The Language of Let and the Nuance of Obstetrical Violence

My doctor said they won’t let me go past 41 weeks.”

“My midwife said they won’t let me eat—I am only allowed to drink clear liquids in labor.”

“My nurse told me the hospital won’t let me push for more than three hours and I’ll have to have a c-section.

Over and over in prenatal meetings with clients, they tell me the things their doctors and midwives will and will not let them do through their pregnancies and labor.  Because of this, for so many of my clients, my primary role as their doula is not to provide comfort measures and emotional support in labor, but rather to help them understand their rights as patients, to question their care providers, and to empower them to maintain agency over their care.  

In 2018, Broadly published a widely shared article, “There is a Hidden Epidemic of Doctors Abusing Women in Labor, Doulas Say”, and the term “obstetric violence” became mainstream. Prior to that, it was used primarily by birth workers and activists to describe the physical, mental and emotional abuse doctors, midwives and nurses use to coerce and force women to certain ends in their pregnancies and labors. It is widely accepted now that obstetric violence is real and prevalent and must be addressed.

Physically violent and emotionally traumatic cases are the ones most easily recognized as obstetrical violence: a rough cervical exam that continues once the patient has said “stop”; manually stretching, tearing or cutting the perineum without consent; proceeding with a cesarean section despite the patient pleading with doctors to stop because she can feel the incisions being made;  or threatening to call law enforcement or Child Protective Services if a patient is not compliant with some protocol.

But there is this super fine line when it comes to the way care providers use language with pregnant and laboring people that disempowers the patient without overtly coercing or abusing them.  Words like “let” and “allow” or phrases like “you can’t”, “you must”, “we will” are decisive and final. They indicate that “this is the way things are and there is no other way.”

The language of “let” positions medical caregivers, doctors, nurses and midwives in a place of power over the pregnant or laboring person. When a care provider says “we won’t let you do such and such...” it ends the conversation and leaves no room for discussion.  So often my clients feel resigned to these “let” statements as their reality. They feel they have no right to request or push for what they need and want because their doctor has already indicated it’s not allowed.

What’s worse is that the language of “let” can create a culture of subversion in some patients.  When patients do something their doctor indicated they were not allowed to do, they may keep pertinent information from their care providers for fear of reprisal.  This could lead to dangerous situations.

For example, a client’s amniotic sac ruptured at home prior to labor starting.  In prenatal appointments the client’s obstetrician indicated that should this happen, the patient “must report to the hospital immediately to be induced because we won’t let you be ruptured for over 24 hours before baby is born.”  The client did not want to use pitocin under any circumstances and chose to not inform her OB that her membranes ruptured. When after 24 hours she had still not gone into labor, she informed her obstetrician that her water had broken but did not mention when.  When she arrived to the hospital she had a low grade fever and was treated with antibiotics for suspected infection--one of the risks from prolonged rupture. Because of the prolonged rupture and the fever, the baby had to undergo blood tests in the first 24 hours of life and was also closely monitored for signs of infection.

I find it deeply troubling that pregnant people feel the need to hide things from their care providers to get the outcome they hope for.  Care for pregnant and laboring individuals should be a partnership, not an autocracy.

It is telling that the American College of Obstetricians and Gynecologists (ACOG) issued a statement in 2016 saying, “pregnancy is not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life“ and further that, “obstetrician–gynecologists are discouraged in the strongest possible terms from the use of duress, manipulation, coercion, physical force, or threats, including threats to involve the courts or child protective services, to motivate women toward a specific clinical decision.”  Obstetrical violence is clearly not a problem limited to a few bad seeds.

Moreover, and somewhat more horrifying, obstetrical violence is not limited to male care-providers.  As a doula, I have seen female doctors, midwives and nurses coerce, discourage, belittle, and demean clients and their choices. Women’s health care is deeply rooted in the misogynistic and patriarchal idea that women need to be saved from themselves because their irrational thoughts and hormones do not allow them to make informed decisions, therefore female bodies must be policed.  Further, because a pregnant body is a vessel for a fetus--and fetal rights are, as a whole, moving to supersede women’s rights--care providers take on the role of protecting the fetus over the patient.

