REPRODUCTIVE JUSTICE

MEDICALIZATION IN MATERNAL HEALTHCARE

**NOTE**  Medical advancements have saved the lives of women and babies at risk for injury or death during pregnancy and birth.  This site is not about the doctors who properly use interventions to save lives; it is about those who use them unethically for profit or convenience.   Improperly used interventions have led to harm and death of women and babies and obstetrics  is the only field in which mortality rates are rising and non-medically needed interventions such as c-sections are related to 66% of maternal deaths. 

**NOTE**  This site is designed to share valid evidence for those working to change the maternal healthcare system who do not have access to databases of peered research. 

**NOTE** Chronological order allows users to find new data.  It also begs the question of why, when we have known for decades that such practices are harmful, do they not only continue to be used but are increasingly used.

HUMAN RIGHTS AND MISTREATMENT OF WOMEN DURING PREGNANCY AND BIRTH

Among the women who give birth, as many as half describe their experience as traumatic.  The majority of this is ascribed to the medicalization of pregnancy and birth and the move to hospital settings which has disempowered women. 

WHAT DOES THE LITERATURE SAY?

2023

CDC Newsroom (2023).  One in 5 women reported mistreatment while receiving maternity care.  Accessed https://www.cdc.gov/media/releases/2023/s0822-vs-maternity-mistreatment.html

• Twenty percent of women surveyed reported experiences of mistreatment during pregnancy and delivery care, according to a new CDC Vital Signs report. Mistreatment during maternity care was higher among Black (30%), Hispanic (29%), and multiracial (27%) women.

2022

Fielding-Singh, & Dmowska, A. (2022). Obstetric gaslighting and the denial of mothers’ realities. Social Science & Medicine (1982), 301, 114938–114938. https://doi.org/10.1016/j.socscimed.2022.114938 

• CONCLUDED: "While modern medicine has enabled advances in patient care, the medicalization of childbirth and the practice of defensive medicine have also meant a shift away from considering birth as a meaningful, personal life event in which a woman has agency, respect, and security (Lyerly, 2013) and as a deeply familial, cultural, and/or spiritual experience. Our study suggests specific systematic changes to maternal care to combat gaslighting. Connecting and insuring mothers with supportive services such as doulas, midwives, and maternity care models such as culturally-centered birth centers could provide greater support and continuity around childbirth (Hardeman et al., 2020)  (material omitted)"

2020

Belizán, Miller, S., Williams, C., & Pingray, V. (2020). Every woman in the world must have respectful care during childbirth: a reflection. Reproductive Health, 17(1), 7–7. https://doi.org/10.1186/s12978-020-0855-x

• CONCLUDED: (from abstract, material omitted) "Yet such timely, respectful and consensual obstetric care is not the norm in many healthcare settings across the globe. There is a wide-spread belief that ensuring safe birth requires placing the needs and priorities of health providers over those of birthing women. This sets up and perpetuates a power imbalance, privileging providers and contributing to obstetric violence. The power imbalance between women and providers is echoed and exacerbated by similar power dynamics between providers (across cadre and seniority) that can produce counterproductive and even toxic interactions between members of the care team, undermining quality of care and contributing to provider burnout [2]."

Jolly. (2020). Why are women buying GOOP? Women’s health and the wellness movement. Birth (Berkeley, Calif.), 47(3), 254–256. https://doi.org/10.1111/birt.12495

• CONCLUDED:  "All birthing persons deserve informed consent and evidencebased medicine from their caregivers, and modern medicine has worked hard to achieve this. Nonetheless, women seeking health care have experiences that remain unrecognizable to or dismissed by their medical providers, but nonetheless are essential to our understanding of their experience of health and illness. As a result, women are increasingly attracted to a wellness industrial complex that grants them a credibility and bodily authority not mirrored in their medical context. And despite a rise in “narrative medicine” and practices that tout “listening to patients,” the needle does not seem to have moved enough within medicine to address the problem at hand. A recent study of 30,000 birth stories found that new mothers continue to view themselves as the least powerful people in the room, after their babies.15 Women are going elsewhere to mitigate their dissatisfaction with their medical care; the success of the wellness movement is Exhibit A in support of women's discontent"

