My First Childbirth Felt Like Assault!

Initially published by Bright Magazine.

Childbirth should not strip a woman of the right to informed consent. But in practice, it sometimes does.

By Family Resemblance

When Kimberly Turbin arrived at a California hospital to give birth in 2013, she made sure to tell a nurse that she has a history of sexual abuse. She was feeling scared and, upon going into labor, began to have a PTSD-related panic attack, so she requested that the healthcare professionals attending to her tell her what they are doing and why before touching her. The nurse said she would tell everyone, including the doctor.

A camera captured the entire birth. The video will later go viral. Turbin was just starting to push when Dr. Alex Abbassi, a physician she had only met once before, was seen on video with scissors and cloth. He informed her that he was going to do an episiotomy, a surgical cut in the perineum (the muscular area between the vagina and the anus) to enlarge the vaginal opening before birth.

Episiotomies used to be performed routinely because they were thought to heal better than natural tears. Thirty years of evidence, however, has shown the opposite is true, with increased risks of blood loss and postpartum pain. Now episiotomies are only recommended if the baby’s heart rate drops too much during pushing or the baby’s position is causing problems. Neither was true in Turbin’s situation. (Despite current best practices, some physicians still regularly perform episiotomies, either because they are not up to date on the latest evidence-based medicine or because they want to speed up labour.)

“Why? We haven’t even tried,” Turbin asked Abbassi in the video. In response, Abbassi told her that her baby will rip her “butthole down clean.” He did not provide a medical reason for this. Turbin repeatedly refused the episiotomy. She came in knowing she didn’t want one.She again asked why she couldn’t try to push without an episiotomy. “What do you mean, ‘Why’? I am the expert here, OK?” Abbassi said. “You can go home and do it! You go to Kentucky!”

Turbin was cut 12 times and her baby was born. Kimberly felt like crying and was horrified when he was cutting her.

Records don’t show any medical reason for Turbin’s episiotomy. In one version of the video, a written note pops up. It’s from Michael Klein, one of the doctors who spearheaded the research on the efficacy of episiotomies. He thinks Abbassi was too impatient to wait for the perineum to stretch.

Every person, regardless of pregnancy status, has the right to informed consent, refuse medical treatment, equal treatment, privacy, and life. (This right was recently codified by the nonprofit Human Rights in Childbirth.) While healthcare professionals can recommend a treatment, the decision to consent to or refuse a procedure is ultimately in the patient’s hands, as long as they are a competent adult.

Childbirth should not strip a person of these rights, yet in practice it sometimes does. While Turbin’s story is particularly horrifying, it is not unique; in one 2015 survey of 2,400 women in the United States, less than half of the respondents who had had an episiotomy said they felt they had a choice about the procedure. Women who give birth often report feeling like they did not have control of their medical care, including the right to make informed choices or refuse care.

Mistreatment during childbirth is a global problem, with abuse ranging from coercive or unconsented medical procedures to poor care and verbal and physical abuse.

One of the most widespread abuses during childbirth is not providing women with enough information to make an informed decision. You can’t truly consent to a procedure if you aren’t provided with accurate information and fully informed of the risks and benefits.

For instance, women with low-risk pregnancies are rarely told that, according to a retrospective population-based study, a C-section will make them three times more likely than women who delivered vaginally to suffer from complications — or even die. A lack of informed consent could be one of the reasons for the U.S.’s high C-section rate (33 percent, versus the WHO’s recommended 15 percent).

“The mistreatment is similar everywhere, although the abuses are more dramatic and extreme in places where women are more dramatically disempowered,” said Hermine Hayes-Klein, a human rights lawyer and the founder of Human Rights in Childbirth. “This is particularly true in countries where women don’t have reproductive control, and are denied access to contraception and abortion.”

People who are the least likely to be listened to or have recourse — women of color, teenagers, unmarried women, women of low socio-economic status, migrant women, women from ethnic minorities, women with HIV — are especially at risk for abuse.

The Mistreatment of Women during Childbirth in Health Facilities Globally, which analyzed 65 studies from 34 countries, found that women who fit these categories were beaten for noncompliance, verbally abused, withheld treatment, and detained at health facilities at higher rates than other populations.

For women that already don’t have a voice in their everyday lives, this is especially traumatic. Mistreatment during childbirth can lead to postpartum depression or even PTSD. It could also, frighteningly, deter women from seeking skilled care in the future.

Turbin’s episiotomy left her with physical and emotional injuries, including recurrence of trauma associated with her prior sexual assaults. After the birth, she was in pain constantly. She bled for months. It was hard for her to sit or breastfeed her son. She was afraid to use the bathroom and continues to take fiber to soften her stools. She suffered from pelvic pains.

She still gets flashbacks and is afraid to have additional children, although she wants more. The idea of having no control over her body in a hospital setting scares her.

Before Lindsay Switzer, a New Jersey attorney, had her second child she also planned to have more children. But after being coerced into an unnecessary C-section with her son, she’s not sure she can risk putting herself in that position again. She was fully dilated at 10 cm and being assisted by a midwife and doula, when the physician on call started yelling at her, demanding that she be put on a fetal monitor. Up to that point, Switzer had been laboring with minimal interventions. When the physician walked in, Switzer was on all fours and pushing (one of several positions that helps your uterus muscles work and uses gravity to open your pelvis).

“I think she walked into room, saw someone laboring on her own terms and couldn’t handle it,” said Switzer.

