What is obstetric violence—and could it have happened to you?

Natalie Benanti* was 39 weeks and five days pregnant with her first child when she went in for her last scheduled obstetric appointment. Her usual OB was off that day, so another OB in the clinic saw her. But the pelvic exam was surprisingly painful, and when she asked the doctor what was going on, she said she had done a stretch and sweep.

“We had never discussed it—not before, and not that day,” Benanti says. “I was surprised and upset.” But it was also Benanti’s first pregnancy, so she hadn’t known that stretch and sweeps are normally optional.

In this procedure, the doctor or midwife inserts a finger through the cervical canal and uses a sweeping motion to detach the amniotic sac, or fetal membrane, from the cervix. Also called a membrane sweep, it releases chemicals that help soften and open the cervix for delivery, encouraging labour. Some people might want the procedure if they’re eager to avoid being medically induced or are past their due date.

Benanti had planned on going home to rest and wait for her body to go into labour naturally. She wasn’t feeling uncomfortably pregnant, and she hadn’t been anxious about her due date or considering an induction.

After the stretch and sweep, she began to bleed profusely and had to go straight to the hospital from her doctor’s office. Then contractions started. At the height of the drama, there was talk of a C-section, but 24 hours later, she eventually gave birth vaginally.

Many pregnant women feel a loss of control of their body as it grows and changes in ways they can’t necessarily predict. Complications can develop in the healthiest of patients, even if you do everything by the book. And then there’s the act of giving birth: The throes of labour, as your muscles and your contractions take over, can feel like an animalistic or even wild experience—as if some force has taken over your body. That loss of control can be exacerbated by how respected and supported—or ignored, or condescended to—you feel by the professionals and family members helping you in the delivery room. Research shows it’s not uncommon for new parents to report rude or aggressive behaviour from their healthcare providers, a lack of communication leading to stress and confusion, or even a failure to obtain informed consent before performing invasive (though possibly lifesaving) procedures and labour interventions.

It’s what maternal-health advocates sometimes refer to as obstetric violence, and while you may not have heard the term before, it’s possible you or someone close to you has experienced it.

“It made me think about consent and bodily autonomy”

Benanti’s unauthorized stretch and sweep was not, apparently, a one-off. The same thing happened during her second pregnancy, when she came in for a routine third-trimester appointment. Her primary OB, whom she’d always liked, wasn’t available that day, and so she ended up with the very same doctor who’d performed the surprise stretch and sweep three and a half years earlier.

During the pelvic exam, this same doctor did the procedure without her consent again, instead of just checking to see if she was dilated. “She hadn’t asked me or told me. And I knew that if I went into labour now, it could derail my plan,” Benanti says.

Benanti’s best guess is that this doctor wasn’t up to speed on her health records. Otherwise, she would have known that Benanti’s baby was breech, and that she was still hoping for a vaginal delivery. She had a very specific birth plan that depended on working with her preferred OB, who supported her choices. She wanted to go into labour when a doctor who was experienced with breech vaginal deliveries was on call.

But the non-consensual stretch and sweep sent Benanti into labour within eight hours.

Because she ultimately gave birth to a healthy baby, Benanti moved on. She was busy with two young kids and didn’t dwell much on what had happened, or why she hadn’t spoken up. But over time, she says, she began to have conversations with other mothers and learned that many women had discussions with their doctors and midwives about stretch and sweeps in the lead-up to their due dates. Some even signed release forms.

“That never happened to me. It made me think about consent and bodily autonomy,” Benanti says. “I know there are exigent circumstances when you have to trust the doctor and let them do their thing. This wasn’t that. There was no reason whatsoever to do something to put me in labour. I wasn’t sick, I wasn’t overdue, and the baby was fine.”

Shining a light on the problem

Experiences like Benanti’s are not necessarily unusual. The Birth Place Lab at the University of British Columbia has been surveying both B.C. women and American women to get a sense of how widespread obstetric violence is. In a study they published in June 2019, one in six out of the 2,138 women who completed the survey said they experienced mistreatment or harassment during the delivery of their babies. The most frequently documented examples in the study, which was called Giving Voice to Mothers, included being shouted at or scolded by the care provider and feeling ignored after requesting help. Doctors or nurses who failed to respond to a patient within a normal amount of time was also a common complaint.

Where you give birth makes a big difference; just five percent of women who had home births reported mistreatment compared to 28 percent who delivered their babies in hospital.

In one extreme example that made headlines last year, a North York, Ont., doctor was found guilty of surreptitiously inserting labour-inducing drugs into the vaginas of patients during stretch and sweeps, so that women would deliver their babies on his schedule instead of starting contractions naturally. (He got paid overtime wages for weekend deliveries.)

In 2017, Kate Macdonald, a 29-year-old mom in Toronto, started collecting and sharing birth stories on a patient advocacy website called the Obstetric Justice Project, after her own bad labour experience. From the submissions she’s seen, Macdonald says that abuse can happen anywhere, from a hospital to a home birth, and it can involve any type of healthcare provider, including doctors, nurses, midwives and anesthesiologists.

