Abusive Treatment in Labor: It Could Happen to You

by | Apr 15, 2024 | Reproductive Rights

I’ve thinking for a while now about whether to cover the topic of abusive treatment in labor in a blog post. I finally decided that I really should because it is a dark side of labor management that is all too common and while recognized as a concern among pregnant women and birthing people of color, is a hidden hazard for everyone. Accordingly, this blog post will:

  • Define your rights during childbirth.
  • Define abusive treatment.
  • Document the occurrence of abusive treatment in the U.S.

And, of course, because it does no good to tell you something alarming without telling you what you can do about it, I’ll also:

  • Make recommendations for how you can protect yourself.

What Are Your Rights During Childbirth?

Abusive treatment during childbirth centers around power and control by those who are in charge, which means it’s about consent and lack thereof and what actions are taken to enforce compliance and what punishments are inflicted on those who resist. I should add, too, that because its victims are solely women and people capable of pregnancy, the issue is rooted in sexual discrimination and carried out as a means of reproductive control.

Let’s start, then, by reviewing what a couple of authoritative U.S. organizations have to say about your rights in pregnancy and childbirth that address this imbalance of power:

“Speak Up for Your Rights,” an infographic published by the Joint Commission, a non-government organization that evaluates and accredits hospitals, has this to say about the rights (among others) of hospital patients):6

As a patient, you have the right to . . .

    • Be informed about your care.
    • Make decisions about your care.
    • Refuse care.
    • Be treated with courtesy and respect.
    • Be listened to by your caregivers.
    • Care that is free from discrimination.

The American College of Obstetricians & Gynecologists (ACOG), the U.S. professional organization for obstetricians, has two documents that address pregnant patients’ rights: “Informed Consent and Shared Decision Making in Obstetrics and Gynecology” and “Refusal of Medically Recommended Treatment During Pregnancy.” Here is what ACOG says about the requirements of informed consent:2

“Meeting the ethical obligations of informed consent requires that an obstetrician-gynecologist gives the patient adequate, accurate, and understandable information and requires that the patient . . . is free to ask questions and to make an intentional and voluntary choice, which may include refusal of care or treatment.”

We have evidence that obstetricians don’t always adhere to the requirement that they provide adequate and accurate information,3 but more to the point for this blog, here is what ACOG has to say about your right to decline recommended treatment and also on the motivations behind why obstetricians may disrespect that right:1

“Pregnancy is not an exception to the principle that a . . . patient has the right to refuse treatment.”

“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, including threats to involve the courts or child protective services, to motivate women toward a specific clinical decision.”

“[ACOG] opposes the use of coerced medical interventions for pregnant women, including the use of the courts to mandate medical interventions for unwilling patients.”

“When the pregnant woman and fetus are conceptualized as separate patients, the pregnant woman and her medical interests, needs, and rights can become secondary to those of the fetus. . . . [The] ethical approach recognizes that the obstetrician-gynecologist’s primary duty is to the pregnant woman. This duty most often also benefits the fetus. However, circumstances may arise during pregnancy in which the interests of the pregnant woman and those of the fetus diverge. These circumstances demonstrate the primacy of the obstetrician-gynecologist’s duties to the pregnant woman.”

“Interventions recommended during pregnancy and childbirth may reflect distortions of risk based on concerns about failure to intervene rather than robust considerations of risks associated with those interventions.”

You may be entitled to complete and accurate information and to decline treatment, but as the next section will document, there’s a huge gap between what you’re entitled to and what may actually happen in the real world with, I should add, no consequences for even the most egregious violations of your rights, as I have previously written about here and here.

What Constitutes Abusive Treatment?

So, what constitutes abusive treatment?

One study defines “disrespectful care” as one or more of the following:5

  • Physical abuse: use of force or physical restraint during delivery.
  • Sexual abuse: sexual abuse or rape.
  • Verbal abuse: harsh language, including judgmental or accusatory comments, threats of withholding treatment or of poor outcomes, and/or blaming for poor outcomes.
  • Stigma and discrimination: discrimination based on ethnicity, race, religion, age, socioeconomic status, or HIV status.
  • Failure to meet professional standards of care: lack of informed consent and confidentiality, refusal to provide pain relief, performance of unconsented surgical operations, and/or neglect or abandonment.
  • Poor rapport between women and providers: ineffective communication, lack of supportive care, and loss of autonomy.
  • Health system conditions and constraints: lack of resources, including staffing constraints and shortages, supply constraints, and lack of privacy, lack of redress, and problems with facility culture.

How Common Is Abusive Treatment in the U.S.?

As we shall see in these recent studies, most instances of abusive treatment don’t rise to the level of “egregious,” as, for example, instances of forced cesarean surgery. Nevertheless, as with abuse in the workplace or home, whether subtle or blatant, the damage to the victim is done. (Note: abusive treatment during pregnancy and birth is a world-wide phenomenon. Specifically, while I confined the studies in this post to U.S. studies, for those of you living in Canada, the U.K., or Australia, I have recent studies in my files finding similar results to the U.S. studies I cite here.)