#MeToo has forced the conversation of the many nuanced and sometimes subtle ways violence and microaggressions are enacted against women as a whole, and particularly women of color and LGBTQIA individuals. As a society, many of us are now actively engaging in identifying, discussing and challenging not only sexual violence, but emotional, financial, and medical forms of violence, as well.

The language of “let” is often nuanced.  While not always outwardly coercive, it does assert the pregnant or laboring person has little or no agency in the decision making process.  It says, as a medical care provider, “I am in a position of power over your body and under my care you need to be obedient or there will be negative outcomes.” Instead, if physician and patient make informed choices together, rather than in opposition of each other, we could improve medical outcomes and patient safety and satisfaction significantly.  


As a Patient

  1. Ask Questions: If you are pregnant or planning on becoming pregnant, do not just stay with your OBGYN practice because the relationship is there.  Ask about their policies regarding going past your due date; changing positions, monitoring and eating in labor; and anything else that feels important to you. Ask common reasons for inducing or augmenting labor or scheduling a cesarean section prior to labor.  Ask about how hospital policies and protocol may impact your plans. If you are with a group practice meet with everyone in it and ask the same questions over and over. The word “let” should be a trigger word--probe deeper or find a different provider who gives you satisfactory answers.

  2. Practice Due Diligence: Join your local parent list-servs.  Ask about your care provider and the hospital they deliver at. Red flags? Run.  

  3. Know Your Rights:  Every state has a patient’s bill of rights. For example, New York State’s Patient Bill of Rights states that you have the right to: 1. receive complete information about your diagnosis, treatment and prognosis. 2. receive all the information that you need to give informed consent for any proposed procedure or treatment. 3. refuse treatment and be told what effect this may have on your health.  These rights are armor--use it as such.

  4. Consent is Never a Blanket Statement: Many hospitals will have you sign an “informed consent form” when you arrive to the hospital in labor.  Have your birth partner (doula, spouse, friend or otherwise), read the consent form--you may strike or caveat anything you are uncomfortable with.  Regardless of how you sign the form, you are always allowed to revoke consent at any stage for any part of your care.

  5. Hire a Doula: Doulas will often know what you care provider is like and what the  hospital you plan to deliver at is like. We know what protocols and policies you may encounter along the way and help guide you though managing these things.  We can help remind you of your rights, empower you to find your voice, and question your care provider or guide you through switching care providers late in the game--I’ve even helped clients fire a care provider while in labor!

As a Care-Provider

  1. Always Ask for Consent: Before touching, before testing, before administering medicines or doing any procedure--ask!  Yes, it is time consuming but consent changes everything. It protects you and protects the patient.  

  2. Create Dialogue: Don’t assume your patient doesn’t know or doesn’t care what is happening. Talk, explain, be open and receptive to answering questions. Before you do anything ask your patient if they have any questions or concerns.

  3. Avoid Banned Phrases:  The following phrases should be stricken from your vocabulary.

    1. “I am going to..” or “I will just…” before doing something to your patient. This does not allow them opportunity to give informed consent.  Instead ask, “would you feel comfortable if I…?” This allows them a chance to explore their feeling about whatever it is and ask questions.  

    2. “You can/cannot…”,  “you may/may not…”, “we will/won’t let…”, “you are/aren’t allowed…” All of these statements take control from your patient.  They are definitive statements and even if you believe what you are saying you do not have the right to impose limits on your patients.  Rather, try: “I strongly encourage/discourage…” or “It is our policy that…”, followed by an explanation, if necessary.

  4. Support Even if you Disagree: Continue to provide quality support even if you disagree with the choice(s) your patient has made.  You can ask if they would like to know the risks/benefits of the issue at hand. But avoid shaming, bargaining, or pressuring your patient to make a different choice.  Once the decision has been made, showing your patient that you support them builds trust and may ultimately help them agree to what you are suggesting.

