries 'done to patients by ineffective, unsafe, and erroneous treatments'. Following Lokumage's original usage of the term, this paper explores 'obstetric iatrogenesis' along a spectrum ranging from unintentional harm (UH) to overt disrespect, violence, and abuse (DVA), employing the acronym 'UHDVA' for this spectrum. This paper draws attention to the systemic maltreatment rooted in the technocratic model of birth, which includes UH normalized forms of mistreatment that childbearers and providers may not recognize as abusive. Equally, this paper assesses how obstetric iatrogenesis disproportionately impacts Black, Indigenous, and People of Color (BIPOC), contributing to worse perinatal outcomes for BIPOC childbearers. Much of the work on 'obstetric violence' that documents the most detrimental end of the UHDVA spectrum has focused on low-to-middle income countries in Latin America and the Caribbean. Based on a dataset of 62 interviews and on our personal observations, this paper shows that significant UHDVA also occurs in the high-income U.S., provide concrete examples, and suggest humanistic solutions.
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Anthropology & Medicine
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Obstetric iatrogenesis in the United States: the
spectrum of unintentional harm, disrespect,
violence, and abuse
Kylea L. Liese, Robbie Davis-Floyd, Karie Stewart & Melissa Cheyney
To cite this article: Kylea L. Liese, Robbie Davis-Floyd, Karie Stewart & Melissa Cheyney (2021):
Obstetric iatrogenesis in the United States: the spectrum of unintentional harm, disrespect,
violence, and abuse, Anthropology & Medicine, DOI: 10.1080/13648470.2021.1938510
To link to this article: https://doi.org/10.1080/13648470.2021.1938510
Published online: 01 Jul 2021.
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ANTHROPOLOGY & MEDICINE
Obstetric iatrogenesis in the United States: the spectrum
of unintentional harm, disrespect, violence, and abuse
Kylea L. Liesea, Robbie Davis-Floydb, Karie Stewartc and Melissa Cheyneyd
aDepartment of Human Development Nursing Science, University of Illinois at Chicago, Chicago, IL, USA;
bDepartment of Anthropology, Rice University, Houston, TX, USA; cObstetrics and Gynecology, University of
Chicago Pritzker School of Medicine, Chicago, IL, USA; dSchool of Language Culture and Society, Oregon State
University College of Liberal Arts, Corvallis, OR, USA
ABSTRACT
‘Medical iatrogenesis’ was first defined by Illich as injuries ‘done to
patients by ineffective, unsafe, and erroneous treatments’. Following
Lokumage’s original usage of the term, this paper explores ‘obstetric
iatrogenesis’ along a spectrum ranging from unintentional harm (UH)
to overt disrespect, violence, and abuse (DVA), employing the acronym
‘UHDVA for this spectrum. This paper draws attention to the systemic
maltreatment rooted in the technocratic model of birth, which includes
UH normalized forms of mistreatment that childbearers and providers
may not recognize as abusive. Equally, this paper assesses how obstetric
iatrogenesis disproportionately impacts Black, Indigenous, and People
of Color (BIPOC), contributing to worse perinatal outcomes for BIPOC
childbearers. Much of the work on ‘obstetric violence’ that documents
the most detrimental end of the UHDVA spectrum has focused on low-
to-middle income countries in Latin America and the Caribbean. Based
on a dataset of 62 interviews and on our personal observations, this
paper shows that significant UHDVA also occurs in the high-income
U.S., provide concrete examples, and suggest humanistic solutions.
Introduction: obstetric iatrogenesis
‘Medical iatrogenesis’ was first defined by Illich (1976) as injuries ‘done to patients by inef-
fective, unsafe, and erroneous treatments. Following Lokumages (2011) original usage of
the term, we explore ‘obstetric iatrogenesis’ along a spectrum ranging from unintentional
harm (UH) to overt disrespect, violence, and abuse (DVA), employing the acronym UHDVA
for this spectrum. We draw attention to systemic maltreatment rooted in the technocratic
model of birth (Davis-Floyd 2001, [1992] 2003), which includes normalized forms of mis-
treatment that childbearers1 and providers may not recognize as abusive (Elmir et al. 2010;
Diaz-Tello 2016; Miller et al. 2016; Castro, Heimburger and Glass 2003; Vedam et al. 2019).
Equally, we assess how obstetric iatrogenesis disproportionately impacts Black, Indigenous,
and People of Color (BIPOC), contributing to worse perinatal experiences.
© 2021 Informa UK Limited, trading as Taylor & Francis Group
CONTACT Kylea L. Liese kylea3@uic.edu Department of Human Development Nursing Science, University of Illinois
Chicago Chicago IL, USA.
https://doi.org/10.1080/13648470.2021.1938510
ARTICLE HISTORY
Received 15 April 2020
Accepted 1 June 2021
KEYWORDS
Birth; obstetrics;
obstetric violence;
disrespect; and abuse;
obstetricians; midwives;
obstetric iatrogenesis
2 K. L. LIESE ETAL.
Much of the work on ‘obstetric violence’ that documents the most detrimental end of the
UHDVA spectrum has focused on low-to-middle income countries (LMICs) in Latin America
and the Caribbean (see Dixon 2015; Sadler et al. 2016, Castro, Heimburger and Glass 2003,
2019; Williamson, this issue). We show that significant UHDVA also occurs in the high-in-
come U.S. Without a clear operational definition and reporting requirements, the prevalence
of obstetric violence is difficult to estimate. However, one study (Roth et al. 2014) found more
than half of birth workers in the U.S. and Canada, including midwives, doctors, nurses, doulas,
had witnessed the forcible performance of a procedure against a womans will, and two-thirds
had witnessed providers routinely performing procedures without informed consent (Declercq
et al. 2014; Diaz-Tello 2016; Sadler et al. 2016; Vedam et al. 2019). Over social media such as
birthmonopoly.com, women have shared experiences of coercive decision making and vio-
lence, such as unconsented vaginal exams, episiotomies, and cesareans.
Recent literature confirms how the obstetric iatrogenic UHDVA spectrum, which is
syndemically structured into technocratic obstetric systems, is more likely to be perpetrated
upon women who are poor, of color, immigrant, non-English speaking, or otherwise socially
or politically marginalized (Vedam et al. 2019). Higher rates of cesareans, morbidity and
mortality fall disproportionately to BIPOC childbearers, with Black women 3-4 times as
likely as white women to die of pregnancy-related causes (Hoyert 2019). Such inequities
occur regardless of income and education, and are often attributed to implicit and explicit
provider bias and the failure to listen to women (Altman et al. 2020). Although white women
with high social capital are more likely to receive humanistic, patient-centered care (Davis-
Floyd 2001, 2018a), UHDVA cross-cuts racial identities (Vedam et al. 2019).
Obstetrics in the U.S. follows an interventive model wherein pregnancy, labor and birth
are approached as inherently risky processes in need of surveillance, monitoring, and cor-
rection (Davis-Floyd 2001, [1992] 2003, 2018a). From the 1970s on, the hegemonic ‘tech-
nocratic paradigm’ (Davis-Floyd 2001, [1992] 2003, 2018a) that took over labor and birth
also yielded higher risks of maternal morbidity (Plough et al. 2017), and increased the U.S.
cesarean rate by 500% (Shah 2017).2 These shifts also resulted from increased costs asso-
ciated with interventions (the profit incentive), the ‘supervaluation’ of technology in med-
icine (Davis-Floyd [1992] 2003), the relative importance of training medical residents, and,
given higher rates of litigation, increasingly defensive medical practices.