Note: All of these studies collected data from births that occurred outside of the COVID-19 pandemic years, which would have been a confounding factor for quality of care.

In one study, 2,781 U.S. and Canadian doulas and nurses responded to a survey regarding their observations of disrespectful care during childbirth.5 The following percentages responded “occasionally” or “often” to these questions:

  • 65%: “Have you witnessed a care provider engage in procedures without giving the woman the choice or time to consider the procedure?
  • 33%: “Have you witnessed a care provider tell a woman that her baby might die if she does not agree to a proposed procedure?”
  • 22%: “Have you observed a laboring woman receive more procedures because of her racial or ethnic background?”
  • 18%: “Have you witnessed a care provider engage in procedures explicitly against the wishes of the woman?”
  • 11%: “Have you heard a care provider mention a woman’s racial or ethnic background in a way that was demeaning?”
  • 9%: “Have you witnessed a care provider use sexually degrading language with a laboring woman?”

In a second study, 2,138 mothers responded to a survey regarding their experiences of inequity and mistreatment during childbirth in the U.S..7 The following percentages responded “yes” to these statements:

  • 9%: “Health care providers (doctors, midwives, or nurses) shouted at or scolded you.”
  • 8%: “Health care providers ignored you, refused your request for help, or failed to respond to requests for help in a reasonable amount of time.”
  • 6%: “Your physical privacy was violated (i.e., being uncovered or having people in the delivery room without your consent).”
  • 5%: “Health care providers threatened to withhold treatment or to force you to accept treatment you did not want.”
  • 2%: “Health care providers threatened you in any other way.”
  • 1%: “You experienced physical abuse (including aggressive physical contact, inappropriate sexual contact, refusal to provide anesthesia for an episiotomy, etc.).”
  • 1%: “Your private or personal information was shared without your consent.”
  • 17% experienced one or more of the above.

    The study also found that these factors increased the likelihood of mistreatment:
  • Being a person of color
  • Young age
  • Low socioeconomic status
  • Pregnancy complications
  • Elevated social risk, i.e., substance use or incarceration
  • Having a hospital as the place of birth (vs. free-standing birth center or home)
  • Being transferred from a birth center or home into the hospital
  • Having an unplanned cesarean or instrumental vaginal birth
  • Having a difference of opinion with their care provider

Of note, having a difference of opinion with the care provider resulted in the highest rates of experiencing mistreatment (79%).

In addition, for many of these factors, respondents of color were more likely to experience mistreatment compared with respondents having these same factors who were White.

Finally, a third study analyzed data from a survey of 2,402 U.S. mothers conducted in 2023.4 The following percentages responded “yes” to these statements:

  • 10%: “Health care providers ignored you, refused your request for help, or failed to respond to requests for help in a reasonable amount of time.”
  • 7%: “Health care providers (doctors, midwives, or nurses) shouted at or scolded you.”
  • 5%: “Your physical privacy was violated (i.e., being uncovered or having people in the delivery room without your consent).”
  • 5%: “Health care providers threatened to withhold treatment or to force you to accept treatment you did not want.”
  • 4%: “Your private or personal information was shared without your consent.”
  • 4%: “Health care providers threatened you in any other way.”
  • 4%: “You experienced physical abuse (including aggressive physical contact, inappropriate sexual contact, refusal to provide anesthesia for an episiotomy, etc.)”
  • 20% experienced one or more of the above.

    Overall, 29% of respondents reported experiencing discrimination for one or more of these reasons:
  • Race, ethnicity, or skin color
  • Disability status
  • Immigration status
  • Age
  • Weight
  • Income
  • Sexual orientation
  • Religion
  • Language or accent
  • Type or lack of health insurance
  • Difference of opinion with caregivers about the right care for themselves or their baby
  • Use of substances (alcohol, tobacco, or other drugs)
  • Involvement with the justice system (jail or prison)

As with the second study, respondents of color were more likely to report discrimination for these reasons than respondents who were White. For example, only 2% of White respondents reported experiencing discrimination because of their race, ethnicity, or skin color compared with 13% of Black respondents, 11% of multiracial respondents; 9% of indigenous American/first nations respondents; 7% of Hispanic respondents, and 6% of Asian respondents.

As these surveys demonstrate, abusive treatment is more likely if you are a person of color, but you are by no means immune if you are White.

How Can You Protect Yourself?

This brings us to what you can do to protect yourself. Let’s start with your care providers and your planned place of birth. If the answers to any of these questions are unsatisfactory, don’t make the mistake of thinking that it will be okay at the birth. If at all possible, you would be well advised to look elsewhere for your care.