MacDougal, C. (2020) Childbirth distress: A call for professional engagement.  Journal of Women and Social Work, vol 35 (3).  https://doi.org/10.1177%2F0886109919873909    Accessed https://journals.sagepub.com/doi/abs/10.1177/0886109919873909

• Abstract: "Among women who give birth, roughly half describe their birth experiences as traumatic. Childbirth trauma is a topic of growing global interest for health and mental health professions. However, social work remains peripheral in this emerging area of scholarship and practice. This article presents a portion of findings from recent feminist narrative social work research exploring women’s narratives of their experiences of emotional distress in childbirth to illustrate the need for increased professional engagement with this important social issue. Analysis of participants’ narratives illustrates how Foucault’s discourse and power/knowledge can be useful in understanding the subtle social forces that shape birth experiences which may result in emotional distress. In this article, I argue the topic of childbirth distress falls within the reproductive rights framework and should be of importance to social workers. The findings presented below are discussed in the context of the International Federation of Social Workers’ ethical principles and its policy statement on women to support this position."

Zampas, C., Amin, A., O’Hanlon, L., Bjerregaard, A., Mehrtash, H., Khosla, R., & Tunçalp, Ӧzge. (2020). Operationalizing a Human Rights-Based Approach to Address Mistreatment against Women during Childbirth. Health and Human Rights, 22(1), 251–264.  Accessed https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7348458/

• CONCLUDED: "Women have a right to dignified, respectful health care, free from discrimination and coercion, throughout pregnancy and childbirth, as protected in international and regional human rights law and standards. States have a due diligence obligation to prevent, investigate, and punish human rights violations during childbirth, including those acts which constitute mistreatment, whether by state or non-state actors. Moving forward, it is important to ensure an enabling legal and policy environment, such that women-centered care during childbirth is part of the implementation of all relevant policies and programs."

2019

Lothian, J. (2019). The Continued Mistreatment of Women During Pregnancy and Childbirth.  Accessed https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6791579/#:~:text=In%201958%2C%20Ladies%20Home%20Journal,withholding%20medication%2C%20and%20restraining%20women

• Mistreatment of women during pregnancy and childbirth continues to define our American way of birth in spite of decades of awareness and concern. The Giving Voice to Mothers study identifies the incidence of mistreatment of childbearing women in the United States, the factors that increase a woman's risk of being mistreated including socio economic and racial characteristics, place of birth, and health-care provider.

Morton, & Simkin, P. (2019). Can respectful maternity care save and improve lives? Birth (Berkeley, Calif.), 46(3), 391–395. https://doi.org/10.1111/birt.12444

• CONCLUDED: (from article) "Respectful maternity care is not a luxury, but a human right with the potential to improve maternal and infant outcomes in all countries. Interest in measuring and providing respectful maternity care has grown rapidly over the past three decades, and the effort to describe, define, enumerate, and implement the elements of respectful maternity care around the world has led to numerous publications and an impressive consensus of these elements.2-8 Work in this area reflects a growing recognition that quality maternity care requires more than increasing access to facility‐based care and skilled attendants and that highly medicalized and impersonal care is not just disrespectful, but increasingly unsafe for women and their infants."

Rania, N. (2019). Giving voice to my childbirth experiences and making peace with the birth event: the effects of the first childbirth on the second pregnancy and childbirth. Health Psychology Open, 6(1), https://doi.org/10.1177/2055102919844492    Accessed https://journals.sagepub.com/doi/10.1177/2055102919844492

• CONCLUDE (from abstract)  "This autoethnographic study describes the author’s waterbirthing experience to evidence the relationship between fear of childbirth and communication with, and support from, healthcare professionals and the medical process during labour and delivery. The study provides a rereading of the author’s experience, which demonstrates how the traumatic consequences of a first childbirth influenced the experience of a second pregnancy and childbirth. This account indicates how lack of training and inadequate communication by medical staff can lead to traumatic childbirth experience. The study enhances understanding of womens’ transition to motherhood with implications for practice, education and research of midwives and other medical providers."