Our paper relies on two sources of data: (1) 62 interviews with American childbearers
conducted and analyzed by Davis-Floyd, Cheyney, and Cheyney’s graduate students between
2016 and 2019; and (2) Lieses, Stewart’s, and Cheyney’s 40-plus years of combined autoeth-
nographic experience as practicing midwives working in multiple regions and settings
across the U.S., including urban/rural hospitals, private/teaching hospitals, birth centers,
and home births. Collectively, these datasets inform our analysis of the continuum of
UHDVA associated with TMTS and TLTL forms of care. In global health, excessive inter-
ventions in labor and birth are captured by the acronym ‘TMTS’ (‘too much too soon’),
while inadequate care is referred to as ‘too little too late’ (TLTL) (Miller et al. 2016).
In general, TLTL obstetric systems are more common in low-resource countries, yet due
to inequality and social, ethnic, and racial stratification, TMTS and TLTL care provision
can, and often do, exist in the same society, including the U.S. (Davis 2018, 2019). Since
TMTS care is more prevalent in U.S. hospitals, our paper explores how TMTS interventions
ANTHROPOLOGY & MEDICINE 3
can constitute obstetric iatrogenesis at individual and systemic levels. In understanding
how U.S. obstetrics perpetuates obstetric iatrogenesis, we seek to contextualize providers
own reasons for engaging in UHDVA practices. While a full analysis of providers’ intentions
is beyond our scope, herein we closely examine a few of the most common examples of,
and reasons for, TMTS-linked obstetric iatrogenesis during labor and birth.
In order to eliminate the kinds of obstetric iatrogenesis that disrupt the normal physi-
ology of birth, and cause physical and psychological harm, we call for approaches that
help—such as continuous labor support with a culturally matched doula (see Oparah et al.
2021; Rivera 2021). In this way, TMTS and TLTL can be replaced with care that offers the
‘right amount at the right time in the right way’ (RARTRW) (Cheyney and Davis-Floyd
2020a, 2020b)—where the ‘right way’ refers to care that is not only ‘right-sized, but also
culturally safe and respectful (Cheyney and Davis-Floyd 2020a, 2020b; Tuncalp et al. 2015;
Cheyney and Peters 2019). Highly technical and intervention-oriented births that can save
lives can also center birthing persons’ rights and respect their autonomy.
The spectrum of obstetric iatrogenesis
The UHDVA obstetric iatrogenic spectrum begins with the routine performance of TMTS,
non-evidenced based procedures not intended to cause harm, yet do. These interfere with
the normal physiology of birth, constituting what Cheyney and Davis-Floyd (2019, 8) have
called the obstetric paradox—intervene in birth to make it safer, and yet, causing harm.
These ‘standard of care procedures’ are confirmed by thousands of hospital births witnessed
by all four authors, and by a vast medical (see Thacker et al. 2001; Declerq 2013; Declerq
et al. 2014; Miller et al. 2016; Mullins, Lees, and Brocklehurst 2017) and social science (see
Castro and Glass 2003; Davis-Floyd [1992] 2003, 2018a, 2018b; Davis 2018, 2019; Cheyney
and Davis-Floyd 2020a, 2020b) literature. They include, among others: artificial rupture of
membranes to speed labor, thereby introducing an avenue for infection; denying laboring
people food, resulting in maternal weakness; performing unnecessary, cervical exams to
assess dilation; unnecessarily inducing or augmenting labor; and utilizing continuous elec-
tronic fetal monitoring (EFM), which inhibits freedom of movement, and thus, fetal descent.
Standard procedures also include coached pushing (as in ‘push, push!’) instead of allow-
ing the laborer to follow the physiologic urge to push; birthing in a supine or semi-sitting
position that compresses the pelvic outlet, making birth more difficult; and cesarean deliv-
ery, which carries multiple harms and risks, especially when overused. (In the U.S., the
national cesarean rate is around 32% [Martin et al. 2019] when, according to WHO, it
should not exceed 10-15% [Betran et al. 2015; WHO Statement and ranges from 6–69%
(Kozhimannil, Law and Virnig 2013) on caesarean section rates 2015].) While UHDVA
includes subtle forms of coercion, such as coaxing a laboring person to have an epidural
against their intention (May 2017), all authors have also witnessed more intentional forms
of harm, such as verbal condescension, demeaning, insulting and yelling, as well as rough
and unconsented vaginal exams and unnecessary episiotomies. We place the physiologic
damage such interventions cause at the ‘unintentional harm’ end of the spectrum, where
they are largely invisible as iatrogenesis because they are grounded in the normative practice
standards for U.S. hospital-based obstetric care (Declercq et al. 2007; Diaz-Tello 2016).
4 K. L. LIESE ETAL.
Protocols and universal management plans: generating iatrogenesis
Rigid technocratic protocols that establish universal care plans for all laboring people are
highly valued as tools to streamline management across various providers, guide the teach-
ing of residents, and protect institutions in case of adverse outcomes. Many of these protocols
are refuted by medical evidence or professional organization recommendations, yet are
established to limit institutional and individual provider liability. For example, against the
American College of Obstetricians and Gynecologists’ recommendations (American College
of Obstetricians and Gynecologists 2017), and despite patients’ preferences and evidence
of the risks of repeated cesareans, in 2018 only 13.3% of women gave birth vaginally after
a previous cesarean (VBAC) (Osterman 2020). Obstetricians’ concerns over liability have
had ‘a major impact on the willingness of physicians and healthcare institutions to offer
trial of labor [after cesarean]’ (National Institutes of Health Consensus Development 2010).
There are also bureaucratic barriers to VBAC embedded in hospital policies and protocols,
and include use of a ‘VBAC calculator’, which estimates a patient’s likelihood of ‘success’ or
‘failure’ (Thornton et al. 2020). The calculator has well-documented limitations. It inaccu-
rately predicts the likelihood of a repeat cesarean and deducts points if a pregnant mother
identifies as Black or Latinx (Harris et al. 2019), reflecting how institutional racism and
implicit bias impact the quantification and delivery of maternity care.
Other non-evidence based protocols limit how long a patient is ‘allowed’ to remain in a
stage of labor before interventions such as amniotomy (breaking of the bag of waters) or
initiation of Pitocin labor augmentation—interventions designed to speed labor—are
enacted (Fraser et al. 2000). Patients are usually unaware of such protocols and their lim-
itations. The standard of care in all hospitals where Liese and Stewart practice exclude
patients from key decision-making processes. Providers confer about treatment plans and
protocols remotely with protocols and colleagues, then enter the patient’s room with a plan
in place. The goal of ‘patient communication’ is to provide an illusion of shared decision
making while establishing consent for the predetermined plan. Burcher et al. (2016) simi-
larly found that pregnant people experience communication around interventions as
unidirectional—physicians explain the need for a procedure and the expected response
from the patient is simply consent to proceed. Asking questions or expressing hesitancy
can be interpreted as challenges to medical authority and can result in provider frustration
being projected back onto the patient (Cheyney, Everson, and Burcher 2014).
In one such form of routine but subtle coercion, a provider decides the laboring person
should be administered Pitocin to speed labor but agrees to ‘allow’ the reluctant patient to go
for a walk, so long as she agrees to start Pitocin if her cervix hasn’t dilated sufficiently in an
hour (see Declerq 2013). The provider knows that one hour of walking is unlikely to produce
significant cervical change; the intent is to make the patient believe that she was given options.
The routine language of ‘allowing’ or ‘not allowing’ basic facets of patient autonomy, including
eating, walking, and going to the bathroom at will, establishes a context of control.
In what follows, we focus on six primary practices of obstetric iatrogenesis that fall along
the UHDVA spectrum: (1) cervical exams and medical education; (2) fetal monitoring and
liability; (3) birth position and the centering of the provider; (4) verbal threats and the
narrative of mother-blame; (5) informed consent (or the lack thereof); and (6) obstetric
racism and racial disparities. It merits note that providers and patients often share the notion
that the interventions we describe—whether medically warranted or not—constitute ‘good
ANTHROPOLOGY & MEDICINE 5
care. These deeply held cultural beliefs about the efficacy of biomedical interventions render
much obstetric iatrogenesis invisible, helping to explain why many women are inclined
to comply.