  • Choose care providers (or confirm that you have chosen care providers) who will respect your right to informed refusal:
    • Ask your doctor or midwife what happens if, after discussion, you turn down a recommendation.
    • Because doctors and midwives generally work in groups, if the answer is satisfactory, ask how you can ensure that whoever attends the birth takes the same approach.
      Tip: A midwife is more likely to provide respectful care.7
  • Choose care providers (or confirm that you have chosen care providers) who respect your autonomy:
    • Ask your care provider their opinion of doulas. Discouraging having a doula is a sign your care provider wants to control your access to outside influence.
    • Ask your care provider their opinion of birth plans. Discouraging a birth plan indicates that your care provider doesn’t recognize your right to participate in decisions about your care.
    • Regarding birth plans, at least, if the care provider’s response is satisfactory, ask: “How can I ensure that the person who attends me in labor will abide by any agreements that you and I may make?”
  • Evaluate interactions during your prenatal visits. Ask yourself:
    • Do I feel rushed?
    • Do I feel listened to?
    • Does this person respect my right to make the ultimate decisions about my care?
    • Were there any red flag responses? Did she or he . . .
      • use scare tactics: “I want to induce labor when you reach 39 weeks. There’s no reason not to, and even though you’re healthy, you never know what might happen if we wait.”
      • bully you: “Decisions will be made by me and are not negotiable.”
      • give you only vague answers: “I only do cesareans when it’s necessary.”
      • get angry: “And what medical school did you go to?”
      • patronize you: “Don’t worry; just relax and let me take care of everything.”
      • ridicule you: “Natural childbirth? Why would you want to suffer in this day and age?”
  • Choose a birth setting (or confirm that you have chosen a birth setting) where your right to informed refusal will be respected:
    • Request a copy of the hospital’s admission consent form. Some forms give blanket permission to perform any treatment or procedure, including cesarean surgery, without seeking further permission. If your hospital’s form is one of those, ask if the form can be modified to stipulate that barring emergency circumstances that deprive you of the capacity to make decisions, you will give consent or refusal on a case-by-case basis for any proposed medications, treatments, tests, or restrictions.
    • On your hospital tour, ask: “What is the general opinion of doulas?” As with your care provider, a negative opinion is a red flag.
      Tips:

      • If you have already engaged a doula, ask what their experience has been at the hospital where you plan to have your baby.
      • Consider a home birth or birth at a free-standing birth center. You are far more likely to receive respectful care in these settings.7

What measures can you take when you are in labor?

  • Exercise your right to make informed decisions about your care. Use the BRAIN acronym to help you do this.

Benefits
Risks
Alternatives
Instinct/intuition
No or not now

As we saw above, if a test, procedure, medication, or restriction is proposed to you, you have the right to know its benefits, in other words, why it is being recommended, and its risks, that is, the potential harms. You are also entitled to know your alternatives, including doing nothing for now, and the benefits and risks of your alternatives. After you have taken in the information, consider what your intuition or instinct is telling you because your gut feelings are important too. Finally, as we also saw above, you have the right to say No or “Not now.” When declining treatment, it may help avoid confrontation if you discuss what would lead you to consider changing your mind rather than giving a flat “no.”

  • Slow down the decision-making process. Once you have the information, ask for time alone to think it over. That will give you the opportunity to discuss it with your intimate partner and your doula if you have one. The conversation may also generate additional questions or concerns you wish to raise with your care provider or alternatives you wish to discuss before making up your mind.
  • Maintain a united front. One not uncommon strategy is an attempt to coopt your intimate partner to assist in getting you to change your mind.
  • Request a different nurse. Don’t be drawn into an argument. Just keep politely repeating your request. Depending on how labor care is organized at this hospital, you may be able to request a different doctor.

These suggestions should help prevent your experiencing abusive treatment, but nothing is foolproof. At least now you can recognize what is happening. That recognition can help you decide what’s best to do, given your circumstances, and that agency is something, even if it is no more than the ability to choose your least worst option.

The consciousness that you were abusively treated in labor can also help if you find yourself dealing with symptoms of childbirth-related posttraumatic distress afterward, and that can help you get the appropriate treatment. This article and this one provide helpful information on this topic.

References

  1. ACOG. Committee Opinion No. 664: Refusal of Medically Recommended Treatment During Pregnancy. Obstet Gynecol 2016;127(6):e175-e82.
  2. ACOG. Informed Consent and Shared Decision Making in Obstetrics and Gynecology: ACOG Committee Opinion, Number 819. Obstet Gynecol 2021;137(2):e34-e41.
  3. Declercq ER, Cheng ER, Sakala C. Does maternity care decision-making conform to shared decision- making standards for repeat cesarean and labor induction after suspected macrosomia? Birth 2018;45(3):236-44.
  4. Mohamoud YA, Cassidy E, Fuchs E, et al. Vital Signs: Maternity Care Experiences – United States, April 2023. MMWR Morb Mortal Wkly Rep 2023;72(35):961-7.
  5. Morton CH, Henley MM, Seacrist M, et al. Bearing witness: United States and Canadian maternity support workers’ observations of disrespectful care in childbirth. Birth 2018.
  6. Speak Up for Your Rights. 2019. (Accessed Jul 16, 2023, at https://www.jointcommission.org/-/media/tjc/documents/resources/speak-up/speak-ups/for-your-rights/speak-up-for-your-rights-85-x-11_.pdf 7/16/2023)
  7. Vedam S, Stoll K, Taiwo TK, et al. The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reprod Health 2019;16(1):77.

 

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