Birth Needs a #MeToo Reckoning

After the birth of Cherrie Newman’s first baby, Newman remembers a comment her doctor made while she was being stitched for a small tear. “The doctor joked that he ‘would put a little extra in for my husband.” I couldn’t fully process what he meant or respond. I felt frozen,” says Newman. The ‘husband stitch’ as it’s known, is when a provider stitches the vaginal opening extra tight for the sexual pleasure of her partner. Newman, 35, says the tight stitching caused her pain until her next birth and, she says, she couldn’t even try having sex for months afterward. The pelvic exam at her six-week postpartum visit was excruciating. “I cried and said it hurt. He laughed and said it couldn’t possibly and continued his exam,” she says.

The success of the #MeToo movement has hinged on the unity of many voices to flip power dynamics that once kept countless victims silent. As that dialogue expands, more people are recognizing a similar pattern of health-care providers overriding people’s “no’s” in birth. It’s even coined its own term: “birth rape,” referring to when a woman’s rights and autonomy over her own body are taken away, or disregarded, during childbirth, and if her body is subsequently violated in the process—from unwanted medication being administered without consent, to forced C-sections. And, while traumatic birth in many countries, including the U.S., has often been dismissed, some countries, like Argentina, Puerto Rico, and Venezuela actually have “Obstetric Violence” laws on the books. Obstetric violence involves dehumanizing treatment, abusive medicalization, and loss of patient autonomy.

Dr. Sayida Peprah, a psychologist, doula, and maternal mental-health consultant, says that there is a culture in birth that disconnects a birthing person’s experience from what is happening to their body. “They just hurry up and go without them saying, ‘I’m going to check you.’ That vagina’s connected to my body and you have to ask me first and tell me, and then I’ve got to give you permission before you put your hands there,” she says.

What Peprah sees the most in her work as a birth doula is an indifference to the preferences, questions, and perspectives of patients. “What I would call the highest amount of maltreatment is just fear-based coercion,” she says. “I see them using it as a way to be manipulative, to make the night shorter, to get mom to do what you want.” As a Black professional, working and advocating for Black parents, Peprah says that this kind of dynamic is particularly harmful for Black families.

The historical trauma and the impact of race-related micro-stressors on a person over time become compounded in birth. “Underlying (the stress) is just am I safe in the world? Can my children go out and play at the park and not get stopped by the police? Can my husband or boyfriend go out without coming home dead? Can I go out without being harassed in the store?” asks Peprah.

Shanon Lee says she felt what appeared to be entitlement demonstrated by her white doctor, and his lack of concern about her pain. While Lee, who is Black, was focused on the nurses caring for her daughter immediately after the birth, she says that the doctor manually ripped out her placenta without her consent or even saying what he was about to do. (In an uncomplicated situation, a patient would push the placenta out with a contraction following the birth.) “I screamed in pain and yelled, ‘Why would you do that?!’ I was in such shock, I turned to my partner and asked him, ‘Why would you let him do that?’ It felt like a violation. It was such an ugly end to what was a beautiful birth experience,” says Lee.

Black women are two to three times more likely to die from childbirth-related causes than white women—studies have pointed to racism as the root cause of those disparities. Peprah says that it’s not just the existing stressors that Black people live with, but it’s also in their ongoing experiences with medical providers. Noting a report published by Black Women Birthing Justice (BWBJ) that surveyed 100 Black women about their experience of giving birth in California, Peprah says that people reported feeling uncomfortable, feeling unwelcome, and feeling stress during prenatals. “And that stress in a pregnancy, in general, is an indicator of preterm labor, of all kinds of health disparities during birth and during pregnancy, and so that’s not great that there’s this dynamic where Black women just don’t feel safe with medical providers.”

Jennie Joseph is an example of a practitioner who is working to address disparities in maternal health care with measurable results. Joseph’s maternity care model, known as The JJ Way, uses a trauma-informed, team-based approach that is centered on patient access, support, education, and empowerment. Research into the method showed that African-American and Black women who received care The JJ Way had not only better outcomes compared to patients of the same race in Orange County, the state of Florida, and the nation, but also had better outcomes than white women at the county, state, and national level.

Research has also indicated that the support of a doula during birth reduces poor outcomes. But because doulas are not typically covered by insurance, the populations most in need of a doula are often left without access to these services. Some organizations, like The Doula Project in New York, have created community doula programs that serve low-income families to try to bridge the accessibility gap. Others, like Healing Hands Community Doula Project in Texas, work to train doulas of color and then pair them with families of color so that every person who wants a doula can have a professional who is culturally competent.

The patient-provider dynamic can influence whether a person feels safe enough to access prenatal care. Peprah says that according to the BWBJ survey, some people stated that they chose to forgo prenatal care, altogether, because of their negative experiences. But, even for those who do maintain care, that patient-provider relationship is the most significant contributor to whether a person will experience their birth as traumatic or not.

