The US maternal mortality rate is higher than it was a quarter of a century ago. For every one person that dies, another 65 almost die. We do not adequately care for mothers and mothers-to-be. Not only that, but as providers, we inadvertently (and at times overtly) inflict obstetric violence, through both individual actions and our complacency in institutionalized policies. It is time for the health care system to turn from obstetric violence toward Birth Justice.
One in three experience trauma during birth
Black mothers are three to four times more likely to die than their White counterparts. And the Black-White infant mortality gap is larger than during chattel slavery. Why? These inequities do not appear to be not explained by socioeconomic status or access to healthcare. Evidence suggests that this may be partly explained by the chronic stress of living in a racist society. 
Above and beyond this societal stress, our maternity care system often disregards basic human rights. An estimated one in three pregnant people describe their births as traumatic. Trauma included untreated pain, a lack of control, and disrespect or lack of communication from their provider.
Obstetric violence includes physical, emotional, and sexual abuse of pregnant people as well as procedures delivered without consent. It is a largely intersectional issue that most often affects LGBTQIA+, Latinx, Black, Indigenous, and other People of Color.
A Struggle for Birth Justice
Earlier this year, I saw a young Black woman in triage for leakage of fluid. She was just halfway into her pregnancy. Her cervix was dilated and she delivered a pre-viable fetus later that day. Her partner, a Black man, was devastated and angry. Someone summoned security as if he (the mother’s support person and grieving father) posed a threat. It was Black Maternal Health Week. The racist irony was lost on most.
A growing Birth Justice movement is closely related to the Reproductive Justice movement. It is led by BIPOC communities, born out of a long history of reproductive oppression. The focus is on a birthing person’s ability to make their own decisions and to be treated with respect during pregnancy, birth, and the postpartum period. Despite the medical field’s troubled history, we continue to shame and violate birthing people’s bodily and decision-making autonomy on a daily basis.
The following are four areas in which we could change to promote Birth Justice.
Urine Drug Screens
I often think about a certain woman I met on labor and delivery. Someone thought she was acting weird when she arrived – she was nine centimeters dilated. They ordered a urine drug screen (UDS). She delivered a healthy baby girl. Her urine showed traces of marijuana. They called Child Protective Services (CPS) on the child’s first day of life.
CPS is a carceral system that primarily targets Black, Brown, and low-income families. By the end of the 1960s, mandated reporting was required in all 50 states. In the late eighties, the war on drugs and increased use of crack cocaine doubled the number of CPS removals. We now know the concern about prenatal crack-cocaine use was mostly unfounded. All the same, the ripple effect of fear has led to an expansion of prison populations and the foster care system, both of which overwhelmingly affects Black families.
Drug use rates are similar among Black and White people. Yet Black infants are much more likely to be screened. Many states do not have a law requiring UDS reporting; but in practice, physicians report most positive screens.
Some states now require informed consent prior to collecting a urine drug screen. But despite new legislation, consent is still rarely obtained properly or at all. Groups like the Movement for Family Power are fighting to change this. Their research illustrates the way that our surveillance of mothers and babies is akin to the New Jane Crow. If you live in New York, call your senator to support their bill.
Shackling in Pregnancy and Labor
A pregnant woman and her partner were fighting; he shoved her, and she shoved back. He called the police and said it was her fault. They sent her to the hospital for monitoring. She arrived in police custody. When I met her, her arm and leg were shackled to the bed. When the medical team protested and escalated the issue, the police supervisor removed only one. They said she was a “flight risk”. She remained in the room all night, with one arm attached to the stretcher and a police officer at her side.
In 2018, the First Step Act prohibited the use of restraints during pregnancy, labor, and the early postpartum period. Yet of the more 225,000 incarcerated women nationwide–75% of whom are of reproductive age–only 15% are protected by the law since it only pertains to federal (not state) prisons. Moreover, it leaves loopholes for medical providers and officers to decide if there is a “safety concern”, as mentioned above.
Some states have similar legislation prohibiting the use of restraints during any part of pregnancy care. Unfortunately, research has shown that many healthcare professionals do not know the laws. Look up if your state has a policy, and if not, write to your representative about how your state lags behind.
Mandated Cesarean Sections
In 2014 in Brooklyn, a woman named Rinat Dray had a cesarean section. A doctor opened her abdomen, separated the layers of her abdominal wall, cut into her uterus, lacerated and repaired her bladder and removed her baby. All without consent. Hospital policy stated that physicians could do so if they believed the life of the fetus is at risk. Her lawsuit against the hospital has been unsuccessful to date, reminding us how hard it can be for patients to fight for control in medical decision-making.
A cesarean section can be as violent and political as it can be lifesaving. Maternal-fetal conflict policies allows physicians to completely ignore the autonomy of the birthing person. Both the American Academy of Pediatrics and College of Obstetricians and Gynecologists stand against mandated C-sections. Yet many hospitals continue the practice. More frequently, providers forgo consent in other procedures like episiotomies and even in simple procedures like vaginal exams.
VBAC Calculators
Ms. Dray was attempting a trial of labor after a cesarean. After one cesarean, patients are usually offered a repeat because of the risk of uterine rupture, a rare but dangerous complication of labor. Until this year, the calculator used to help physicians determine a person’s chances of vaginal birth after cesarean (VBAC) asked if the person was “African American” or “Hispanic or Latino”. The inclusion of such a social (rather than biological) factor, was likely perpetuating the overuse of C-sections in those women.
Overall cesarean rates in the U.S. have been rising for years and rates are highest among Black women, likely due in part to higher repeat C-section rates. Surgery done without consent attempt control the birthing person’s body, and are eerily reminiscent of antebellum gynecology. It also reflects the focus on infant mortality over maternal mortality, which has decreased significantly while maternal mortality continues to rise.
For health care providers reading this, talk to your patients about their rights and offer them the opportunity to choose a physician or midwife, location of delivery (considering current medical conditions), and offer to connect them with a doula or birth advocate. There is evidence that doulas can help reduce the likelihood of having a C-section and improve other birth outcomes.
Be An Advocate, Not an Aggressor
Racial bias, patriarchy, and hierarchy pervade westernized medicine, maternal-child health included. We need to stop the various forms of maternal violence and heal the relationship between providers and their patients and communities. And to do so, we need to hear and learn about the ways that the medical field has inflicted trauma.
For me, and others who identify as maternal caregivers, this idea that we may be doing harm can be painful. It feels easier to dismiss responsibility as a pawn in the medical-industrial complex. With the professional titles we earn, we have more power than patients. We should be their advocate, not their aggressor. Where do we start?
- Read about Birth Justice and collaborate with other care providers (doulas, midwives) and community organizations.
- Listen to your patients. Take it seriously if they say something is wrong. Treat their pain. Ask if they understand what’s going on. Use shared decision-making.
- Practice asking for consent. Full informed consent is incredibly nuanced and important. Include the consequences when talking about urine drug screens (if necessary at all). For exams and procedures, consider obtaining consent a continual process. Is the patient still okay with this vaginal exam? Has she asked you to stop?
- Know your state law regarding police engagement with pregnant people. If police aren’t following the law, write down their badge number and ask to speak with supervisors.
- Speak up. If something doesn’t feel right, it probably isn’t. From lack of consent to rude and racist comments and disregard for patient autonomy, the culture of obstetrics and medicine at large must change.
- Support governmental and institutional policies that promote reproductive justice and reduce infant and maternal mortality. From lack of paid parental leave, limited access to fertility treatment, and short post-partum Medicaid coverage [pdf], we have a long way to go.
Libby Wetterer