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Posts Tagged ‘medical ethics’

(TMI alert, especially for the medically squeamish, and trigger alert for medical violence.)

The story of how I birthed my first child is a far cry from the dimly-lit, romantic scenarios pictured in hospital brochures and natural birth guides alike.

The Bear got stuck before his head was even properly engaged. I was in Germany, so you can’t blame what happened next on medicalized childbirth, American-style. I did have an epidural (at my own request, nay, demand!) and enough Pitocin to deliver a small elephant. My midwife tried acupuncture. We tried every possible position: all fours, squatting, draped over an elevated bed with my head hanging down. I even swallowed some homeopathic remedy. This was Germany, after all.

Still, he was stuck. After seven hours (!) of being fully dilated – which is four or five hours longer than a U.S. ob/gyn would tolerate without a c-section – my midwife had to turn me over to a doctor. Even then, he didn’t go straight for the knife. He proposed trying vacuum extraction, with a c-section as backup. Three tugs, three giant pushes, and three mighty shoves on the top of my uterus – out came the Bear.

I was grateful my son was healthy, and glad I’d avoided a cesarean. I thought I’d gotten off easy. The recovery proved me wrong. I’d lost a lot of blood and my healing was difficult and incomplete. In the long run, I probably would have been far better off with a c-section. The pushing on my uterus (“fundal pressure”) did a lot of damage to my pelvic floor, which persists a decade later. I was given a lengthy consent form that explained the risks of a potential c-section, but it said nothing about the risks of fundal pressure and vacuum extraction, particularly an extraction from so high in the pelvis.

In other words, I had no crack at informed consent for what was actually done to me. And I don’t want to hear that none of it matters since my baby was healthy. The violence of my delivery severely affected my ability to be an effective mother. Try hauling around a 13-pound infant six weeks postpartum, feeling as though your viscera are about to fall out. Then try it again with a 19-pounder at four months. The Bear was not a sleepy, contented baby. He was irked at the world. He needed to be walked around. I couldn’t do it. Not on the scale he demanded. For optimal healing, I shouldn’t have been lifting anything heavier than ten pounds. I felt utterly trapped.

Many women have traumatic childbirth stories. Many are uglier than mine and revolve around disrespect by medical personnel, which sometimes edges into outright violation. Over the past few years, some birth activists and feminists have started to label such stories “birth rape.” The term struck me as wrong when I first saw it (which I’m pretty sure was this post at the F Word). So I was glad to see a flurry of criticism ripple through the feminist blogosphere over the past few days, starting with Irin Carmon at Jezebel and then spreading to Amanda Marcotte at XX, Tracy Clark-Flory at Broadsheet, and Lindsay Beyerstein at Big Think. Even my friend figleaf has weighed in against using “rape” to characterize traumatic birth experiences.

In discussions of sexual violence, it’s not unusual for women who’ve actually experienced the trauma in question to use their experience as a trump card against anyone who disagrees with them. Ditto for childbirth experiences. In actuality, experiences vary, as do our interpretations of them. One woman may feel violated by a c-section, while another might feel relief.

So far, none of the feminist bloggers who’ve criticized “birth rape” have actually experienced childbirth in their own flesh. Their opponents may well say that this disqualifies them. I’m weighing in to support them, partly as a mother (and partly as a professional historian of childbirth and critic of medicalizaiton) who has in fact experienced a failure of informed consent and a traumatic birth (and who has studied some truly egregious instances of it in the past). Of course, my labor experiences don’t give me the right to trivialize other women’s feelings of violations, and I would never want to do that. At the same time, the trauma women experience doesn’t justify the inflationary and misleading use of “rape” to describe violations of medical consent.

It’s important that we can talk about birth trauma. We need a language of childbirth that will help us protect women’s autonomy. But it’s hyperbolic to call incidents of unwanted vaginal exams or artificial rupture of the membranes “rape.” It does an injustice to victims of actual rape by conflating two different phenomena, thus watering down the meaning of “rape.” It’s not as bad as the trivialization that goes along with saying, “Man, that test really raped me,” but both uses are on a continuum, because they’re both metaphorical, not literal.

I realize that proponents of the term say that a speculum is no different than a penis. Here’s how Amity Reed expressed it at the F Word:

A woman who is raped while giving birth does not experience the assault in a way that fits neatly within the typical definitions we hold true in civilised society. A penis is usually nowhere to be found in the story and the perpetrator may not even possess one. But fingers, hands, suction cups, forceps, needles and scissors… these are the tools of birth rape and they are wielded with as much force and as little consent as if a stranger grabbed a passer-by off the street and tied her up before having his way with her. Women are slapped, told to shut up, stop making noise and a nuisance of themselves, that they deserve this, that they shouldn’t have opened their legs nine months ago if they didn’t want to open them now. They are threatened, intimidated and bullied into submitting to procedures they do not need and interventions they do not want. Some are physically restrained from moving, their legs held open or their stomachs pushed on.