Cervical exams and medical education
The majority of births U.S. births (69%) take place in teaching hospitals that train resident
physicians (Fingar et al. 2018). Thus, much of the obstetric system is organized to facilitate
physician education. Since cervical exams are a learned manual skill crucial to obstetrics,
medical students and residents are encouraged to practice on patients (Goldberg 2020).3
Cervical exams, which should be performed only when knowing the cervical dilation can
impact care, such as before administering medications or at the patient’s request—range
from uncomfortable to excruciating (Declerq 2013). The pain is exacerbated when
performed during contractions and/or on women with histories of sexual abuse; some
people experience or equate them to a form of rape (see Kitzinger 2006 and below). The
practice moves from unnecessary to aggressive when exams are performed without provider
introduction, consent, explanation or heeding a patients direct instruction to stop. Those
who try to push the provider’s hand away or say ‘STOP!’ may be responded to in ways
disturbingly akin to the language used by rape perpetrators: ‘You’re okay’ and ‘I’m
almost done.
Although patients may be aware that they are giving birth at a teaching hospital, both
Liese and Stewart routinely observe laboring people are not informed of the residents
relative (in)experience in performing procedures or that more experienced physicians are
available. However, the medical education system encourages residents to learn procedures
by ‘see one, do one, teach one, which does not account for medical necessity, patient auton-
omy or patient comfort.
Surveillance and liability: the electronic fetal monitor
The electronic fetal monitor (EFM) records the fetal heart rate (FHR) and contraction
patterns, and has been shown to increase cesarean rates births without reducing neonatal
or maternal mortality (Devane et al. 2010; Alfirevic, Devane, and Gyte 2013; Alfirevic et al.
2017). It shows every single fetal heart rate deceleration, most of which are normal, yet may
be interpreted as fetal distress, leading to an ‘emergency’ cesarean. Despite an estimated
99.9% false positive rate for fetal distress as a primary indication for cesarean (Devane et al.
2010; Alfirevic, Devane, and Gyte 2013; Alfirevic et al. 2017), and even though FHR tracings
hold no clear predictive value (American College of Obstetricians and Gynecologists 2010,
Nagoette 2015), nearly 90% of U.S. births are electronically monitored for at least some time
during labor, and often continuously (Declercq et al. 2014). Alternatively, intermittent
auscultation of the fetal heartbeat via a fetoscope or Doppler at regular intervals provides
more useful information in low-risk pregnancies than the EFM (Vintzileos et al. 1995;
Sholapurkar 2010; Blix et al. 2019)—but requires more hands-on care.
Despite the overwhelming body of evidence against the routine use of EFM, EFM data
are supervalued in US obstetrics because they represent ‘objective’ information on the baby’s
condition while enacting cultural values on information gained from the use of high
6 K. L. LIESE ETAL.
technologies (Davis-Floyd 2001, [1992] 2003, 2018a). Additionally, they allow several
patients to be tracked remotely by one practitioner, reducing patient/provider ratios and
limiting patient/practitioner interaction. Perhaps most importantly, EFM tracings serve as
evidence in litigation. Thus, providers have strong motivation to intervene when something
potentially concerning is recorded by the monitor, lest their lack of response be called into
question later.
Lying down for birth, centering the provider
A reclining position compresses the pelvic outlet by one-third and makes it harder to push
(Reid and Harris 1988; Deliktas and Kukulu 2018), yet this position is routinely used in the
U.S. Obstetric beds are designed so that the bottom of the bed ‘breaks’ or detaches, placing
the birthing person on her back with her legs up in stirrups, unable to change positions,
with the provider at her perineum. ‘Breaking the bed’ conflicts with evidence in favor of
upright positions for birth, including the hands-and-knees position, which opens the pelvic
outlet to its maximum capacity (see Walker et al. 2012; Gupta et al. 2017; Moraloglu et al.
2017; Berta et al. 2019). ‘Breaking the bed’ is primarily for the physician’s comfort, conve-
nience and status—the doctor is able to sit upright between the birthing persons knees,
while the birthing person is lying down in a position of vulnerability (Davis-Floyd [1992]
2003). Upright positions and keeping the bed intact reverse polarities, as the provider must
accommodate to the lower position, often sitting at an angle on the bottom of the bed or
kneeling on the floor, giving central stage to the laboring person. Even laborers with epi-
durals can deliver in upright positions. Yet the option of adopting such positions is rarely
explained or offered. The aforementioned invasive procedures force the endogenous phys-
iologic processes of labor to submit to the control of exogenous practices that are convenient
for practitioners, yet de-center the birthing person and interfere with normal physiologic
birth (see Alfirevic, Kelly, and Dowswell 2009; Devane et al. 2010; Alfirevic et al. 2017;
Anim-Somuah et al. 2018; Berta et al. 2019).
Verbal threats and mother blame
In our experiences, the language used by physicians to convince/coerce consent from
patients ranges from subtly to overtly abusive, with BIPOC and gender non-binary child-
bearers being especially affected. Verbal threats occur most often when interventions or
outcomes are posed as ‘inevitable. Most egregiously, pregnant mothers can be threatened
with endangering the lives of their unborn children if they do not accept the doctor’s
advice. This tactic is observed in both in emergency and non-emergency situations, and
pits the mother against her unborn baby, supporting a narrative of ‘good’ motherhood in
which the mother’s needs are subservient to the child’s (see note 2). And despite evidence
that vaginal breech birth can be safe when attended by skilled practitioners (see Daviss
and Bisits 2021), such pregnancies are considered medically high-risk, and women are
often told that attempting a vaginal birth risks their child’s life. Because today’s obstetricians
and residents have little experience with vaginal breech delivery techniques, which con-
stitute a special skillset, U.S. mothers with breech pregnancies often have no option besides
a cesarean birth.
ANTHROPOLOGY & MEDICINE 7
On several occasions in urban teaching hospitals, Liese and Stewart have had to transfer
to obstetric providers patients who have been pushing for two hours, where they were told
‘the baby can’t fit’—or that continued pushing will increase the risk of fetal death—to encour-
age consent for a cesarean. In one case, Liese witnessed a physician telling a mother, who
was struggling to move from a gurney across to the operating table during a contraction,
that if she didn’t hurry up and move, her baby would die and it would be her fault. In this
scenario, the provider may be concerned about the baby dying before the cesarean can be
performed, as well as about the risk of lawsuit if the baby dies—given that obstetrics is the
most litigated medical specialty in the U.S. In these lawsuits, the amount of time from
decision to incision’ is used as evidence of whether the provider reacted quickly enough in
proceeding to a cesarean. Neither of these explanations helped the mother to move more
quickly during the throes of a contraction, nor do they excuse the verbal abuse. Should the
baby be born with any complications, the physician’s threat may be internalized by the
mother as evidence that she was responsible for harming her baby.
Women who resist providers’ threats can face significant consequences. Cate (a pseud-
onym), a white, heterosexual, cis-gendered middle-class woman, described how:
About six days past my due date, my water broke, and when I went into the hospital, I was only
a fingertip dilated and my doctor was not on call—the other doctor came in and checked
me—he didn’t tell me his name—and he turned to the nurse and said, “Prep her, we’re going
to cut it out.” I said, “Hold it, hold it—you’re not doing anything until you tell me what is going
on here.” He said, “You’re not dilating, you need a C-section.” I said, “That will be fine as long
as you can write down a medical reason why I need a section.