2018

Betron, McClair, T. L., Currie, S., & Banerjee, J. (2018). Expanding the agenda for addressing mistreatment in maternity care: a mapping review and gender analysis. Reproductive Health, 15(1), 143–143. https://doi.org/10.1186/s12978-018-0584-6

• CONCLUDED:  "Conclusion: While the evidence base is limited, the literature clearly shows that gender inequality—for both clients and providers—contributes to mistreatment and abuse in maternity care. Researchers, advocates, and practitioners need to further investigate and build upon lessons from the broader gender equality, violence prevention, and rightsbased health movements to expand the agenda on mistreatment in childbirth and develop effective interventions"

Cohen Shabot, & Korem, K. (2018). Domesticating Bodies: The Role of Shame in Obstetric Violence. Hypatia, 33(3), 384–401. https://doi.org/10.1111/hypa.12428

• CONCLUDED (from abstract): "Obstetric violence—violence in the labor room—has been described in terms not only of violence in general but specifically of gender violence. We offer a philosophical analysis of obstetric violence, focused on the central role of gendered shame for construing and perpetuating such violence. Gendered shame in labor derives both from the reifying gaze that transforms women’s laboring bodies into dirty, overly sexual, and “not-feminine-enough” dysfunctional bodies and from a structural tendency to relate to laboring women mainly as mothers-to-be, from whom “good motherhood” is demanded. We show that women who desire a humane birth are thus easily made to feel ashamed of wanting to be respected and cared for as subjects, rather than caring exclusively for the baby’s well-being as a good altruistic mother supposedly should. We explore how obstetric violence is perpetuated and expanded through shaming mechanisms that paralyze women, rendering them passive and barely able to face and fight against this violence. Gendered shame has a crucial role in returning women to “femininity” and construing them as “fit mothers.” To stand against gendered shame, to resist it, on the other hand, is to clearly challenge obstetric violence and its oppressive power."

Kukura, E. (2018). Obstetric Violence.  Accessed https://www.law.georgetown.edu/georgetown-law-journal/wp-content/uploads/sites/26/2018/06/Obstetric-Violence.pdf

• Maternity care in the United States is in a state of crisis, characterized by high cesarean rates, poor performance on various mortality and morbidity measures, and a steep price tag. There are many factors that impede access to high-quality, evidence-based maternity care for certain women. Grassroots organizers have raised awareness about the extent to which giving birth in the United States has become overly medicalized. Perhaps less widely known, however, is the extent to which women experience abuse, coercion, and disrespect while giving birth.

Lambert, Etsane, E., Bergh, A.-M., Pattinson, R., & van den Broek, N. (2018). “I thought they were going to handle me like a queen but they didn”t’: A qualitative study exploring the quality of care provided to women at the time of birth. Midwifery, 62, 256–263. https://doi.org/10.1016/j.midw.2018.04.007  

• CONCLUDED "Healthcare providers generally have the knowledge regarding what good quality of care is and how this could be better provided. However, organisational and structural challenges such as shortage of staffing, many referred cases and poor referral pathways, shortage of supplies, and, the labour ward lay-out and structure are often barriers which do not enable healthcare providers to implement what they know to be good practice." (material omitted)

Madula, P., Kalembo, F.W., Yu, H., Kaminga, A.C., (2018). Healthcare provider-patient communication: a qualitative study of womens perceptions during childbirth. Reproductive Health, 15, 135.: https://doi.org/10.1186/s12978-018-0580-x. Accessed https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-018-0580-x 

• CONCLUDED: "This study has revealed the existence of some communication barriers such as disrespecting and verbally abusing pregnant women, language limitations by some healthcare providers and discrimination due to one’s status which are affecting maternal service delivery in some health facilities in Malawi. The study has also shown that pregnant women who are happy with the way healthcare providers communicate with them have the motivation to deliver at a health facility. There is a need, therefore, to develop an intervention that could help healthcare providers to communicate better with their patients."