Dr. Leslie Butterfield, a clinical psychologist and educator who specializes in pre- and perinatal psychology, says, “You can have somebody who says, ‘I want to have a natural, vaginal birth’ and they end up having an IV, and having an epidural, and having Pitocin, and maybe even having a C-section, but if they feel that they were treated kindly and treated with respect and dignity, and they were included in all the decision making, they don’t usually think their birth was traumatic and they don’t usually develop PTSD.” On the other hand, Butterfield says, if that same person was insulted or treated in a degrading manner, or left alone for long periods of time, they would be more predisposed to feeling traumatized.

When someone does endure trauma from mistreatment during birth, it is common for them to feel responsible for anything that went wrong, or that that they’ve failed at some essential task. “That, I think, keeps people quiet,” says Butterfield. The power dynamics at play between a physician and patient also play into people’s silence. “I think it is hard to take on the medical establishment. They’re very well respected and most of us certainly have some thoughts about doctors are helpers, and they work so hard, and they go to school for so long, and they’re good people, that it probably does feel more difficult to kind of out that person.”

People who have experienced maltreatment during birth are not alone; they’re not even a small exception. Health-care provider bullying and coercion during childbirth is so ingrained in obstetric culture that the American College of Obstetrics and Gynecology (ACOG) issued an opinion statement that condemns the practice. The opinion says, “It is never acceptable for obstetrician-gynecologists to attempt to influence patients toward a clinical decision using coercion. Obstetrician-gynecologists are discouraged in the strongest possible terms from the use of duress, manipulation, coercion, physical force, or threats.” The paper concludes, “Pregnancy does not lessen or limit the requirement to obtain informed consent or to honor a pregnant woman’s refusal of recommended treatment.” The World Health Organization, too, has called for action, research, and advocacy in order to prevent and eliminate disrespect and abuse during facility-based childbirth.

Even so, there are some hospitals that have unspoken or written policies that say that if a pregnant patient is not compliant they may be overruled by a physician. The case of Rinat Dray, who was forced in 2011 to have a C-section against her will and subsequently sued the hospital, is a well-publicized example of this. “In their defense, the doctors and the hospital explicitly argue that Ms. Dray (and pregnant people in general) should be forced to accept any harm that could come to them for the benefit of their babies,” says Indra Lusero, a staff attorney for National Advocates for Pregnant Women and founder of the Birth Rights Bar Association, an organization that works to build the capacity of lawyers to bring cases related to rights abuses during birth.

“And in fact they did harm Ms. Dray, not only psychologically, but by cutting into her bladder during the procedure. And that points to how the logic is flawed. Her baby did not benefit from having a traumatized mother recovering from major surgery. Her baby did not benefit from having to be away from her in the hours after birth while her bladder was repaired. She certainly did not benefit from suffering those injuries—it is a zero-sum proposition,” Lusero says.

Lusero says that although the hospital claims that Dray’s situation was dire, Lusero contends that forcing someone to endure major abdominal surgery without due process of law is what is dire and, they say, never warranted. “The cost to our system of justice, to human rights (not to mention to individuals and their babies) is so grave when a human being’s body can be violated like that, no counterbalancing benefit can overcome it,” says Lusero.

Lusero understands the complexity of balancing the interests of the “almost-born baby” with that of the person giving birth, but adds, “What interest does an almost-born baby have in a parent whose human rights have been trampled? What baby would say, ‘Mom, you’ve done a lot for me already, but, I don’t trust you or your body and I should be able to break out of here with a knife even if it harms you in immeasurable ways’? Almost-born babies need intact mothers more than anything, the more intact in all the ways, the better. These are beings in a dance with life. In that moment, especially, they are not adversaries.”

For Lee, the #MeToo Movement has opened up an opportunity to engage in a dialogue about various ways people have been violated and the ways that those traumas intersect with one another. “There are few situations that compare to the vulnerability women feel while they are in labor. Women are still dying during childbirth,” Lee says. “We deserve to be respected enough to have our birth plans followed as closely as possible. As pregnant moms, our birth plan is our consent form and the guide they should be following. Any medical decisions that vary from our birth plan should be discussed with us during labor.”

Newman, who is autistic and a past sexual abuse survivor, says that her inability to speak up for herself during her child’s birth mirrored the reactions and resultant trauma she experienced as a child. While she sees a few more people opening up about the consent connections between birth to the #MeToo movement, she says, “There is still a feeling that birth rape is not ‘real rape’ and we are just complaining about ‘normal’ birth practices we don’t like.”

Reducing people’s trauma and demands for consent as petty “complaining” is an example of how parents tend to be shamed into silence around the issue. “Because of that idea that pregnant people, and women in particular, should sacrifice their bodies there is another hurdle to overcome that stretches the #MeToo movement beyond its current bounds,” Lusero says. “It will take more work, more conversations like this, before un-consented touching during pregnancy or birth is considered a legitimate harm and social ill.”