Knowing that, according to that hospital’s protocols, she had 24 hours to deliver after
her waters had broken, Cate ‘laid there all day’ with the doctor repeatedly coming in to
demand that she have a cesarean ‘because you need one. Just as repeatedly, Cates response
was the same. Once her labor picked up, she had the support of helpful nurses—who kept
saying ‘You’re doing fine, the baby’s fine, everything’s fine’—and her Lamaze teacher Fran,
and enjoyed her labor process when the obstetrician wasn’t present. She said, ‘As long as I
knew everything was fine, I could last forever’. But:
[The obstetrician] was very nasty. He would come in, send my husband out, check me, yell at
me because I wasn’t doing what he told me to do. He made my husband sign a paper saying
that we would take full responsibility for the death of my child. “You know,” he said, “you’re
killing this baby because you won’t have a section.” I said, “I’ll have one if you tell me why.” He
said, “Just because I say you need one,” and I said, “That’s not good enough.
…when she was born [at 5:36 am], he cut a radical [unnecessarily large] episiotomy when her
head was only 13 inches…and he didn’t even say, “It’s a girl or it’s a boy, it’s a dog, it’s a cat”
And he stitched me up with nothing. I kept telling him I could feel everything he was doing,
and he kept saying “No you can’t feel that, you’re crazy.” I knew he did it just for spite. It was
very enjoyable when he wasn’t there, but he would come in and check me during a contraction
and scare me to death…as soon as he would leave the room, my body would involuntarily
tremble all over.
Cates story illustrates many forms of UHDVA, including laboring in the supine position,
verbal coercion and abuse, and physical violence via the unnecessary extensive episiotomy
and stitching without local anesthetic (Kozhimannil et al. 2017) (see note 3). Cate stated
8 K. L. LIESE ETAL.
that she was empowered to achieve a vaginal birth despite that doctor’s demands because
Fran was at her side, squeezing her hand while the doctor yelled at her, and her nurses were
kind and supportive. Her positionality and social capital likely also facilitated her ability to
resist. The psychological cost to childbearers of overt DVA is high (Grekin and O’Hara 2014;
Yildiz, Ayers, and Phillips 2017; Beck and Casavant 2019). Our data confirms that the more
overt forms of DVA on our spectrum are not wanted by any childbearers, Interlocutors who
had been subjected to such forms of DVA described themselves as traumatized by their
birth experiences. Like Cate, many suffered from postpartum depression and/or PTSD.
Intentionality and informed consent
Violence and injury resulting from obstetric iatrogenesis are grounded in attempts to treat
or manage a patient. The intent driving providers’ treatment and management practices,
and their knowledge (or lack thereof) of the harms that may result, are therefore of central
importance. More ethnographic work is needed to understand provider intentionality and
subjectivity in relation to UHDVA (see Castro 2019; Castro and Savage 2019). When Liese
was in her first year of independent practice, a patient presented to the obstetric triage unit
bearing down. While assessing the patient to be completely dilated, Liese palpated the bag
of waters. Without removing her hand and without thinking it through, she maneuvered
her fingers to release the waters, which released the fetal head into the vagina; the baby was
born almost immediately. Because patient consent was neither requested nor received, this
was an act of UHDVA. Liese’s intent was benign; she had assumed that removing her hand,
offering this option, and, if the woman consented, reinserting her fingers, would be ‘worse’
for the woman. She did not intend to cause harm, yet took away the woman’s right to be
informed and give consent. Iatrogenic actions that disregard patient autonomy in the name
of urgency must be questioned. When providers insist they were unable to take the time to
obtain consent because ‘the baby was crashing’, we should ask how much time it takes to
inform a patient of what is happening, and request consent.
Obstetric racism, disparities, and DVA
The intentional DVA that we describe, and have witnessed and participated in, is deeply
embedded in racial and socio-economic structures disproportionately impacting BIPOC
pregnant people. Syndemic (systematic and endemic) racial discrimination has long pro-
duced worse maternity and health outcomes overall for pregnant people of color and other
minoritized groups (see Bridges 2011; Cooper Owens 2017). Intersectional identities mark
certain pregnancies as ‘high-risk’, leading to increased rates of intervention, harmful treat-
ment, and poor outcomes (Dressler, Oths, and Gravlee 2005; Philibert, Deneux-Tharaux,
and Bouvier-Colle 2008; Viruell-Fuentes, Miranda, and Abdulrahim 2012; Creanga et al.
2015). For example, higher rates of adverse perinatal outcomes among BIPOC patients
are rooted in structural and ‘obstetric racism’, which Davis defines as the convergence of
obstetric violence and medical racism (2018, 2019, 2020). Black women suffer the highest
rates of maternal morbidity and mortality, premature birth, and low-birth weight new-
borns. These outcomes are intricately tied to the wear and tear of chronic stress (e.g.
allostatic load) associated with racism and sexism (Rich-Edwards et al. 2001; Giurgescu
ANTHROPOLOGY & MEDICINE 9
et al. 2011) including birthing people’s experiences of racist violence (Bridges 2011; Cooper
Owens 2017).
Most of the Black interlocutors in Davis-Floyd and Cheyney’s dataset experienced some
form of racial discrimination in their hospitals, which was compounded if they were over-
weight and/or on Medicaid, as Shawna Lee (a pseudonym), demonstrates:
When I first got to the hospital, security wouldn’t let me upstairs because he thought I was
there to steal a baby. He kept asking me why are you here—are you really pregnant? Because,
since I was already overweight, the pregnancy didn’t really show. And I said “Yes, I promise I
am pregnant [and in premature labor] right now.” The OB on call was a little Hispanic lady
and she was really nasty to me …. [She] said “We are going to drug test you because usually
that is what causes preterm labor.” I was like well that was really nasty—is she saying that
because I am Black and I am young?
Shawna continued, ‘I feel like there was a lot of preconceived notions and bias as soon
as I walked in the door … So, it was just very frustrating, and I felt like no one was listen-
ing to me.
The COVID-19 pandemic has served to dramatically exacerbate maternal health dis-
parities in the U.S. (Obinna 2021; Santos et al. 2020; Cunningham et al. 2021). With BIPOC
disproportionately impacted by COVID, it follows that the restrictions imposed on COVID-
19 positive mothers disproportionately impact BIPOC people. Against the American
Academy of Pediatrics’ evidence-based recommendations, many hospitals prohibit support
people for COVID + laborers, with the effect that the women most vulnerable to overt forms
of DVA were made more so by their institutional isolation and lack of a witness or advocate
during labor (Castañeda and Searcy 2021; Claudio et al. 2020; Profit et al. 2020; Davis-Floyd,
Gutschow, and Schwartz 2020). Hospitals also separated COVID + mothers from their new-
borns at birth, and prevented contact until discharge (Gutschow and Davis-Floyd 2021;
Oparah et al. 2021; Rivera 2021). This disruption in bonding and breastfeeding not only
defies medical logic, since the baby is discharged to the mother 48 hours after birth, but
reinforces a cycle of syndemic racism underlying health disparities.
Conclusion: obstetrics’ shadowside
For this collection on medicines ‘shadowside’, we illustrate the shadowside of U.S. obstetrics.
Galtung (1990, 291) spoke of structural violence as forms of violence embedded in a social
structure that perpetuate inequity, thereby causing preventable suffering, and noted that ‘a
violent structure leaves marks not only on the human body but also on the mind and the
spirit’ (1990, 294). Certainly, on our obstetric iatrogenic spectrum, the more overt forms
of DVA leave such marks, ranging from physical to emotional and psychological scars. Here
we reiterate that along the entirety of the UHDVA spectrum, the performance of unnecessary,
non-evidence-based procedures, and most especially unnecessary cesareans (unless they are a
pregnant persons choice), constitutes obstetric violence and iatrogenesis and exemplifies the
obstetric paradox—causing harm by intervening in birth, supposedly to keep it safe.
