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.
WHAT DO YOU DO?
As a Patient
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.
Practice Due Diligence: Join your local parent list-servs. Ask about your care provider and the hospital they deliver at. Red flags? Run.
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.
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.
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
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.
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.
Avoid Banned Phrases: The following phrases should be stricken from your vocabulary.
“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.
“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.
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.
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?