This article contains stories of medical abuse that may be disturbing for some readers.

Most of us understand the importance of knowing our rights against the coercive force of the state. Yet there are other ways in which authority and power intervene to control people in dangerous ways. Coercion can be particularly pernicious when it comes to health care, where tragic violations like those of the Tuskegee experiment have demonstrated that medical authorities are no more trustworthy than political authorities in determining what happens to other people’s bodies.

Unfortunately, such violations are not historical artifacts, and one area where they continue today is maternity care.

Violations of consent during birth

Pregnancy and birth represent a particularly vulnerable time for women’s autonomy, and violations of consent during this time are not uncommon. Kimberly Turbin, for example, is a sexual assault survivor whose doctor cut her perineum 12 times while she is heard clearly verbally refusing consent to an episiotomy in the background.

Her case is disturbing and, unfortunately, not rare. What is rare about her case is that the incident was caught on video, which allowed for a civil suit against the doctor and an eventual settlement. You can read about Kimberly’s case and many other cases of violations of consent during birth here (warning: these stories may be disturbing for some readers). Other examples of violations and assault during birth can be found via the powerful Exposing the Silence Project.

For most relatively healthy women, pregnancy, labor, and delivery may be the only times in their lives when their bodies will be under the control of authority figures over whom, it would seem, they have little power. Women may have no idea what they will confront when they arrive at the hospital. And they may have little idea which procedures are evidence-based, which are not, and which they can refuse.

Just as the ACLU suggests that drivers know their rights when they get pulled over for a traffic stop, all women and their loved ones should read about and understand the rights they have over their bodies and how those rights translate into the real world of medical care.

A broken system

There are many contributing factors to violations of consent during childbirth. Some are related to the government policies outlined in my blog post last month. Others are linked to hospital policies and liability concerns. Some come down to simple conflicts of interest between the provider and the patient.

Physicians and nurses perform birthing procedures every day, on many women. It’s natural for practitioners to take an assembly line approach to care. But for the woman involved, her body is not simply an object to be placed on an assembly line. She’s a human being whose unique experiences and situation require individualized attention and who should retain complete control over her body and what happens to it.

This conflict between medical authority and patient autonomy is difficult to bridge, and the conflict can be seen in private discussions among doctors and nurses about “good” patients who submit quietly to medical authority and “bad” patients who question treatments and insist on taking an active role in medical care.

Submission is expected in hospitals in part because the assumption is that doctors and nurses want to help you. So being a “good” patient and going with the flow seems reasonable.

Putting the hospital’s needs first

Unfortunately, the system is not solely, or even sometimes mainly, set up to help women and their infants. As I mentioned in my last post on childbirth, many hospital protocols do not help women or their infants, but instead reduce the hospital’s liability, increase the staff’s efficiency, or, despite being completely outdated, adhere to hospital culture like vestigial limbs. Examples include mandates against eating or drinking while in labor (which are harmful to women, but reduce liability for hospitals), use of routine IV fluids for laboring women (which are harmful to women and may interfere with breastfeeding later, but which limit liability for hospitals and reduce staff labor load), and routine episiotomies (which are harmful to women and based on outdated research, but still common in some hospitals and practices).  You can find more information on evidence-based standards of care here and here, including the research on the examples given above.

Because so much of what can happen in labor is NOT actually in women’s best interests, being informed about what may happen and practicing both giving and refusing consent is imperative.

This is why birth plans – documents laying out a woman’s goals and preferences during birth – while so often ridiculed by the obstetrics community, are so important. Some birth plans, of course, are poorly written and demonstrate a lack of understanding by the women themselves of what happens during labor and delivery. This is why the best birth plans are constructed alongside one’s medical provider, not in isolation. But either way, documenting and paying attention to women’s wishes about what happens to their bodies is an integral and important part of high-quality medical care.

Being an informed patient who can self-advocate is crucial to moving through the medical system in a way that limits harm to both a woman and her infant. Doing so respectfully and politely is important as well, though admittedly not always possible given the stress of the labor and delivery process. But the vast majority of doctors and nurses are practicing medicine in what they know to be a broken system. These workers do not want to harm patients. They went into health care largely to help people. But they have jobs to do in a dysfunctional system, and it’s worthwhile to view them as allies rather than as cogs in the machine. Keep this in mind as you learn about your rights during pregnancy and childbirth.

Women’s rights during childbirth

Fortunately, after a series of tragedies, the courts have set clear standards on many issues surrounding birthing women’s rights. Note, this list is NOT exhaustive, and other organizations are in the process of creating more comprehensive lists (see another example here).

  • A woman may refuse any and all medical intervention, regardless of the harm such refusal may cause to the infant. In the eyes of the law, the mother’s right to control what happens to her body trumps any right the fetus has.
  • Hospitals CANNOT force a woman to undergo a procedure or treatment without her consent, even to save the life of the fetus (although depending on the stage of pregnancy, the hospital can refuse to treat a woman who rejects one facet of care).
  • Women have the right to ask questions about their care and inquire into alternatives.
  • A woman has the right to a second opinion. She can also request a different nurse or doctor, if one is available.
  • Consent forms signed during prenatal visits or at hospital admission do NOT count as ongoing consent to every procedure. Women have the right to refuse consent to any procedure at any time.
  • A woman has the absolute right to leave the hospital against medical advice, though doing so may limit the birth settings and providers available to her and may have insurance coverage implications.
  • Women have the right to request to speak to supervisors or to consult the hospital’s administration if they feel their rights are being violated.
  • Women have the right to privacy during pregnancy, labor, and delivery. This means the right to control how many people are in the delivery room, for example.
  • All women have the right to receive equal medical treatment regardless of their race, disability, HIV status, body mass index, and other factors. Some conditions do increase risks to the mother or infant during labor and delivery. A woman should know if she faces any of these risks and what the evidence-based approach to care is, given her health status.

How women can protect themselves before and during childbirth

  • Women should work with their medical providers ahead of time, if possible, to understand the likely scenarios that may develop and to construct a birth plan detailing how they would like to be treated.
  • Women should clearly make their wishes known (if possible) during hospital admission.
  • If a woman wishes to refuse consent to a procedure, she should make that refusal clear and repeat it as necessary.
  • A woman should recognize that unforeseen circumstances may make parts or all of her initial goals for birth irrelevant, but that she always retains the final control over her own body.
  • A woman should know the laws in her state that cover interventions on mothers and babies. Hospital staff may imply that a procedure is a legal requirement, but this may be inaccurate, depending on the intervention.
  • Hiring a support person such as a doula can help women advocate for themselves during the labor and delivery process. More information on the importance of doulas can be found here.

Other resources to inform and empower

Childbirth Connection – For information on evidence-based care during pregnancy and delivery.

Improving Birth – For information on evidence-based practices and women’s rights during pregnancy, labor, and delivery. Also has an emergency contact form for women whose rights are being violated during labor and who need immediate support.

Birth Monopoly – Advocates for evidence-based maternity care, works against obstetric violence and assault, and advocates against government policies that limit women’s care options.

Human Rights in Childbirth – For education and advocacy on women’s rights during pregnancy and childbirth.

The Joint Commission – Accredits and certifies hospitals in the United States. Violations of patient consent can be reported directly to its website.