For years, we’ve been told that the doctor knows best. Care providers are held up in many cases as the decision-maker, the one with the right answer; the person to whom we should defer for all sorts of personal and life-changing decisions. In the same way that we hold doctors to a high standard of care, we also give them a lot of decision-making power without necessarily questioning the why or the how in what they decide.
This approach, this submission to the “expert”, is more pronounced during pregnancy, particularly, I would argue, in Italy. Pregnancy is a time for joy but also a moment of continuous doubts and worries for both parents which sends us in search of answers and assurance that everything will be ok. However, I would argue that a greater deference without respect for fundamental human rights is dangerous in terms of trauma, both physically and emotionally for the birthing individual[i]. Considering that gender discrimination exists already for women in the medical community[ii] [iii], when we combine this discrimination with the perception of women during labour as incompetent[iv], the mistreatment of women and the attack on their bodily autonomy is more frequent than the general public realizes[v].
The use of general consent forms can allow hospital protocol and personal preferences of the doctor, rather than what is desired by the birthing parent, to determine many outcomes[vi]. While there has been a shift in many parts of the world towards a patient-centred approach, has this shift truly happened in Italy? Do we, as a culture, appreciate, understand and give importance to the rights of birthing individuals in Italy?
In a 2016 social media project, OVOItalia asked birthing individuals to share their experiences of trauma, violation and abuse at the hands of medical professionals during labour and delivery[vii]. Their responses, known already by many advocating for change, put a public light on a very serious issue in Italian hospitals. The response to their campaign was significant: over 1000 individuals responded with personal accounts of obstetrics violence. Some violations, such as this one, highlight an extreme violation that cannot be ignored:
“naked, on my back, surrounded by strangers, they block my shoulders, force my legs apart. They give me orders. They alternated sticking their hands in my vagina, they didn’t listen to my cries or my cry of “no” ….it seems like the scene of a group rape, instead it was my birth, then ending in an emergency caesarean.”
– anonymous contributor, OVOItalia #bastatacere campaign 2016, translated from Italian[viii]
In any medical situation, there must be a dialogue between the health care provider and the patient. This is not a request but rather it is a protected human right, even in Italy[ix]. The concepts of bodily autonomy and informed consent are protected by international and domestic law[x]. Yet despite this protection, many birthing individuals report receiving inadequate information and having their right to informed consent violated[xi]. Why do we tolerate this violation and let it continue?
Many factors play a role in the fact that birthing individuals all over the world, including Italy, are reluctant or unable to defend their rights and successfully have them respected. Many of the victims of these violations are already marginalized groups that garner little respect in the medical field[xii] (people of colour[xiii], Roma, aboriginal groups). We also have the cultural tendency to give great regard to what medical professionals say, even if they provide no medical basis for their decision, but rather a preference for a certain outcome.
The idea that nothing else besides a healthy baby matters also allows our rights to be violated without regard for the trauma or damage it inflicts. The response by those around us after birth continues this idea. The often-heard discourse: “why are you upset? You’ve got your baby. You should be happy” further perpetuates the idea that a birthing person’s body, emotional and mental well-being, as well as their legal rights, are far less important than those of an unborn or newly born child. The reality is that both a mother and the newborn have rights, particularly regarding bodily autonomy[xiv] whereas an unborn child does not. We need to place a greater weight on the mental, emotional and physical well-being of new parents rather than casting it aside in the hopes that greeting their new baby will erase everything else.
Some claim that obstetrics violence is so far ingrained in our society as normal that it is hard for many of us to even recognize it[xv] even by those who work in the field[xvi]. But once you take a deeper, more informed look at the main routine visits, medical procedures and interventions that women are given (or denied) during pregnancy and childbirth in combination with the legal rights that exist for birthing individuals, I believe that any rational person would immediately start to question the methods used and the valid medical reasoning behind so much of what we do and whether informed consent and patient-centred care is really obtained in obstetrics. For example, if one were to review the many studies and commentaries on birthing positions that are more conducive to giving birth for the birthing individual, it becomes quite easy to question the hospital protocol of insisting that women give birth in the uncomfortable, ineffective and in some cases, denigrating supine or lithotomy position where a specific request to give birth in a different position has been made[xvii].
The point needs to be made and repeated again and again until it becomes common knowledge and common practice: during pregnancy and birth, the right to informed consent, combined with many other birth rights, exist and belongs to birthing individuals where and when it pertains to their bodies. These rights cannot be undermined with fear tactics or threat of denial of services[xviii] [xix]. For every medical question asked by a birthing person to a medical professional regarding a procedure that is being proposed, there needs to be a truthful, complete and timely answer[xx]. And the decision made by the birthing parents must be respected even if and, dare I say, especially where it does not align with the wishes of the medical professional[xxi].
