Episode 160 - Keeping yourself safe from obstetric violence
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD, and each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey.
[0:25] Welcome to today's episode of the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson, and today we're talking about keeping yourself safe during childbirth. Physical safety is part of it, of course, but today we're talking about keeping yourself safe from something called obstetric violence. You aren't just at risk of obstetric violence if you have a doctor. Systematic abuse is embedded into the fabric of maternity care all over the world, including wherever you are listening from today. Now, this is an important topic that a lot of women think they don't really need to listen to. In fact, a lot of maternity care providers think they don't need to listen to this topic. Okay. Today, although I'm going to tell you what obstetric violence is, I want to focus on solutions because it's one thing to be talking about the problem and it's a whole other thing to offer you solutions for how you can avoid becoming the victim of obstetric violence. I'll explain what obstetric violence is, of course, but many women might not listen to this episode because they believe they're somehow immune from violence in the birth room. But the truth is, is that all women are at risk of violence during birth. And as we will discover through this episode, it doesn't matter which country you're in, what type of model of care you've chosen, there still exists a risk of obstetric violence.
[1:53] So today I'm going to help you understand what it is, identify it in the real world, what does obstetric violence look like, and give you some tips on how you can keep yourself safe during birth. In our lives as women we are always on high alert to protect ourselves from violence. Who amongst us has not walked a little faster in parking lots and been prepared to weaponize your keys? Some of you out there have been the victims of violence in your lives and in society women are vulnerable. Here in Australia one in six women are the victim of physical or sexual violence and one in four are victims of emotional abuse.
[2:32] We would be foolish as women to assume that we are safe from violence in the birth space. We are never truly safe as women in the world due to the power imbalances that are foundational in society and these power imbalances carry through into the birth room. Now I'm not saying this to scare you, I'm saying this to prepare you. You can keep yourself safe but we have to name it to tame it and today we are naming and explaining obstetric violence.
[3:06] Obstetric violence is no doubt an uncomfortable topic, but pretending it doesn't exist across both low, middle, and high-income countries alike puts you at risk of becoming a victim. If you're a care provider listening and argue against the terminology and the existence of obstetric violence, then you are part of the problem. This episode is about equipping you to identify and understand obstetric violence, and I'm going to offer you some strategies for how you can keep yourself safe from it. So this is one for your partner as well. If your partner is coming to your birth with you, if they're in a position to advocate for you, they also need to know how to identify obstetric violence so that they can call it out and protect you from it. So consider sharing this episode with whoever is coming with you into the birth space. Now, of course, in this one episode, we cannot cover all of the issues around obstetric violence. We're going to have a broad topic discussion. And as with all the Great Birth Rebellion podcast episodes, if you're on the mailing list, you'll be sent out a link each week to the podcast resource folder, which has all of the resources and references that we use to create every single podcast episode. So if you would like to see and read the research that I used to create this episode, I'll invite you to join the mailing list at melanethemidwife.com. The link is in the show notes.
[4:32] Okay, let's get started on understanding obstetric violence and how to protect yourself from it during childbirth. So let's explore exactly what it is. What is obstetric violence? The truth is that the definition and wording of obstetric violence is highly contentious. There are members of the maternity care community who don't appreciate the terminology of obstetric violence and they feel that this word is too aggressive and strong and that using this terminology might be interpreted as a deliberate act of violence perpetrated by healthcare providers and people don't like the idea that they're being blamed for deliberate violence against women. But proponents of this argument suggest that words like obstetric mistreatment might be a better way to describe it because mistreatment encapsulates systematic issues, lack of training or misunderstandings rather than intentional violence. So there are some clinicians who will suggest that obstetric violence is not a terminology that should be used and they potentially also don't believe that clinicians are intentionally violent against women.
[5:47] Some people believe that obstetric mistreatment is a more comprehensive term because it encompasses a broader range of behaviours and actions. And the word mistreatment is more general and refers to abuse, harm or control exerted over another person, which includes things such as non-consensual medical procedures, verbal abuse, disrespect, discrimination and stigmatisation or neglect. I mean, if you're looking at those words and thinking that's just obstetric mistreatment, I think potentially we've got a misunderstanding as well. Things like abuse, harm or control over another person sound violent, as are non-consensual medical procedures, which we all know as clinicians. If you do a medical procedure without the consent of a woman, it's considered assault, which is violence.