Morton, Henley, M. M., Seacrist, M., & Roth, L. M. (2018). Bearing witness: United States and Canadian maternity support workers’ observations of disrespectful care in childbirth. Birth (Berkeley, Calif.), 45(3), 263–274. https://doi.org/10.1111/birt.12373

• CONCLUDED: "Conclusions: Doulas and nurses frequently said that they witnessed verbal abuse in the form of threats to the baby’s life unless the woman agreed to a procedure, and failure to provide informed consent. Reports of witnessing some types of disrespectful care in childbirth were relatively uncommon among respondents, but witnessing disrespectful care was associated with an increased likelihood to leave maternity support work within three years, raising implications for the sustainability of doula practice, nursing work force shortages, and quality of maternity care overall."

Solnes Miltenburg, van Pelt, S., Meguid, T., & Sundby, J. (2018). Disrespect and abuse in maternity care: individual consequences of structural violence. Reproductive Health Matters, 26(53), 88–106. https://doi.org/10.1080/09688080.2018.1502023

• CONCLUDED: "Conclusion In this study, all women experienced disrespect and abuse starting from their first obligatory and expected visit to the health facility for ANC and during birth. From the perspective of structural violence, non-supportive care is symptomatic of systemic gender inequality in society, which is manifested in health providers’ interactions with women. Disrespect and abuse in health facilities has been normalised and legitimised as a consequence of women’s lives not being valued. Health providers, however, are also victims of structural violence, even though at the same time they can be perpetrators of abuse. To achieve respectful maternity care for all, interventions to prevent disrespect and abuse cannot be implemented without recognition of structural inequalities that foster the conditions that make mistreatment of women possible."

2017

De Vries. (2017). Obstetric Ethics and the Invisible Mother. Narrative Inquiry in Bioethics, 7(3), 215–220. https://doi.org/10.1353/nib.2017.0068

• CONCLUDED: (Abstract.) These mother-told stories of birth, describing disrespectful and harmful care, make the invisibility of birthing women visible. The concerns and needs of women in labor fade in the face of hospital policies and the perceived needs of their soon-to-be-born babies. Bioethics contributes to this lack of regard for mothers by framing the moral problems of birth in terms of maternal-fetal conflict, where the autonomy of the mother is weighed against the obligation of beneficence to the baby. Replacing the principlist commitment to autonomy with respect—an obligation that does not compete with beneficence—is a first step toward correcting the problems in care identified here."

Hollander, M. H., van Hastenberg, E., van Dillen, J., van Pampus, M. G., de Miranda, E., & Stramrood, C. A. I. (2017). Preventing traumatic childbirth experiences: 2192 women’s perceptions and views. Archives of Women’s Mental Health, 20(4), 515–523. https://doi.org/10.1007/s00737-017-0729-6

• CONCLUDED: (from abstract) "Women attribute their traumatic childbirth experience primarily to lack and/or loss of control, issues of communication, and practical/emotional support. They believe that in many cases, their trauma could have been reduced or prevented by better communication and support by their caregiver or if they themselves had asked for or refused interventions."

Reed, Sharman, R., & Inglis, C. (2017). Women’s descriptions of childbirth trauma relating to care provider actions and interactions. BMC Pregnancy and Childbirth, 17(1), 21–21. https://doi.org/10.1186/s12884-016-1197-0 Accessed https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-1197-0

• CONCLUDED "In this study women’s descriptions of childbirth trauma centred on the actions and interactions of care providers. Women described how care providers prioritised their own agendas; disregarded embodied knowledge; used lies and threats to gain compliance; and violated them. Findings contribute to the growing body of literature relating to women’s experiences of traumatic birth. Interpersonal birth trauma is becoming increasingly recognised as a global issue, and measures are required to address it. Recommendations include changing the current technocratic paradigm by including holistic and humanistic approaches to care delivery. Maternity service provision needs to be underpinned by the World Health Organization’s ‘five actions’ [38] to develop, promote and sustain respectful woman-centred care. Care providers require training and support to understand, value, and practice in ways that optimise psychological outcomes for women."

