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Cristen Pascucci, Founder of Birth Monopoly and Director of ‘Mother May I’, reflects on the cost of caring in the context of obstetric violence and highlights pressing concerns about secondary traumatic stress. An essential read for those working on obstetric violence.

I had been doing advocacy work around obstetric violence for several years before I started identifying how much it traumatised me. It took an intervention by some close colleagues to bring my attention to how deeply it was affecting me, and how much it had impacted my health.


By then, I had interviewed hundreds of women, birthing people, doulas, midwives, and nurses, and worked closely with dozens of them, focusing on cases of obstetric violence and rights violations. I was working 24/7 with advocates and lawyers around the country and the world, trying to solve a massive problem that was causing more casualties by the day, and absolutely immersed in my work with no boundaries on my time or energy. It felt like there was this bottomless pit of need, and every single harmed person needed so much—validation, attention, advocacy, resources—and I could not say no.


I could see the same patterns in my colleagues, burnout and struggles to hold their own emotional boundaries… and, especially from doulas, constant distress: feeling helpless and hopeless. They described holding in sobs as they watched their clients being mistreated during birth, screaming in the car on the way home, their dissociation from their families and themselves after a particularly tough incident. It was—for me, as well—an awful pattern of feeling chained to a wheel, like nothing you were doing was actually changing anything, but you could not stop because there was always one more person in front of you.


High rates of burnout, suicide, and PTSD are well-documented in healthcare workers, and more and more of them are speaking out about the ‘moral injury’ they suffer when unable to provide patients with high-quality care and healing. Midwives and nurses witnessing mistreatment describe themselves using words like ‘powerless’, ‘ashamed’, and ‘guilty’, and roughly one-third report symptoms of PTSD related to their jobs.


Specifically, secondary traumatic stress (sometimes called vicarious trauma or compassion fatigue) is the distress we experience from witnessing or simply hearing about someone else’s traumatic experience. We can take home this distress, where it manifests in ways like sleeplessness, nightmares, depression, and replaying the event(s) repeatedly in our minds.


Everyone I know who does advocacy work in birth has a personal reason for it. And my guess is that most of us are drawn to something about it that resonates with our own experience of having our bodies appropriated; our consent taken for granted or ignored; our rights violated. Whether these traumas happened in a birth setting or somewhere else, our own personal history of trauma correlates with the likelihood we will experience secondary traumatic stress.


Even if we are researching, practicing, and advocating through the sophisticated lens of a law degree or medical degree or a professorship or position as CEO, each of us advocates is essentially doing the same thing on repeat: revisiting an old wound in an attempt to make sense of it, to change the ending of the story.


Just like the majority of my female friends and colleagues, I have experienced numerous instances of sexual harassment and assault in my life. When I gave birth, I did not ultimately have the induction that was being pushed on me, but I still experienced trauma around being pressured and manipulated to get me to consent to something I did not want or need—something that happened to involve my vagina. And, although my brain knew the setting was not a sexual one, my body did not. Someone else felt entitled to me, like they deserved access to my vagina whether I agreed or not. The difference in setting was negligible.


These parallels between obstetric violence and sexual assault are just so glaring for me. I remember early on being shocked at the language survivors were quoting to me: providers telling them to ‘just lie back and relax’ as the patient was declining an exam, and things like ‘if you would stop resisting, it wouldn’t hurt so much’. It sounded… rapey. Over time, those parallels have only become more and more obvious. I used to cringe to hear the phrase ‘birth rape’ and now, thousands of stories later, I completely understand why people use it. The rape culture in maternity care is a deep trigger for me as a woman.


Whether or not that personal experience is where we are coming from, humans are empathetic creatures. We do respond in our bodies to the distress and pain of others, and we can only take on so much before we have to offload. To be mentally healthy, we have to have emotional release that equals our emotional intake. But there is so little of that for those who work in advocacy around obstetric violence.


In addition to necessary concerns about patient privacy, there is a culture of silence around this field of work that actively prevents emotional release. Obstetric violence is not generally accepted as a real and common phenomenon; its very existence is up for debate by those who would deny that women and birthing people are routinely mistreated in maternity care.


Obstetric violence also operates within an ever-present sexist framework that maybe that woman was being dramatic or oversensitive; there are two sides to every story and maybe the provider was just helping her. The pressure to minimise and explain away the truth of abuse can also come from liability concerns and potential retaliation for those who call out the behaviour—issues that persist because of a power dynamic that says a victim who speaks up is the real troublemaker and the perpetrator is actually the victim.


All together, these things build towards an oppressive silence that harms both the people who have experienced obstetric violence and those who work with and support them. It is hard to even talk about our work in a world that questions whether a need exists for it, let alone gives us space to give it the release and healing it deserves.


There is a real cost to caring in a system that does not properly support the carers or the patients, in a job that is inherently traumatising. It is time we started taking seriously the traumatic cost to birth professionals and advocates who care. I am so glad to say that my work and life today are night-and-day different from what they were even five years ago. It took a lot of time and work, but I have figured out ways to heal and the guideposts I need to have in place to stay (mostly) mentally healthy while continuing to visit the place of grief and horror where much of this work lives.


Whether we are survivors of obstetric violence and birth trauma or witnesses to it, all of us are capable of healing, given the right support and tools. First, we must recognise that our common humanity makes us susceptible to significant psychological impact from the distress of others, and then we can start implementing policy and culture change that protect both birthing people and those who pay the price of caring for them.


Cristen Pascucci, Founder of Birth Monopoly and Director of ‘Mother May I