According to our data, the most common forms of obstetric iatrogenesis in the U.S. are
the invisible ones of non-evidence-based routine procedures experienced by all birthing
people. By ‘invisible, we mean that they may not be perceived as iatrogenic by most of those
who perform and receive them. Due to technocratic norms, to supervaluation of high
10 K. L. LIESE ETAL.
technologies such as EFM, and to the common belief that such interventions do make birth
safer, the majority of Davis-Floyd and Cheyney’s 62 interlocutors reported relative satisfac-
tion with their births. Such findings reiterate how TMTS routine procedures make cultural,
not scientific, sense.
The hegemonic nature of U.S. obstetric care and the structural nature of obstetric
racism discourage pregnant people from questioning providers and normalize interven-
tions as necessary components of safe birth. This additional paradox of patient satisfaction
amidst unnecessary and harmful procedures is a significant obstacle to addressing obstet-
ric iatrogenesis in a profit-driven capitalist health care system that benefits from inter-
ventions and only responds to financial threats from dissatisfied patients. Importantly,
the highest levels of birth satisfaction were expressed by those who had doulas and mid-
wives supporting them, demonstrating the positive effects of labor companionship and
midwifery care.
It will take an epic paradigm shift to ensure that the care all laboring people supports
the normal physiology of birth and women’s emotional and psychological needs. UHDVA
and obstetric racism especially re-confirm the absolute need for RARTRW care—the right
amount at the right time and in the right way (Cheyney and Davis-Floyd 2020a), where the
‘right way’ refers to care that explicitly respects the rights and dignity of all birthing people
(Cheyney and Davis-Floyd 2020a; Cheyney and Peters 2019). Racism underlies BIPOC
pregnant people’s vulnerability to UHDVA and also helps to explain health systems’ failures
to enact necessary reforms. An important first step to address the interpersonal structural
racism underlying UHDVA is to center the voices of BIPOC clients as experts on their own
experiences (see Altman et al. 2020). Innovative interdisciplinary studies to measure and
describe experiences of obstetric racism open more possibilities to address the issue (Scott,
Britton, and McLemore 2019). Facilitating concordant care with providers of color has been
well documented as a strategy for facilitating respectful care for BIPOC patients (Abbyad
and Robertson 2011; Altman et al. 2020).
Tenable strategies to mitigate iatrogenesis also include increasing access to midwifery
care and doula support/advocacy and to gender-inclusive care for all pregnant people.
Although obstetric iatrogenesis is perpetuated by providers of all kinds, the care provided
by midwives and doulas is generally grounded in minimizing interventions and supporting
physiologic birth (International Confederation of Midwives 2005; ten Hoope-Bender et al.
2014; ICM, WHO, and WRA 2016; Davis-Floyd 2018c). However, only 10.2% of U.S. births
are attended by midwives—including certified nurse-midwives (CNMs), certified midwives
(CMs), and certified professional midwives (CPMs) (Martin et al. 2019).
We conclude by suggesting that obstetric care providers be made aware during their
education of what constitutes the full spectrum of UHDVA and of obstetric racism and of
how to avoid perpetuating them. Provider awareness of implicit bias in clinical care—the
practices and the structures that perpetuate UHDVA—is key; if you do not recognize a
phenomenon, you cannot address it. Providers should be actively enlisted to help dismantle
structures that facilitate UHDVA, such as rigid protocols and prioritizing teaching and
technology over patient experience. The evidence-based protocols and individualized,
patient-centered care prioritized by diverse midwives and doulas are two strategies for
limiting UHDVA, even in the litigious context of U.S. obstetrics. The obstetric iatrogenic
spectrum, from unintentional harm to overt disrespect, discrimination, violence, and abuse,
will have no role in a fully humanized U.S. maternity care system in which all care is
ANTHROPOLOGY & MEDICINE 11
compassionate, fully explained, and responsive to pregnant peoples wishes, voices, and
desires—even during pandemics.
Notes
1. Transgender and gender non-binary people have reproductive health needs and experiences
that can be similar to, but also unique from, those of cisgender women. To reflect this inclu-
sivity, we employ a mix of words: “women,” “people,” “persons,” “childbearers,” and “mothers”.
2. The technocratic model is also associated with substantially higher costs (e.g., $12,516 for an
uncomplicated vaginal birth in the U.S. and between $14,099 and $28,617 for a cesarean
birth, depending on the state [Childbirth Connection 2013]), and worse outcomes. Studies
have suggested that, if only 10% more U.S. births took place in homes and freestanding birth
centers, nearly $11 billion could be saved annually (Daviss, Anderson, and Johnson 2021).
3. There are no documented data on how many cervical exams have been performed without
consent, but one survey found that a majority of medical students had performed such exams
on unconscious patients, and in nearly 3 of 4 instances, they believed that informed consent
had not been obtained. These examples of iatrogenesis highlight how technocratic birth and
the educational interests of residents often supercede the autonomy of the laboring person.
Ethical approval
All procedures followed were in accordance with the ethical standards of the responsible committee
on human experimentation (institutional and national) and with the Helsinki Declaration of 1975,
as revised in 2000. Informed consent was obtained from all patients for being included in the study.
The study was approved by the Oregon State University IRB protocol #6645.
Acknowledgments
We thank Ashish Premkumar, Elizabeth Nalepa, and our editors and anonymous reviewers for their
helpful edits and comments on this paper. We also thank Maria Dana, Emily Garcia, Victoria Keenan
and Susanna Snyder for their help.
Disclosure statement
We confirm the authors have no financial or personal relationships that might bias the work being
submitted.
ORCID
Melissa Cheyney http://orcid.org/0000-0001-5672-3353
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... One is a qualitative interview study that examined how obstetric gaslighting worked to deny and destabilise mothers' realities about their negative birth experiences and showed how obstetric gaslighting works as an under-recognised mechanism of obstetric violence. 45 The second study, by Liese and colleagues, 50 determined that the performance of unnecessary, non-evidence-based proceduresespecially unnecessary caesareansconstitutes obstetric violence and iatrogenesis. The third study examined the association between statelevel structural sexism and low-risk caesareans across the United States and found that women living in states with higher structural sexism scores were more likely to have a caesarean. ...
... The term combines the classic understanding of iatrogenesis as injury or harm caused by the clinician in the course of providing medical care together with the specificity of the problem in obstetric care, where obstetric iatrogenesis was examined along a spectrum ranging from unintentional harm to overt disrespect, violence, and abuse. 50 An overarching reason for gaps in the research on obstetric violence is that publications that use alternative terminology do not claim the concept of obstetric violence as a distinct topic of inquiry or a related finding. For example, The Giving Voice to Mothers -US Study is important for advancing the understanding of obstetric violence and inequity in US maternity care because the mistreatment examined is representative of obstetric violence. ...
... 24,36,37 For example, in a high-income country like the United States obstetric violence is often an unintended consequence of the normalisation of a depersonalised, hyper-medicalised, technocratic model of care. 28,45,50,60,62 Explicit violence in the maternity care systems of most high-income countries is less common compared to obstetric violence in middle-and low-income countries where obstetric violence can be seen more overtly in the forms of hitting, pinching, cursing, profound humiliation, and sometimes avoidable death. 30,36 The defining attributes of obstetric violence do not change, but the particularities of how it is produced, perceived, and experienced can vary across different settings and with different clinicians. ...