It’s common for her to hear stories about verbal abuse, discrimination and bias against people of colour, queer people and trans people, as well as a general absence of clear communication.

“There’s even a lack of consent before someone puts their hand in someone’s vagina,” Macdonald says. “It’s alarming what professionals think is OK. I also felt like things weren’t being explained to me—my nurse seemed really grumpy and busy,” she adds.

Macdonald also has a history of sexual trauma, and when she gave written feedback to the hospital, she told them they “need to be treating people as if they have been violated and traumatized before, because, statistically speaking, most have, and most people aren’t going to disclose that to you.”

“I left very traumatized,” Macdonald says. “I’m due in April with my second baby, and I’m doing lots to make sure this time around it’s a different story.”

“At the heart of it, obstetric justice is about human rights,” she says. “It’s important for people to know about it, so they can speak up.”

The lasting effects of trauma

Birth trauma or post-traumatic stress disorder after childbirth can also stem from unexpected labour interventions, like an episiotomy or the use of forceps. And the trauma can have long-term consequences that new parents are too overwhelmed to deal with.

Kristie Douglas,* a 26-year-old mother of two, is still struggling after the harrowing birth of her first child at an Ontario hospital. She wasn’t yet in labour when her doctor did the first vaginal exam.

“I was not prepared for it. I understand that these exams are supposed to be uncomfortable and they can be upsetting at times, but I wasn’t even lying on the bed before he tried to perform a cervix check,” says Douglas, who was 22 at the time. “He said, ‘Well, if you lay down and spread your legs, it would be easier.’ That obviously set the tone for the day: This doctor is going to be mean to me.”

Douglas, whose mom was in the delivery room with her, was better prepared and able to get into position quickly for the second cervix check, but the third time, things went downhill.

“It started really hurting, like it was painful. I was in tears; I was crab-crawling off the hospital bed. I hit my head on the wall. I was begging him and screaming to stop. I had people holding me down so he could complete the check,” Douglas says.

She says he then “mumbled” that he was going to break her water, and she told him not to, but he did it anyway. “He totally performed that without my consent, without permission, without educating me on what he was doing, or what that would look like—none of the things he should have done.”

She says she was also “bullied” into getting an epidural, though she wanted to avoid interventions, and ended up having a C-section.

The trouble continued even after Douglas gave birth. When she asked a question about breastfeeding, she says a nurse stuffed her breast in her baby’s mouth without obtaining consent to touch her. Douglas also remembers a nurse suddenly grabbing her son from her arms and feeling his testicles before returning him to her.

“She just took my baby, played with him and put him back. Nobody explained that it’s a specific newborn check,” Douglas says. “Nobody was communicating to me what they were doing. It was: ‘This is what’s happening and you have to deal with it.’”

Douglas eventually complained to all three professional colleges that oversee midwives, nurses and doctors in Ontario. (She is waiting to hear back from the nurses’ board.) Her doctor was told he could have communicated better, but Douglas feels like he got off with “a slap on the wrist” from the College of Physicians and Surgeons, and she has since appealed the decision.

The trauma of her first birth experience continues to this day, even though she describes the birth of her second child as an “amazing” home birth, on her couch, supported by her boyfriend.

Douglas says her relationship to sex and intimacy still suffers from the lingering memories. “Some nights I have to stop because I’m having flashbacks of my son’s delivery. It was hard then, and it’s still hard now.”

Race matters

The biggest finding from the Giving Voice to Mothers study was that families of colour reported significantly higher rates of mistreatment. Indigenous women were the most likely to report mistreatment, at 33 percent, followed by Hispanic women, at 25 percent, and Black women, at 23 percent. White women were the least likely to report any form of mistreatment, at 14 percent.

Even when accounting for economic disparity, 27 percent of women of colour with low socio-economic status reported mistreatment compared to 19 percent of white women with low socio-economic status.

“There’s a disconnect between how service users and service providers talk about the same thing,” says the study’s lead author, Saraswathi Vedam, a professor, trained midwife and lead investigator at the Birth Place Lab. It’s very possible—and often likely—that in many cases, the actions healthcare providers take are necessary and lifesaving. But, Vedam says, if they don’t take a moment to explain what’s happening, the patient could end up feeling like they’ve lost control of decisions about their own body.

“It’s not just [about] being nice,” Vedam adds. “Yes, it’s important to be nice to people, but it’s also a matter of life and death. If patients are not listened to, then things can get missed. This is about informed decision-making.”

Her team is launching a similar Canada-only study, called RESPCCT (Research Examining Stories of Pregnancy and Childbearing in Canada Today), in March 2020. They hope to focus specifically on disadvantaged communities, including recent immigrants, pregnant people living with disabilities, LGBTQ parents, those who are intersex or asexual and First Nations/Indigenous people.