If and when your rights are violated, you do have a recourse. Your voice can and should be heard and procedures are in place to allow that to happen. The movement towards patient-centred care in the maternal setting is not to question the qualifications of a doctor or their capacity as a medical professional but rather to create a culture of dialogue between health care providers that is built on mutual respect. By increasing the understanding of what true informed consent means, rather than simply obtaining a signature for consent, medical malpractice suits could actually decline[xxii] [xxiii]and postnatal outcomes in terms of postpartum depression and trauma could improve.
[i] PTSD and obstetric violence, https://eipmh.com/ptsd-and-obstetric-violence/
[ii] Sex matters: gender disparities in quality and outcomes of care, Arlene S. Bierman, CMAJ December 04, 2007 177 (12) 1520-1521; DOI: https://doi.org/10.1503/cmaj.071541
[iii] SteelFisher GK, Findling MG, Bleich SN, et al. Gender discrimination in the United States: Experiences of women. Health Serv Res. 2019;54 Suppl 2(Suppl 2):1442‐1453. doi:10.1111/1475-6773.13217
[iv] Ladd, R. (1989). Women in Labor: Some Issues about Informed Consent. Hypatia, 4(3), 37-45. Retrieved June 1, 2020, from www.jstor.org/stable/3809824
[v] I Was Pregnant and in Crisis. All the Doctors and Nurses Saw Was an Incompetent Black Woman; January 8, 2019, Time Magazine (online) https://time.com/5494404/tressie-mcmillan-cottom-thick-pregnancy-competent/
[vi] Reed, R., Sharman, R. & Inglis, C. Women’s descriptions of childbirth trauma relating to care provider actions and interactions. BMC Pregnancy Childbirth 17, 21 (2017). https://doi.org/10.1186/s12884-016-1197-0
[vii] Basta Tacere Campaign, OVOItalia, https://ovoitalia.wordpress.com/bastatacere/
[viii] #bastatacere, 2016 Social media campaign, OVOItalia, https://drive.google.com/file/d/0B_KmD2knv2O6TXlwa3VmNTQwd2M/view
[ix] Legge sul consenso informato e sulle DAT (Italian law on Informed consent and Advanced Directives), Legge 22 dicembre 2017, n. 219
[x] Respectful Maternity Care, The Universal Rights of Women & Newborns, White Ribbon Alliance, 2019
White Ribbon Alliance. Respectful Maternity Care Charter: Universal Rights of Mothers and Newborns 2020 [Available from: https://www.whiteribbonalliance.org/respectful-maternity-care-charter/
[xi] Basta Tacere Campaign, OVOItalia, https://ovoitalia.wordpress.com/bastatacere/
[xii] “There’s no kind of respect here” A qualitative study of racism and access to maternal health care among Romani women in the Balkans Teresa Janevic1*, Pooja Sripad2 , Elizabeth Bradley3 and Vera Dimitrievska4
[xiii] The American maternal mortality crisis: The role of racism and bias, Publish date: May 5, 2020, Sharon Worcester, https://www.mdedge.com/obgyn/article/221705/obstetrics/american-maternal-mortality-crisis-role-racism-and-bias
[xiv] Council of Europe, European Convention for the Protection of Human Rights and Fundamental Freedoms, as amended by Protocols Nos. 11 and 14, 4 November 1950, ETS 5, available at: https://www.refworld.org/docid/3ae6b3b04.html [accessed 1 June 2020]
[xv] S Shabot, S. C. (2020). Why ‘normal’ feels so bad: violence and vaginal examinations during labour – a (feminist) phenomenology. Feminist Theory. https://doi.org/10.1177/1464700120920764
[xvi] PTSD and obstetric violence, by Ibone Olza, MD, PhD, Originally Published in Midwifery Today Int Midwife. 2013 Spring;(105):48-9, 68 https://eipmh.com/ptsd-and-obstetric-violence/
[xvii] The Evidence on: Birthing Positions, Evidence Based Birth, updated February 2, 2018, https://evidencebasedbirth.com/evidence-birthing-positions/
[xviii]Respectful Maternity Care, The Universal Rights of Women & Newborns, White Ribbon Alliance, 2019
White Ribbon Alliance. Respectful Maternity Care Charter: Universal Rights of Mothers and Newborns 2020, Available from: https://www.whiteribbonalliance.org/respectful-maternity-care-charter/
[xix] Council of Europe, European Convention for the Protection of Human Rights and Fundamental Freedoms, as amended by Protocols Nos. 11 and 14, 4 November 1950, ETS 5, available at: https://www.refworld.org/docid/3ae6b3b04.html [accessed 12 June 2020]
[xx] Birthrights, Factsheet on Rights, https://www.birthrights.org.uk/factsheets/human-rights-in-maternity-care/
[xxi] Ladd, R. (1989). Women in Labor: Some Issues about Informed Consent. Hypatia, 4(3), 37-45. Retrieved June 1, 2020, from www.jstor.org/stable/3809824
[xxii] Informed consent and Italian physicians: change course or abandon ship – from formal authorization to a culture of sharing.
[xxiii] A review and analysis of new Italian law 219/2017: ‘provisions for informed consent and advance directives treatment’. Di Paolo et al. BMC Medical Ethics (2019)