  5. Be Kind: Practice empathy and kindness.  Take a step back and remember that ultimately you share the same goals as your patient: to have a healthy baby and a healthy new parent.  What steps can you both take to achieve this goal that feels safe and satisfying to both of you?

Beautiful Births: A Birthing Center Experience

Note from Jesse: Birth stories are written by parents, in their own words.  The only edits I make are to preserve their privacy and keep their identities anonymous, if they wish to. These stories may include very real moments of emotion, trauma and emergency situations.  All births are variable and unique, I hope to show that by sharing these stories. If you wish to share your story, please email

My mother had all four of us at home, with only my father and a midwife by her side. She never spoke about giving birth as this terribly difficult and challenging experience, and always made it sound quite natural and special. Of course I was hoping I could have a similar experience to hers, the only problem being that I would be giving birth to my first child in the USA instead of the Netherlands, my home country. The medicalisation of birth, the scare mongering and the sheer C-section rate in the US scared me. Hence, my husband and I poured some effort into finding a midwife, birthcentre and doula to help us have the most natural and empowered experience as possible. Medical assistance would be only seconds away if we needed it (the birthcentre was part of a hospital) but it shouldn't dominate the experience if it wasn't necessary. In hindsight these were some of the best decisions we could have ever made, because I look back with marvel and awe at the birth of my daughter. It was difficult, painful and hard, but I wouldn't have missed it for the world. It was a great start to her life.

I lost my mucus plug (never knew this was a thing btw) early in the morning on a Saturday, my due date actually, but went on with my day as normal. Sure, I felt a bit more cramping and 'off' but we had a nice brunch scheduled with friends who were in town, and I was supposed to meet another friend for coffee. It was a cold day, and it was pretty tiring to walk around Brooklyn for these appointments, so in the afternoon I decided to take it easy and hang out at home. Around dinner time the contractions started to come, and my husband and I basically tried to do what we'd been told by the midwife and doula: eat, rest, keep your cool. We cooked dinner even though I regularly had to grab the kitchen table to catch the contractions, but managed to go on like this for a while. Only later in the evening it became so difficult that I couldn't be comfortable in any other position than being on my hands and knees. That's when our doula came to our home, and I will always remember how comforting it was for both of us when she came in. My husband had someone to tell him what to do, and I was grateful for the support. She helped me labor in the bath and helped us decide when to go to the hospital. We didn't give our midwife as much of a heads up as we should have, so we hoped to arrive at the birthcentre around the same time as her. The cab ride was also memorable, our doula wedged herself between the front and back seats so she could stabilize me while I rode the cab on hands and knees (!). 

Once we arrived in the hospital I went through the most unpleasant part of the whole night. I had to pass 'triage' in order to be allowed to give birth in the birthcentre. It basically required a bunch of tests, including monitoring the baby's heart rate for a continuum of 20 minutes. I was in pain, and at 19 minutes the heart monitor fell off because the baby moved around so much. They made me repeat it, and I was practically in tears. However, once I got into the birthcentre (hurray!) the scene returned to be calm and reassuring. The room was dark, I again spent a lot of time in the bath, and when it was time to push, my husband and I both have a memory of being surrounded by the nurse, midwife and doula, all sitting on the hospital floor around us (I was sitting on a birthstool). They constantly provided positive reinforcement and encouragement and gently advised me when to change positions or try something else. And then at some point the moment was there, our daughter was born and she crawled to my chest. Breastfeeding was painful at first, but again, there were several women around me to help me figure it out. We spent the next day just staring at her and holding her. The birthcentre was incredible. Fortunately we didn't have to leave the room, so we had a lot of privacy in those first hours of being a family of three. 

I'm extremely grateful that the women who supported me in birth where there for me. It's something I wish for every woman, and it saddens me that this isn't the case. Of course it's not always possible, medical issues are real, and need adequate interventions, but we can't forget that birth is not a disease. I remember being overtaken by my own body, it knew what to do, so when I had people around me that recognised these signs, knew how to respond and guide me through it, the birthing process basically unfolded. This story is very personal of course, not one I would normally share with anyone, but if it can help change the system than this is the least I can do.