2016

Diaz-Tello. (2016). Invisible wounds: obstetric violence in the United States. Reproductive Health Matters, 24(47), 56–64. https://doi.org/10.1016/j.rhm.2016.04.004 

• CONCLUDED (from abstract) "In recent years, there has been growing public attention to a problem many US health institutions and providers disclaim: bullying and coercion of pregnant women during birth by health care personnel, known as obstetric violence. Through a series of real case studies, this article provides a legal practitioner’s perspective on a systemic problem of institutionalized gender-based violence with only individual tort litigation as an avenue for redress, and even that largely out of reach for women. It provides an overview of the limitations of the civil justice system in addressing obstetric violence, and compares alternatives from Latin American jurisdictions. Finally, the article posits policy solutions for the legal system and health care systems"

Greenfield, Jomeen, J., & Glover, L. (2016). What is traumatic birth? A concept analysis and literature review. British Journal of Midwifery, 24(4), 254–267. https://doi.org/10.12968/bjom.2016.24.4.254   Accessed https://www.researchgate.net/publication/300002591_What_is_traumatic_birth_A_concept_analysis_and_literature_review

• CONCLUDED: Conclusions: ‘Traumatic birth’ is a complex concept which is used to describe a series of related experiences of, and negative psychological responses to, childbirth. Physical trauma in the form of injury to the baby or mother may be involved, but is not a necessary condition.

Hennig, S. (2016). “Shut Up… and Push!” - Obstetrical Violence, Dignified Health Care and the Intersection with Human Rights. Journal of Integrated Studies, Vol 8, No 1  Accessed https://www.researchgate.net/publication/313877505_Shut_Up_and_Push_-_Obstetrical_Violence_Dignified_Health_Care_and_the_Intersection_with_Human_Rights

• CONCLUDED: (abstract) "Violence against women is a globally pervasive issue that can take multiple forms affecting women regardless of age, class, race/ethnicity, or ability. Within a patriarchal paradigm the subjugation of women is consistent across cultures and is reflected in social structures including health care facilities and systems. Obstetrical violence is understood to be actions of abuse or disrespect experienced by women during the prenatal and postnatal periods and is especially prevalent during labour and delivery. During a time of intense vulnerability women can be subjected to verbal and physical abuse, lack of respect, acts of coercion, gross violations of privacy and the withholding of pain medication, often occurring at the hands of their care providers. These acts can be paralleled with similar experiences of women who have been abused by domestic partners and may inform a woman’s decision making related to future access to health care services. Pregnancy and child birth continue to be one of the leading causes of death amongst women of childbearing age. In response, governments have worked to increase women’s access to appropriate health care services, including emergency obstetrical care, which can be provided in a health care facility with skilled birth attendants in place. The application of a human rights framework to women’s sexual and reproductive health shows promise as an effective tool to address the underlying structural inequalities that lead to acts of violence and pose a threat to women’s health."

Khosla, R., Zampas, C., Vogel, J. P., Bohren, M. A., Roseman, M., & Erdman, J. N. (2016). International Human Rights and the Mistreatment of Women During Childbirth. Health and Human Rights, 18(2), 131–143.  Accessed https://www.hhrjournal.org/2016/11/international-human-rights-and-the-mistreatment-of-women-during-childbirth/

• This article reviews international human rights standards related to the mistreatment of women during childbirth in facility settings under regional and international human rights law and lays out an agenda for further research and action.

Sadler, Santos, M. J. D. ., Ruiz-Berdún, D., Rojas, G. L., Skoko, E., Gillen, P., & Clausen, J. A. (2016). Moving beyond disrespect and abuse: addressing the structural dimensions of obstetric violence. Reproductive Health Matters,24(47), 47–55. https://doi.org/10.1016/j.rhm.2016.04.002  Accessed https://www.tandfonline.com/doi/full/10.1016/j.rhm.2016.04.002

