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Obstetric Violence: The Elephant in the (Delivery) Room

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Melissa Brock
November 17, 2023

In 2012, Caroline Malatesta was admitted to an Alabama hospital to give birth to her fourth child. During her labor, nurses forced Malatesta on her back despite her objections and held her infant’s emerging head inside her body for more than five minutes. Malatesta was the victim of obstetric violence and she successfully sued the hospital responsible for her injuries (which include permanent nerve damage, chronic pain and ongoing psychological distress) in 2016. Unfortunately, Malatesta’s experience is not an isolated one.

While much research and legislative action is devoted to the prevention of violence against women, the United States lags behind other nations in defining and providing medical and legal standards. Mistreatment around the time of pregnancy and childbirth is pervasive and persistent. O’Brien & Rich (2022) provide a succinct history of the issue, replete with its inextricable ties to religiosity, racism and classism. Little has changed today. Racial and ethnic minorities, individuals of low socioeconomic status, and other disadvantaged groups (e.g. individuals with disabilities, youth, incarcerated persons) are more likely to experience obstetric violence than wealthy members of the racial majority.

What is Obstetric Violence?

Obstetric violence is physical or psychological abuse of birthing persons by medical providers during the birthing process. It can include forced or coerced medical procedures, physical restraint, vaginal examinations without consent and, as in Malatesta’s case, physical measures taken to prevent birth until a doctor’s arrival. This list is by no means exhaustive; obstetric violence can also include non-physical acts such as humiliation, intimidation, bullying, separation of mother from newborn and inadequate pain management. However, there is little consensus as to what practices meet the threshold of violence and there is no legal definition of the term in the United States.

Estimates of the prevalence of obstetric violence vary by country and by definition. One study reports as many as two-thirds of birthing persons experienced some form of abuse during childbirth, with another finding that number to be closer to 75 percent. The lack of a uniform definition of obstetric violence, compounded by the likelihood that there is underreporting of incidents, means the actual magnitude of the problem may not be fully appreciated.

A Social Syndemic: The Impact of COVID-19 and Dobbs

COVID-19 significantly altered the experience of being pregnant in the United States. Many pregnant individuals’ birthing plans were scrapped over objection to conform with hospital isolation protocols, as induced labors and cesarean sections are more conducive to containment than the unpredictability typically associated with the onset and progress of labor. Some patients gave birth without a support person in the room. Others were separated from their newborns. Concurrently, hospital staff was pushed to the brink as the number of the infected soared; in the cacophony of global disaster, it was easy to silence the humanity of maternity patients in the name of disease prevention.

A second challenge has come in the form of the 2022 Dobbs v. Jackson ruling. Limiting access to legal abortion is tantamount to withholding life-saving medical care in some cases, such as ectopic pregnancy. Forcing an unwanted pregnancy to be carried to term, and forbidding practitioners to provide abortions in emergent situations dehumanizes and can physically harm women, amounting to violence perpetrated by the state.

Implications for Policy

The 2020 health crisis left many hospitals and doctor’s offices short-staffed and many shortages have yet to be filled, placing prolonged pressure on current administrators, support staff and practitioners to perform at acceptable levels. Dobbs has since exacerbated this problem. OBGYNs are no longer free to use medical judgment in some areas, instead turning to lawyers for guidance to remain in compliance with legal restrictions to their scope of practice. Doctors are leaving states with abortion restrictions, contributing to the growing number of maternity care deserts in the South and Midwest regions of the country. Finally, medical students are unable to receive full training in states with abortion bans, and are declining to accept residencies in these areas.

Obstetric violence is a nuanced topic, and defining it will require difficult and honest conversations with patients, practitioners, advocates and researchers. U.S. scholars and decision makers may find a path forward by way of Bowser & Hill (2010), who grouped a continuum of adverse obstetric behaviors into seven categories of disrespect and abuse. In this way, physical abuse may be differentiated from non-physical experiences such as scolding or divulgence of personal health information. This has a legal precedent in assigning “degrees” to a criminal charge based on the details of the offending act. Similarly, there may be distinguishing features separating obstetric “violence” from obstetric “mistreatment.”

A legal definition of obstetric violence is merely the first step towards achieving justice for the victims of abuse during pregnancy and childbirth. It is an important step to take if the United States expects to keep pace with the rest of the developed world in providing safe, dignified and accessible healthcare to birthing individuals. Pregnancy carries an inherent risk of complications which can result in any number of negative outcomes; violence in the delivery room need not be another threat to the well-being of pregnant individuals.

Author: Melissa Brock is a graduate student at John Jay College studying public administration. She previously earned a Master of Arts in Forensic Psychology and Counseling. Melissa currently works as a counselor in an adult county correctional facility. She is a certified Disaster Response Crisis Counselor and has provided instruction to correctional police officer recruits enrolled in her county’s public safety training academy. Contact: [email protected]

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