Almost right away, the physician pushed for a C-section. In the medical records, the physician claimed that the baby’s heart rate had decelerated to such an extent that a C-section was necessary. While his heart did slow down three times during a contraction, the baby recovered.

The physician went on to suggest that if she didn’t have a C-section her baby could have brain damage and threatened to call child protective services and remove her older child.

Though Switzer signed the consent form for a C-section, “I would never say I consented. While it was happening, I was completely shut down. We think of reactions to threats as flight or fright, but you can also just freeze, and I froze. On the surgery table, she was talking about going out that night. She even asked if I had any other special requests, since I was being so difficult. It was total disassociation for me.”

For a couple months, Switzer thought she was fine, but then she started having flashbacks and anxiety attacks. She was later diagnosed with complex PTSD. She filed a complaint with the board of medical examiners but they found nothing wrong. Eventually she sued the physician, who in her deposition said she had to take a patriarchal approach to Switzer’s care and didn’t believe that she needed to get informed consent from her laboring patients.

“I felt like I was treated like a car in a repair shop, not a person,” said Switzer.

In almost every other scenario, it would be unthinkable for someone to go into the hospital for a routine procedure and not be listened to, but when it comes to childbirth it’s considered normal.

As Susan Hodges explained in a 2009 article, “Abuse in the hospital-based birth setting may not seem the same as domestic abuse and violence, but it is no less harmful. Verbal abuse includes behaviors such as threatening, scolding, ridiculing, shaming, coercing, yelling, belittling, lying, manipulating, mocking, dismissing, and refusing to acknowledge — behaviors that undermine the recipient’s self-esteem while enhancing the abuser’s sense of power… Most of us would recognize these as abusive behaviors in just about any other setting. However, because we are socialized to both expect trustworthy and professional behavior in the hospital setting and to be ‘compliant’ with medical directives, these behaviors are seldom recognized and interpreted as abuse.”

Power imbalances between healthcare professionals and patients, restrictive hospital polices that don’t always take into account the latest evidence-based medicine, and the expectation that birth is injurious by definition, have allowed abuse during childbirth to persist.

“Women often think that’s the way it’s supposed to be. The reality is we are mistaking the trauma of the maternity care system for the trauma of childbirth,” said Dawn Thompson, president and founder of improving birth and former Vice President of the San Diego Birth Network.

Many women may not even recognize the problem and remain silent. Which means the problem could be a lot more widespread than is reported. And even when it is recognized, there is little recourse. There isn’t enough leadership regarding human rights in childbirth, and a corresponding lack of enforcement for national laws.

Suzanne Mohammad, a registered nurse who is involved with humanitarian health care, encountered all of these issues when she gave birth in her native Jordan. (Her name has been changed for privacy concerns). She was forced to have an episiotomy after arriving at a public hospital fully dilated and ready to push. In Jordan, there is the persistent belief that first-time mothers have tight vaginas that will tear horribly if they aren’t surgically cut and stitched. They also believe being sewn will also keep women tight. Correspondingly, the episiotomy rate is 41.4 percent.

“I tried to explain to them the research…in a very clear-headed manner, despite being in second-stage labor,” said Mohammad. “I hadn’t taken any pethidine or had any epidural (which includes morphine) and was not in any altered state. I was very much aware and capable. I was studying for my nursing final exams. I wanted them to understand.” They pulled, pushed, hit, ridiculed, insulted and humiliated her in an attempt to coerce her. They told her her baby would die without an episiotomy. They threatened to abandon her (to which she replied, “Please do”). They shushed her for moaning and discouraged her from moving.

When an obstetrician came in impatient and angry, she realized things were no longer in her hands. She knew she was defeated.

“Not being listened to or protected from harm had been a greater theme in my life, with my family and marriage,” said Mohammad. “This felt like further abandonment, abuse, and exploitation — more harassment, humiliation and intimidation… I felt like I was completely capable and in control of my body, but estranged and forsaken. I was content that I had not hurt my baby in any way and had to accept being hurt myself in order to birth her safely. I wanted my husband to intervene and protect me. Neither happened.”

She had urinary incontinence and pain during intercourse for a year, and like many of the women in this article, PTSD.

Obstetricians who practice respectful maternity care — i.e., care that respects women’s basic human rights, including their autonomy, dignity, feelings, choices, and preferences — help combat the problem on an individual level. Likewise, media attention from Turbin’s case and two other recent cases (brought by Caroline Malatesta and Michelle Mitchell) have gotten more people talking about maternity care. “Media attention may be the best defense against these practices,” said Mark Merin, Turbin’s lawyer. “It’s cases with this kind of notoriety that will help.”

Most national and international organizations, including the WHO, agree that ensuring respectful care during childbirth requires a mix of advocacy, social justice, accountability, reeducation, and research.

When Turbin met with the director of women’s service at the hospital, she recalled that the director was careful with her words. She apologized and recommended filing a complaint with the medical board. She also said that the hospital could not do anything because Abbassi is only contracted with them.

Left with no other recourse, Turbin looked for a lawyer, and she crowdfunded legal fees. After 18 months and requesting the services of 80 lawyers, civil rights attorney Mark Merin finally agreed to take her case. In June 2016, the judge allowed the trial to go forward — becoming one of the only cases to acknowledge obstetric violence and human rights violations during childbirth.

“I filed the lawsuit because consent was so blatantly ignored and has been for so many others as well,” said Turbin. “I’m really glad it’s going forward as an assault and battery because it was. This proves obstetric violence is real and it highlights how important consent is while giving birth. I really hope it helps change the way providers act and treat their patients.”

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