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Obstetric violence has been documented throughout the world, yet this human rights issue has mostly been investigated in middle- and low-income countries where the intensity and brutality of abuse and mistreatment is more easily recognised as problematic. This integrative review aimed to analyse sources about obstetric violence in high-income countries with the objective of identifying gaps in the research, challenges to the study of obstetric violence, and solutions to framing research that meets those challenges. A systematic search was conducted using the PubMed and CINAHL databases from February to June 2022. Empirical and non-empirical sources, published in English, with no date restrictions, were retrieved. Citation searching was also done. Forty-six sources were included. Identified gaps in the research were: (a) scarce attention to obstetric violence in most high-income countries; (b) most US sources are non-scientific and from outside the healthcare disciplines; (c) inconsistencies in terminology; (d) most studies were conducted with samples of women who had given birth, with scant research about healthcare providers and obstetric violence, and (e) the association between obstetric violence and traumatic birth was under-recognised. Identified challenges to the study of obstetric violence were: (1) factors that enable and perpetuate obstetric violence are multilevel and nonlinear; (2) the phenomenon is contextually complex; and (3) blind spots from routinised harmful practices and normalised mistreatment can prevent healthcare providers and birthing people from recognising obstetric violence. A systems approach and complexity theory are guiding frameworks recommended as solutions to the challenges of studying and correcting obstetric violence.
... In the US context, where mental health conditions and lack of care access contribute highly to mortality, understanding D&A is necessary to improve maternal health. However, studies in the US are limited [18][19][20]. One in six US birthing persons report being mistreated, with higher rates of mistreatment reported by younger patients, those with higher-risk pregnancies, and by Black, Indigenous, and people of color [20]. ...
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Background/Objectives: Disrespectful care during childbirth has been observed as a global issue and a factor influencing maternal morbidity and mortality. While the United States has experienced worsening rates of maternal mortality, perceptions of respectful maternity care have been understudied. Methods A cross-sectional study was conducted Boston from April 2023 to January 2024 among 46 labor and delivery physicians, midwives, and nurses at Massachusetts General Hospital. The survey evaluated their observation of disrespectful care, performance of respectful care, and stress and support factors influencing respectfulness of care. Results: The most reported observed disrespectful behaviors were dismissing patients’ pain (87.0%), discriminatory care based on physical characteristics (67.4%) and race (65.2%), and uncomfortable vaginal examinations (65.2%). Respondents self-reported very high levels of respectful maternity care performance. Reported barriers to respectful care included workload (76.1%) and fatigue (60.9%). Conclusions: Disrespectful care in childbirth is an issue reported by health care providers. Implicit bias and working conditions of health care providers are factors in disrespectful care. This information can be used to strategize future training and other areas of intervention to improve maternity care.
... In the US context, where mental health conditions and lack of care access significantly contribute highly to mortality rates, understanding D&A is necessary to improve maternal health. However, studies in the US are limited [21][22][23][24]. A nationwide study of US birthing persons found that approximately one in six respondents reported being mistreated, with higher rates of mistreatment reported by younger people, those with higher-risk pregnancies, and by Black, Indigenous, and people of color [23]. ...
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Background/Objectives: Disrespectful care of birthing persons during childbirth has been observed as a global issue and a possible factor influencing maternal morbidity and mortality. While birthing persons’ experiences of mistreatment in childbirth have been examined, perceptions from obstetrical providers of respectful maternity care have been understudied. Methods: A mixed-method cross-sectional study was conducted in Boston from April 2023 to January 2024 among 46 labor and delivery physicians, midwives, and nurses at Massachusetts General Hospital. The survey evaluated their observation of disrespectful care, the performance of respectful care, and stress and support factors influencing respectfulness of care. Results: The most reported observed disrespectful behaviors were dismissing patients’ pain (87.0%), discriminatory care based on physical characteristics (67.4%) and race (65.2%), and uncomfortable vaginal examinations (65.2%). Respondents self-reported very high levels of respectful maternity care performance. Reported barriers to respectful care included workload (76.1%) and fatigue (60.9%). Conclusions: Disrespectful care in childbirth is an issue reported by healthcare providers. Implicit bias and the working conditions of health care providers are factors in disrespectful care. This information can be used to strategize future training and other areas of intervention to improve maternity care.
... This is particularly true given that non-patient-centered and paternalistic care are well documented to occur during perinatal care, particularly for those with minoritized racial/ ethnic identities. (Akinade et al., 2023;Altman et al., 2020;Bohren et al., 2022;Hamed et al., 2022;Hemphill et al., 2023;Liese et al., 2021;Logan et al., 2022;Thompson et al., 2022). Exploring the literature about perinatal contraceptive counseling applying a person-centered and reproductive justice-aligned lens can inform future work to ensure that pregnant people and those who have recently given birth are supported in their reproductive decision making. ...
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Introduction Contraceptive counseling during the perinatal period is an important component of comprehensive perinatal care. We synthesized research about contraceptive counseling during the perinatal period, which has not previously been systematically compiled. Methods We developed search criteria to identify articles listed in PubMed, Embase, and Popline databases published between 1992 and July 2022 that address patients’ preferences for, and experiences of, perinatal contraceptive counseling, as well as health outcomes associated with this counseling. Search results were independently reviewed by multiple reviewers to assess relevance for the present review. Methods were conducted in accordance with PRISMA guidelines. Results Thirty-four articles were included in the final full text review. Of the included articles, 10 included implementation and evaluation of a contraceptive counseling method or protocol, and 24 evaluated preferences for or experiences of existing contraceptive counseling in the perinatal period. Common themes included the acceptability of contraceptive counseling in the peripartum and postpartum periods, and a preference for contraceptive counseling at some point during the antenatal period and before the inpatient hospital experience, and direct provider-patient discussion instead of video or written material. Multiple studies suggest that timing, content, and modality should be individualized. In general, avoiding actual or perceived directiveness and providing multi-modal counseling that includes both written educational materials and patient-provider conversations was desired. Discussion The perinatal period constitutes a critical opportunity to provide contraceptive counseling that can support pregnant and postpartum people’s management of their reproductive futures. The reviewed studies highlight the importance of patient-centered approach to providing this care, including flexibility of timing, content, and modality to accommodate individual preferences.
... 8 The literature reveals several categories of obstetric violence that vary on individual and systemic levels. 9 This includes verbal and physical abuse, coercion and/or lies, the appropriation or medicalization of natural processes, patient neglect, discrimination, and lack of informed consent. 10 The term is often misconceived as intentional harm by health care providers, but it encompasses a broader scope, including systemic issues, disrespectful treatment, and neglect. ...
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Introduction In the United States, 1 in 6 women reports obstetric violence in the form of physical and verbal abuse, coercion, and lack of informed consent. Despite recommendations against routine episiotomy, its use in the United States remains notable and varies considerably. This study aimed to analyze the various forms of obstetric violence associated with undergoing an episiotomy and having a choice in undergoing an episiotomy. Methods Data from the cross‐sectional Listening to Mothers in California survey were analyzed using weighted sample. Logistic regression models were conducted to compute adjusted odds ratios (aORs) and 95% CIs for undergoing episiotomy and having a choice in it. Results Overall, 21% of the respondents reported undergoing an episiotomy, and 75% of them reported not having a choice in undergoing this procedure. After adjusting for covariates, feeling pressured to induce labor (aOR, 1.31; 95% CI, 1.28‐1.35) and to use an epidural analgesia (aOR, 1.82; 95% CI, 1.77‐1.88) increased the odds of undergoing an episiotomy. Having a midwife during childbirth significantly reduced the odds of an episiotomy. Respondents who indicated being handled roughly by health care providers were 95% less likely to have a choice in receiving an episiotomy (aOR, 0.05; 95% CI, 0.04‐0.06). Discussion This is the first study to examine other forms of obstetric violence as correlates of episiotomy and having a choice in it. Standardized institutional measures against obstetric violence, patients’ ability to make autonomous decisions through informed consent, and engaging midwives could decrease medically unnecessary labor procedures and associated complications.
... Many of the exposures we evaluated had a significant association with PMADs, and are directly related to the role and behaviors of the personnel on the maternity care team (i.e., mistreatment, obstetric violence, birth experience, support of maternity care team, presence of a birth companion). We postulate that the very process of receiving care for pregnancy and birth may be iatrogenically contributing [146,147] to inequities in maternal mental health, especially for marginalized women and birthing people who report more negative care experiences and mistreatment and higher rates of PMADs. ...
