Gemma McKenzie continues the blog series on naming and framings of violations in maternity care. In her post, she distinguishes ‘birth trauma’ from ‘obstetric violence’, and explores key concerns with the use of ‘birth trauma’ to describe abuse and violence during childbirth.
In a chapter written by Maddy Simpson and Agy Cater entitled ‘Birth Trauma: the noxious by-product of a failing system’, Cater describes her horrific experiences of giving birth in an Australian maternity unit. She writes that during the entirety of her labour and birth: “…I felt harassed, questioned, coerced, undermined and bullied … [and] … was made to feel like I was not entitled to receive basic human rights including declining the type of care I wished to have.” (p 258) Her experience included being physically restrained, with an obstetrician and midwife “both taking turns in hammering their fingers into my vagina with each contraction to ‘guide’ my pushing.” (p 263)
This chapter invokes a sense of horror. Cater had been deeply traumatised both psychologically and physically by her experience. Her descriptions reflect something out of a nightmare or a twisted Stephen King novel. Such an account leads to a broader question: What exactly was Cater describing? Was this birth trauma as the title of the chapter suggests? Was this a clear example of obstetric violence? Or is this a case of both?
It is at this point worth unpacking the two terms, starting with birth trauma. The implication is physical or psychological trauma caused by or connected to birth. We may imagine people frightened, distressed and deeply affected by their birthing experience. In the same chapter as Agy Cater, Maddy Simpson highlights how birth trauma is “subjective”, has been linked to “personal satisfaction with the birth process and outcome” and in the worst cases can result in a diagnosis of post-traumatic stress disorder (p 257).
The second, more recently coined term obstetric violence, implies violence within an obstetric or maternity setting. It suggests that a pregnant woman or person is experiencing some form of abuse in a medical capacity either on an individual or systemic level. The term is more sinister, there is a hint of unequal power dynamics and we can imagine a person being deemed a ‘victim’ or ‘survivor’ of such violence. The issue has been considered to be of such a serious nature that the term has been codified into the legal frameworks of some Latin American countries, and the UN Special Rapporteur has recently published a report on the problem.
From these very brief explanations, we can see how the two terms may be connected. In fact, in literature on the subject, it is typical to read about how birth trauma can be caused by negative interactions with health care professionals. Reed et al. for example, documented a range of horrific incidents that participants described in their study on women’s experiences of “trauma whilst giving birth.” These included descriptions of violation and physical abuse, including examples of women being held down by health care professionals during birth and others being subjected to non-consensual invasive procedures.
When I read these accounts, I get the sense that the term ‘birth trauma’ is being used to describe the physical and psychological injury someone experiences as well as its cause. Whilst someone may be traumatised by events at their birth, when they have experienced abuse, is it not more accurate to use the term ‘obstetric violence’ to describe that abuse? And in these situations, even if people have been traumatised, are they really traumatised by birth? Or have they been traumatised by abuse during birth? In both cases, ‘birth trauma’ does not appear to be an accurate portrayal of the circumstances.
It is each person’s prerogative to use the language that they see fit to describe their own experiences of giving birth. But what concerns me is that the use of the term ‘birth trauma,’ especially in academic, obstetric or midwifery circles, to describe women’s accounts of abuse is problematic. To do so - even if unintentionally - masks the unlawful and unethical nature of the practices that women describe.
When obstetric violence is caught under the umbrella of birth trauma and not highlighted as something very specific in its own right, we lose an opportunity to challenge it. It is important to recognise that obstetric violence is something doctors and midwives can always actively resist and avoid. Obstetric violence is a problem that can be prevented, challenged and eradicated. Birth trauma is different. A woman can be traumatised by an unexpected and unavoidable stillbirth regardless of the support she received from medical staff. Birth trauma may therefore exist even with the highest standards of care, but high standards of care are anathema to obstetric violence.
If birth takes place under abusive circumstances, trauma can be a potential emotional response. But it should be remembered that obstetric violence is not an emotional response; it culminates in an act – touching, cutting, entering, penetrating or some other form of abuse. It is not predicated on the subjectivity of how a person feels. Law and ethics exist to determine appropriate standards of care. To be violent is to potentially act both unethically and unlawfully. Applying the term birth trauma to violent acts carried out against someone can problematise the survivor of that violence, their body or their perceived ‘vulnerabilities’. In contrast, obstetric violence problematises the behaviour of the health care professional and the system within which he or she works. The term shifts the emphasis and highlights that someone should be held accountable or that something needs to change.
In academic, obstetric and midwifery circles, when we see acts or descriptions of obstetric violence, we must label it as such. Muting the act of obstetric violence with the phrase ‘birth trauma’ is deeply problematic. Any refusal to say or acknowledge the term will not make the issue disappear. In the same way that domestic violence is not defined as marriage or relationship trauma, we should not use ‘birth trauma’ to describe abusive acts. To do so risks failing to identify the true nature of the problem and allowing it to continue unabated. Labelling relevant incidents as obstetric violence is the first step in being better able to target the issue and thus challenge and eventually eradicate it completely.
Gemma McKenzie, PhD Candidate, King's College London
For more details about Gemma and her research see www.gemmamckenzie.co.uk