• CONCLUDED "Moving beyond the focus on the interactional dimensions of disrespect and abuse in childbirth makes way for an integrated perspective over this global issue. A dynamic dialogue between health and social sciences, mobilising the existing knowledge about the structural dimensions of obstetric violence and recognising this phenomenon as a particular form of violence against women, naturalised within health care systems, can set the ground for structural improvements in maternity care. As such, the concept of obstetric violence can be used as a tool to potentially reframe the international agenda on disrespect and abuse in childbirth, and to contribute to change in maternity care worldwide

2015

BoBohren, M. A., Vogel, J. P., Hunter, E. C., Lutsiv, O., Makh, S. K., Souza, J. P., Aguiar, C., Saraiva Coneglian, F., Diniz, A. L. A., Tunçalp, Ö., Javadi, D., Oladapo, O. T., Khosla, R., Hindin, M. J., & Gülmezoglu, A. M. (2015). The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Medicine, 12(6), e1001847; discussion e1001847–e1001847; discussion e1001847. https://doi.org/10.1371/journal.pmed.1001847

• CONCLUDED: "We must seek to find a process by which women and health care providers engage to promote and protect women’s participation in safe and positive childbirth experiences. A woman’s autonomy and dignity during childbirth must be respected, and her health care providers should promote positive birth experiences through respectful, dignified, supportive care, as well as by ensuring high-quality clinical care. The development of validated and reliable tools to measure the mistreatment of women during childbirth, as well as interventions to prevent mistreatment and promote respectful care, is a critical next step. Future research and interventions addressing quality care during childbirth must emphasize that high-quality of care is respectful, humanized care"

FFFreeman. (2015). Confronting diminished epistemic privilege and epistemic injustice in pregnancy by challenging a “panoptics of the womb.” The Journal of Medicine and Philosophy, 40(1), 44–68. https://doi.org/10.1093/jmp/jhu046

• CONCLUDED (from abstract) "This paper demonstrates how the problematic kinds of epistemic power that physicians have can diminish the epistemic privilege that pregnant women have over their bodies and can put them in a state of epistemic powerlessness. This result, I argue, constitutes an epistemic injustice for many pregnant women. A reconsideration of how we understand and care for pregnant women and of the physician–patient relationship can provide us with a valuable context and starting point for helping to alleviate the knowledge/power problems that are symptomatic of the current system and structure of medicine. I suggest that we can begin to confront this kind of injustice if medicine adopts a more phenomenological understanding of bodies and if physicians and patients—in this case, pregnant women—become what I call “epistemic peers.”

J  , Jewkes & Penn-Kekana, L. (2015). Mistreatment of Women in Childbirth: Time for Action on This Important Dimension of Violence against Women. PLoS Medicine, 12(6), e1001849–e1001849. https://doi.org/10.1371/journal.pmed.1001849  Accessed https://journals.plos.org/plosmedicine/article/comments?id=10.1371/journal.pmed.1001849

• CONCLUDED (abstract) "The mistreatment of women in childbirth has been documented by researchers for over three decades in all global regions. The scale of the problem is indicated by a systematic review conducted by Meghan Bohren and colleagues [1], which provides a foundation from which a typology of violence can be developed and used as a basis for developing measurement instruments and tools. This is a valuable complement to other work that is currently underway in this area [2]. A multicountry study on the mistreatment of women during childbirth could be extremely valuable in generating comparable information on prevalence, risk groups and facilities, and the health consequences (physical and mental, including future health-seeking practices and expectations). It would provide the foundation needed for developing health policy, monitoring its impact, and advocating for proper resources.

     Perry, S. (2015)Most women would be better off giving birth in U.K. than U.S., says American ob-gyn. MinnPost.com.  Accessed https://www.minnpost.com/second-opinion/2015/06/most-women-would-be-better-giving-birth-uk-us-says-american-ob-gyn/#:~:text=2022%20Election-,Most%20women%20would%20be%20better%20off%20giving%20birth%20in%20U.K.,An%20American%20obstetrician%20agrees.

•   Concluded: After reviewing all the available evidence, the organization (which is the equivalent of the U.S. National Institutes of Health) decided that healthy women with uncomplicated pregnancies are safer giving birth at home or in a midwife-led birthing center or hospital unit than in a hospital maternity ward under the supervision of an obstetrician

2011