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Background: Mental health disorders are the number one cause of maternal mortality and a significant maternal morbidity. This scoping review sought to understand the associations between social context and experiences during pregnancy and birth, biological indicators of stress and weathering, and perinatal mood and anxiety disorders (PMADs). Methods: A scoping review was performed using PRISMA-ScR guidance and JBI scoping review methodology. The search was conducted in OVID Medline and Embase. Results: This review identified 74 eligible English-language peer-reviewed original research articles. A majority of studies reported significant associations between social context, negative and stressful experiences in the prenatal period, and a higher incidence of diagnosis and symptoms of PMADs. Included studies reported significant associations between postpartum depression and prenatal stressors (n = 17), socioeconomic disadvantage (n = 14), negative birth experiences (n = 9), obstetric violence (n = 3), and mistreatment by maternity care providers (n = 3). Birth-related post-traumatic stress disorder (PTSD) was positively associated with negative birth experiences (n = 11), obstetric violence (n = 1), mistreatment by the maternity care team (n = 1), socioeconomic disadvantage (n = 2), and prenatal stress (n = 1); and inverse association with supportiveness of the maternity care team (n = 5) and presence of a birth companion or doula (n = 4). Postpartum anxiety was significantly associated with negative birth experiences (n = 2) and prenatal stress (n = 3). Findings related to associations between biomarkers of stress and weathering, perinatal exposures, and PMADs (n = 14) had mixed significance. Conclusions: Postpartum mental health outcomes are linked with the prenatal social context and interactions with the maternity care team during pregnancy and birth. Respectful maternity care has the potential to reduce adverse postpartum mental health outcomes, especially for persons affected by systemic oppression.
... While women form all backgrounds experience obstetric violence, research shows that the form it takes typically differs according to income, class, and race: Well-off, white, middle-class woman are often subject to many unnecessary medical interventions ("too much too soon"), while socioeconomically disadvantaged, marginalized, minority women or Women of Colour suffer typically in the form of "too little too late" [54]. Liese et al. [55] have shown that obstetric iatrogenesis disproportionately impacts Black, Indigenous, and People of Color, resulting in worse perinatal outcomes. Given this lack of diversity, my conclusions are preliminary, and narrative accounts of a more balanced sample is needed to foster phenomenological research in embodied subjectivity during labor and childbirth. ...
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The aim of this paper is to get from a phenomenology of birth towards an ethics of obstetric care: Human rights violations in obstetrics are currently a globally debated phenomenon. Research suggests that maltreatment is widespread and a global phenomenon. However, the prevalence cannot yet be clearly quantified. In view of this problem, it is necessary to take the subjective perspective of those affected seriously. Narrative and phenomenological accounts of birth experiences could help to foster the dialogue between persons giving birth and health professionals. First, I will present narrative accounts of birth experiences recorded by feminist phenomenologists. Second, I will interpret these narrative accounts within a feminist phenomenological framework in order to contribute to a phenomenology of birth, which, in a third step, shall help to develop an ethics of obstetric care. In engaging with the phenomenology of care outlined by feminist care ethicists, I will analyze the elements and conditions of good care, and draw conclusions for an ethic of obstetric and midwifery care. Drawing additionally on the theory of relational autonomy, my paper argues for a relational implementation of self-determination in childbirth. Lastly, I will discuss to what extent the ethical ideal of care has an affinity to the midwifery model of childbirth, and how the current situation of obstetrics prevents a women-centered birth culture.
Article
Post-vaginal birth protocols frequently require women and other birthing persons to undergo rectal examinations. Protocols for these examinations, which we refer to as PVREs, vary widely, however, and there is a lack of agreement within the medical community concerning whether they are needed at all. This article explores women’s experience of PVREs in light of this ambiguity which, we argue, reflects and reproduces aspects of gendered power relations that are implicated in systemic sexual violence. We show that some women experience PVREs as sexual violence, the effects of which include guilt, self-blame, shame and sexual humiliation. Given its defining characteristics, we further argue that PVREs constitute a form of obstetric violence.
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This article extends the findings of a rapid response article researched in April 2020 to illustrate how providers’ practices and attitudes toward COVID-19 had shifted in response to better evidence, increased experience, and improved guidance on how SARS-CoV-2 and COVID-19 impacted maternity care in the United States. This article is based on a review of current labor and delivery guidelines in relation to SARS-CoV-2 and COVID-19, and on an email survey of 28 community-based and hospital-based maternity care providers in the United State, who discuss their experiences and clients’ needs in response to a rapidly shifting landscape of maternity care during the COVID-19 pandemic. One-third of our respondents are obstetricians, while the other two-thirds include midwives, doulas, and labor and delivery nurses. We present these providers’ frustrations and coping mechanisms in shifting their practices in relation to COVID-19. The primary lessons learned relate to improved testing and accessing PPE for providers and clients; the need for better integration between community- and hospital-based providers; and changes in restrictive protocols concerning labor support persons, rooming-in with newborns, immediate skin-to-skin contact, and breastfeeding. We conclude by suggesting that the COVID-19 pandemic offers a transformational moment to shift maternity care in the United States toward a more integrated and sustainable model that might improve provider and maternal experiences as well as maternal and newborn outcomes.
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Birth-related decisions principally center on safety; giving birth during a pandemic brings safety challenges to a new level, especially when choosing the birth setting. Amid the COVID-19 crisis, the concurrent work furloughs, business failures, and mounting public and private debt have made prudent expenditures an inescapable second concern. This article examines the intersections of safety, economic efficiency, insurance, liability and birthing persons’ needs that have become critical as the pandemic has ravaged bodies and economies around the world. Those interests, and the challenges and solutions discussed in this article, remain important even in less troubled times. Our economic analysis suggests that having an additional 10% of deliveries take place in private homes or freestanding birth centers could save almost $11 billion per year in the United States without compromising safety.
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This article documents the experiences of Black birthworkers supporting pregnant and birthing people and new mamas during the first six months of the COVID-19 pandemic. Building on the methodology and outcomes of Battling Over Birth–a Research Justice project by and for Black women about their experiences of pregnancy and childbirth–the authors utilized a “community-based sheltered-in-place research methodology” to collect the narratives of Black birthworkers, including doulas, certified nurse-midwives (CNMs), homebirth midwives, lactation consultants, community health workers and ob/gyns. The article examines the impact of restrictions put in place by hospitals and clinics, including inadequate or inconsistent care, mandatory testing, separation from newborns, and restrictions on attendance by birth support people, including doulas. Birthworkers shared the innovative approaches that they have devised to continue to offer care and the ways that they have expanded the care they offer to make sure the needs of Black birthing people and new parents are being met during this uncertain time. The article also explores the threats to health, safety, and financial security faced by Black birthworkers as a result of the pandemic, and the overt and subtle forms of racism they had to navigate. Finally, it documents the sources of strength that Black birthworkers have found to sustain them at the frontlines of a maternal health care system in crisis.
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This contributed volume explores flexible, adaptable, and sustainable solutions to the shockingly high costs of birth across the globe. It presents innovative and collaborative maternity care practices and policies that are intersectional, human rights-based, transdisciplinary, science-driven, and community-based. Each chapter describes participatory and midwifery-oriented care that helps improve maternal and newborn outcomes within minoritized populations. The featured case studies respond to resource constraints and inequities of access by transforming relations between providers and families or by creating more egalitarian relations among diverse providers such as midwives, obstetricians, and nurses that minimize inefficient hierarchies within maternity care. The authors build on a growing awareness that quality and respectful midwifery care has lower costs and improved outcomes for child bearers, newborns, and providers. Topics include: • Sustainable collaborations including transfers of care among midwives and obstetricians in India, The Netherlands, Germany, United Kingdom, and Denmark • Midwifery-oriented, femifocal, indigenous, and inclusive models of care that counter obstetric violence and gender stereotypes in Mexico, Chile, Guatemala, Argentina, and India • Doula care and midwifery care for women of color, previously incarcerated women, indigenous women, and other minoritized groups in the global north and south • Practices and metrics for improving quality of newborn and maternal care as well as maternal and newborn outcomes in disruptive times and disaster settings Sustainable Birth in Disruptive Times is an essential and timely resource for providers, policy makers, students, and activists with interests in maternity care, midwifery, medical anthropology, maternal health, newborn health, obstetrics, childbirth, medicine, and global health in disruptive times.