A history of violence

In 2006, Sarah Wolfe founded Seventh Generation Midwives Toronto, a midwifery practice focused on the GTA’s Indigenous population, as a response to the discrimination experienced by her family and fellow Indigenous women.

As a midwife, and earlier as a nurse, Wolfe says she would advocate for patients who encountered refusal or ridicule when they wanted to keep their placenta or have a smudging ceremony in the hospital. She says she also witnessed pain medication withheld from Indigenous patients as a result of subconscious stereotypes about the so-called “stoic Indian.”

“There were these presumptions that Indigenous women were less intelligent or that they [don’t have a] right to know, so doctors would gloss over information and then they would make decisions on behalf of Indigenous women and families because they thought they knew better,” Wolfe says. “They’re not doing it because they intend to be malicious. It’s because of very deeply ingrained biases.”

For over 50 years, women in remote northern communities have been routinely relocated for childbirth, a practice intended to reduce high rates of maternal and infant mortality but met with strong resistance from those who deem it a colonialist strategy.

A class-action lawsuit filed in Saskatchewan in 2018 alleged mass sterilization of Indigenous women in Canada as recently as the 1990s. More than 100 women were allegedly coerced, without proper informed consent, into tubal ligations when they were already under anaesthesia for their C-sections.

Then there’s the cultural gap between the patient and the healthcare provider. Less than one percent of general physicians and specialists in Canada identified as Aboriginal in the 2016 census, and less than three percent of nursing professionals.

It all adds up to a history of bad experiences with mainstream healthcare, leading to distrust.

“[Having a baby] is a very primal thing. You have zero control over what’s happening to your body when you’re in labour,” Wolfe says. “It’s very scary, so you need to be surrounded by people who make you feel safe, and Indigenous people just don’t feel safe around healthcare providers because they’ve often been treated with disrespect.”

Fixing the system

An approach healthcare providers should take, Wolfe says, is practising trauma-informed care. About one in four women in Canada have been sexually violated in the past. That statistic jumps to 80 to 90 percent for Indigenous women, Wolfe says.

“A lot of women, when they’re in the hardest part of labour, transition and pushing, will dissociate. It means that your mind is not in the same place as your physical person,” she says. A sexual violence survivor will often be reliving the trauma in their head at that moment.

“Healthcare providers who don’t understand that—or are not anticipating it—assume it’s somebody being difficult. So then they will try to assume more control, which is replicating the abuser’s power,” Wolfe says. “It’s a vicious cycle. You need to de-escalate that.”

Seventh Generation midwives act on the assumption that the patient has a history of sexual trauma, and they know how to recognize signs of a flashback. They also use plain language, instead of medical jargon, to explain everything, so the patient can understand what’s going on.

“These are the options you have. This is what happens when we do it, this is what it feels like, you can stop me at any time and I will,” explains Wolfe. “It’s about empowering people in advance. I think hospitals and the entire healthcare system could do a much better job at being patient-centric rather than provider-centric.”

Providing culturally safe, or culturally competent, care is just as important, says University of Toronto graduate student and entrepreneur Elsie Amoako. Prenatal care should take into account a patient’s values, beliefs and feelings. After researching the discrimination faced by Black, Latin American and Caribbean women during the birth process, as well as issues of them falling through the cracks after gaps in follow-up care, Amoako decided to launch Mommy Monitor, an organization and platform aiming to educate and empower parents on childbirth and maternal health.

Amoako runs annual conferences (the next one is this April), offers resources like sample birth plans, e-books, birth justice workshops and “maternal mentors,” and is launching an app that would connect new moms with personalized healthcare providers.

“Realistically, culturally sensitive care is difficult to obtain. I think the expectation that every care provider will understand every culture is something that won’t happen,” Amoako says. But her app would help link care providers who are “culturally connected to different people either through religion or background or ethnicity” directly with those who need them.

“There [should] fewer barriers, fewer issues around communication. Then there’s more support, and there’s more of a likelihood that moms will be able to have those important conversations, so they’re more prepared,” Amoako says. The app will start off with services from doulas and midwives, but Amoako hopes to expand so that hospitals offer the app to their patients free of charge.

Vedam, the UBC professor, says a focus on culturally safe and other types of patient-focused care needs to come in the form of official policies and mandates. In Toronto, for instance, a University Health Network policy introduced in 2017 paves a clear path for Indigenous smudging ceremonies in hospitals. The policy recognizes the 94 Calls to Action from the Truth and Reconciliation Commission, one of which urged the healthcare sector to recognize the value of Indigenous healing practices.

Birth workers want to ensure patients feel safe and supported, Vedam says. “This is not about midwives versus doctors versus nurses. Everybody is concerned about it and trying to be self-reflective,” she says. “But the experience will likely be better when we have a workforce that is ready to embrace person-centred decision-making; when respectful communication is considered a requirement, not optional. And when the emotional standard that we have to hold to is as important as, say, handwashing.”

*Names have been changed.

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