These things happened commonly in the past, and they still occur today. A commenter at Salon wrote:

Once, while still a nursing student, I heard a nursing supervisor inform a screaming patient in labor – “maybe you should have yelled like that 9 months ago and you wouldnt be here”. Later, during my own labors, I remembered her remark and it made me smile.

She smiled? Boy, I’m glad she didn’t attend one of my births. And it gets worse. A self-identified midwife commented at Salon:

The quickest example I can come up with is the time a doula friend of mine heard the OB say while a VBAC mom was pushing (pretty much under his breath, I don’t even think the mom heard this): “It’s the LEAST you can do for your VBAC” and he put one end of the scissors in her vagina and one in her anus and cut her a 4th degree episiotomy. No fetal distress, no reason beyond what I guess was his irritation at not just doing a repeat cesarean?

(Her whole comment was terrific, if you can stand to wade through the morass of misogyny that is Salon’s comment section.)

Stories like these are appalling. I feel sick and angry when I read them.

And yet, this is not rape. There’s nothing sexual about it, even though the assault is perpetrated on a woman’s genitals.

Let’s take a look at the legal definition of “rape.” It requires, as Amanda Marcotte points out, intent to violate someone sexually against her will. This is what the law calls “mens rea,” or awareness that one is committing a crime. If a prosecutor fails to demonstrate mens rea in a rape case, it’s still possible to convict on a lesser count of sexual assault (e.g., gross sexual imposition). “Rape,” however, is off the table.

The intent of this OB was to hurry the birth along. I don’t think it’s a stretch to say that he was also high on his own power, getting off on his dominance. But he wasn’t getting off sexually. Nor was he intending to commit a sexual act. What he perpetrated was neither rape nor a lesser form of sexual assault.

“Birth rape” is not just an exaggeration, though. It also does not say enough. It fails to specify what makes such violations of autonomy in labor reprehensible in their own awful way. First, doctors and nurses enjoy a high degree of trust. The minority of them who break our trust deserve contempt. Similarly, the discourse on medical ethics has been hammering on the importance of informed consent for the past few decades. We rightly expect medical professionals to have internalized this. Most of all, a woman in labor is extremely vulnerable. I don’t know of any situation where I’ve felt comparably exposed, defenseless, and liminal. To receive abuse from the very person charged with expecting you and your child has got to leave emotional scars.

What should we call these violations, then, if not “rape”? Well, “medical battery” works for me. (“Medical assault” would be more satisfying because of the parallel to “sexual assault,” but legally the correct category, as far as I understand, is battery, not assault.) I would also distinguish between situations where real bodily harm is perpetrated, as opposed to assholish behavior such as slut-shaming women in labor, and also as opposed to neglect of informed consent, such as I experienced. (I’m not speaking here of outright malpractice, though some cases of abuse may also constitute malpractice too.)

Medical battery in childbirth ought to be treated as a criminal offense. That’s not a stretch, legally. For instance, except in an emergency, a physician who performs surgery against the patient’s will is guilty of battery, and is subject to both criminal and civil law. Even failure to obtain informed consent is already subject to criminal penalties. In cases of assholish behavior or flawed consent (as in my own experience), medical professionals should be sanctioned by their peers. In those cases where professionals protect their own and refuse to discipline offenders, patients should go public with their stories.

The law already supports a woman’s right to autonomy in labor, just like it does for any other patient. Actually enforcing that right in court is tricky. Doctors may argue that they were forced to act due to an emergency. Proving otherwise may be difficult. But just the awareness that medical battery carries penalties could work as a deterrent to battery and lesser forms of abuse. In addition, it might serve as a counterweight to the pressure OBs often feel to take action – any action, even if it’s not supported by evidence – to avoid a later malpractice suit.

To avoid failures of informed consent, obstetrical doctors and nurses could do much more to enlighten expectant mothers on possible interventions, their justifications, and their risks. I would have been better off if I’d been provided any information on the risks of vacuum extraction. I knew a lot about forceps because they were used in the period of history I study. Vacuum extractors are newer, and so I was flying blind, even though I was an exceptionally well-educated parturient. I didn’t even know that vacuum extraction carries a significant risk of damage to the baby’s brachial nerves. Most women would’ve known less. This is just not necessary in childbirth, where there’s usually nine months to prepare and become truly informed. And yet, neither doctors nor nurses nor midwives nor childbirth educators are really preparing the women whose bodies and children are at stake.

I don’t imagine that these potential solutions would be a panacea. I do think, though, that they’re closer to the mark than the tactics that a notion of “birth rape” would suggest.

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