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In response to COVID-19, many doulas, including community-based doulas (CBDs), have shifted to virtual doula work, placing aspects of doula care online. CBDs typically center Black and Brown mothers and come from the same community as their clients, granting access to doula care for many individuals who would traditionally not have access. Two partner CBD organizations in Central New York—Village Birth International and Doula 4 a Queen—transitioned to virtual doula work, continuing to center Black and Afro-Latinx people. As CBDs began to transition their work online, they had to create new ways to include both the community and doula aspects of their work. My research has captured these doulas’ experiences since mid-2019 and has documented their transition from in-person doula work to virtual work. This also included their experiences of hosting doula trainings that were originally designed to be held in person. To understand this turn to virtual doula work, in this article I draw on social media engagement, online interviews, Zoom discussions, and personal experience to capture how CBD work shifted to virtual platforms can still center Black and Afro-Latinx folks in their communities and beyond.
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From around the world, report the impact of new COVID-19 restrictions on their ability to provide continuous emotional, physical, and informational support to pregnant people and their families. In a qualitative survey conducted in March and April 2020, we heard from over 500 doulas in 24 countries. Doulas practicing across the world revealed rapid changes to hospital policies. Even accounting for different public health responses across countries, the doulas in our study pointed to one common theme - their absence at births and the subsequent need to support birthing people virtually. In a follow-up survey and in interviews we conducted in July, we reconnected with doulas from our initial study to track their access to institutional birthing spaces. As countries experienced the effects of “flattening the curve,” we found that doulas were still not considered “essential” workers and the majority could not attend births. Our research shows that doulas have ambiguous feelings about the efficacy of virtual support, that they raise concerns about the long-term impact of COVID on their profession and that they are concerned about mistreatment and obstetric violence as birthing people enter hospitals alone.
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Black women bear the burden of a number of crises related to reproduction. Historically, their reproduction has been governed in relation to the slave economy, and connected to this, they have been experimented upon and subjected to exploitative medical interventions and policies. Even now, they are more likely to experience premature births and more likely to die from pregnancy-related complications. Their reproductive lives have been beleaguered by racism. This reality, as this article points out, shapes the use of assisted reproductive technology (ART) by Black women. Using the framework of obstetric racism, I suggest that, in addition to the crisis of adverse maternal health outcomes, such as premature birth, low-birthweight infants and maternal death, Black women also face the crisis of racism in their medical encounters as they attempt to conceive through ART. Obstetric racism is enacted on racialized bodies that have historically experienced subjugation, especially, but not solely, reproductive subjugation. In my prior work, I delineated four dimensions of obstetric racism: diagnostic lapses; neglect, dismissiveness or disrespect; intentionally causing pain; and coercion. In this article, I extend that framework and explore three additional dimensions of obstetric racism: ceremonies of degradation; medical abuse; and racial reconnaissance. This article is based on ethnographic work from 2011 to 2019, during which time I collected narratives of US-based Black women and documented the circumstances under which they experienced obstetric racism in their interactions with medical personnel while attempting conception through ART.
Article
Objectives-This report presents 2019 data on U.S. births according to a wide variety of characteristics. Trends in fertility patterns and maternal and infant characteristics are described and interpreted. Methods-Descriptive tabulations of data reported on the birth certificates of the 3.75 million births that occurred in 2019 are presented. Data are presented for maternal age, livebirth order, race and Hispanic origin, marital status, tobacco use, prenatal care, source of payment for the delivery, method of delivery, gestational age, birthweight, and plurality. Selected data by mother's state of residence and birth rates by age are also shown. Trend data for 2010 through 2019 are presented for selected items. Trend data by race and Hispanic origin are shown for 2016-2019. Results-A total of 3,747,540 births were registered in the United States in 2019, down 1% from 2018. The general fertility rate declined from 2018 to 58.3 births per 1,000 women aged 15-44 in 2019. The birth rate for females aged 15-19 fell 4% between 2018 and 2019. Birth rates declined for women aged 20-34 and increased for women aged 35-44 for 2018-2019. The total fertility rate declined to 1,706.0 births per 1,000 women in 2019. Birth rates declined for both married and unmarried women from 2018 to 2019. The percentage of women who began prenatal care in the first trimester of pregnancy rose to 77.6% in 2019; the percentage of all women who smoked during pregnancy declined to 6.0%. The cesarean delivery rate decreased to 31.7% in 2019 (Figure 1). Medicaid was the source of payment for 42.1% of all births in 2019. The preterm birth rate rose for the fifth straight year to 10.23% in 2019; the rate of low birthweight was essentially unchanged from 2018 at 8.31%. Twin and triplet and higher-order multiple birth rates both declined in 2019 compared with 2018.
Article
Objectives Transforming the landscape of American healthcare, COVID-19 has had unprecedented effects on the African American community. African Americans are more likely to contract COVID-19, develop complications and die from the virus. Amid the growing research on COVID-19, this manuscript pays particular attention to African American women who are disproportionately represented as ‘essential’ or frontline workers, yet often lack job security and risk contagion. Faced with limited testing centers, they are also at risk of having their symptoms minimized or dismissed by medical practitioners even when they show visible symptoms of COVID-19. Methods Using the theoretical framework of intersectionality developed by scholars like Kimberlé Crenshaw and Patricia Hill Collins, this manuscript examines the impact of COVID-19 on African American women. It emphasizes that African American women are vulnerable to COVID-19 due to the twin legacies of racism and sexism. Intersectionality theory espouses that racism and sexism often combine with social determinants of health such as economic stability and socio-environmental factors to shape health outcomes. Within the context of COVID-19, this work underscores that African American women are susceptible to the virus due to their higher likelihood of co-morbidities like obesity, diabetes and high blood pressure. They are also likely to face eviction and homelessness if they are laid off or furloughed as a result of the pandemic. Conclusion This manuscript asserts that decades of racism and discrimination have isolated communities of color and made them particularly vulnerable to the COVID-19 virus. As many African American women deal with unemployment or continue to work as ‘essential workers’, the intersectionality framework sheds light on the continued legacies of racism and sexism. It asserts that targeted policy interventions are needed to mitigate the effects of COVID-19 and lessen the devastating impact(s) it has had on African American communities.
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In Part 2 of this two-part article, we further employ the lens of evolutionary medicine to explore similarities in premodern biocultural features of birth, arguing that these were an outgrowth of our common evolutionary heritage as bipedal primates. These practices grew out of the empiricism of millennia of trial and error and supported humans to give birth in closer alignment with our evolved biology. We argue that many common obstetric procedures today work against this evolved biology. In seeking to manage birth, we sometimes generate an obstetric paradox wherein we (over)intervene in human childbirth to try to keep it safe, yet thereby cause harm. We describe premodern birthing patterns in three sections: (a) eating and drinking at will and unrestrained movement in labor with upright pushing; (b) obligate midwifery and continuous labor support; and (c) the low-intervention birth/long-term breastfeeding/co-sleeping adaptive complex, and discuss how these are still relevant today. We conclude with a set of suggestions for improving the global technocratic treatment of birth and with a futuristic epilogue about a 7th, cyborgian pig that asks: What will become of birth as humans continue to coevolve with our technologies?