[6:40] Honestly, I have an issue with any care provider, though, who is trying to control the conversation about what we can describe as violent or not. I think that the choice about what to call violence, abuse or mistreatment from the hands of maternity care providers, including myself, I think this should be the women and families themselves and the victims should be the ones to decide the terminology, not the perpetrators. So we can all, as care providers and policy writers and researchers, sit around and discuss what exactly obstetric violence is, but perhaps the victims of mistreatment by maternity care providers should be the ones to be offering up the definition that they believe should be applied to it. The victims, not the perpetrators, should be defining this. Having said that, I'm not going into detail or arguing for or against the wording because that would detract from the point of today, which is to say that women, maternity care providers and academic writers are finally...
[7:49] Starting to be heard on the issue of obstetric violence. Women are starting to be believed that they experienced abuse at the hands of their care provider. So I'm not going to spend this episode arguing for or against particular wording. And of course, I'm not accusing all maternity care providers of violence. So for lack of a formal description, obstetric violence is defined as behaviours of verbal or physical abuse, coercion, unconsented and unnecessary interventions, violations of privacy and women's autonomy. And that means that you take a woman's control away from her and take control of her body. There is, however, no consensus on what obstetric violence is, but it generally describes the mistreatment of women during childbirth. And, you know, We could go through the raft of papers that try and define this, but essentially, obstetric violence involves violation of a woman's rights, dehumanizing care, disrespect and abuse and mistreatment. And it can be psychological violence.
[9:00] It can be the denial of support during labor if the woman feels humiliated or her privacy is violated. It can be verbal, such as people yelling at or scolding pregnant women and making threats. It can be physical, such as procedures being carried out on women without their
[9:19] consent or the use of coercive language to gain consent. If you are coerced into something that you didn't want and your care provider used language that aimed to push you towards a particular decision, that's considered violent behavior.
[9:38] Now, violence can also be a lack of access to analgesia or pain relief when it is required. And if you're a care provider, you've all seen this. You've all seen women receive medical procedures without adequate pain relief. You might not realize it because it's become so culturally acceptable and so embedded in what we expect to see at work. But I've seen doctors extract women's placentas from them in the room without pain relief and sometimes not even telling the woman it was going to happen. I've seen a midwife complete a perineal repair without effective analgesia with partial analgesia and just continued with the repair. I've seen women who have had peroneal checks on severe degree tears and the clinician was very rough and encouraged the woman to just tolerate it and get through it instead of offering pain relief.
[10:33] Clinicians frequently perform painful, unnecessary fundal robbing, even in the absence of any vaginal bleeding. So these are just some of the things that I've seen, and I've barely even entered hospital services these days as a home birth midwife. But I can remember times where I've seen women expected to tolerate management of their birth, medical management of their birth, and clinical procedures without adequate pain relief and told to just suck it up in a way. Now, although there is no international accepted definition of obstetric violence, women and care providers know that women are not being treated right in birth, but we're still working out what to call it. So for now, obstetric violence is our terminology. And it's important to get that right because that allows us to have a global conversation about what is happening to women in childbirth, so far obstetric violence is the wording that's been taken up most frequently. So depending on where you are in the world, obstetric violence manifests differently and it looks different. So let's explore what obstetric violence is around the world. And this study that I'm looking at now is from 2025.
[11:49] It was recently released. It's an Australian study by Australian researchers all who I know and respect in their fields and it's called maternity care providers perspectives and experiences of obstetric violence in low middle and high income countries and this was an integrative review which looked at 54 research articles and looked at what maternity care providers have witnessed and it kind of gives insider knowledge of what's going on and what obstetric violence looks like.
[12:22] Across low, middle and high income countries, depending on where you are in the world. So for example, in some countries, hitting, slapping, pinching and rough handling of women and yelling at them is a normalised part of care during birth. Some of the studies in this paper reported maternity care providers said they were doing this to motivate women to push harder.
[12:48] And so think about this, if you're a care provider, how many times have you seen a nurse, a midwife or a doctor, hold a woman's legs open or push a woman's leg up into, you know, up towards her nipples and yell, push, push, push, push, push, push, push.
[13:04] I mean, you did just take control of her body, whether or not you asked her or not, I don't know, and start yelling at her. It happens all the time, but because we haven't called it out and it's normalized, this is what we're told to do. I was told to do this as a student. grab that leg and tell her to push she's having a baby so what are we gonna do manipulate her body and yell at her to push without asking what what she wants it we've normalized it but shouting or yelling or pulling on women's legs or opening them without asking is is considered a form of obstetric violence and it's not appropriate in day-to-day life and it's not appropriate at birth so we might not recognize it as violence from our perspective as maternity care providers but how women experience it is a different story and women who participated in my PhD research described this kind of thing happening to them and explained things like being held down or their legs being held open or during a vaginal examination the doctor refusing to stop even though they ask them to stop. This is not just mistreatment or unconsented medical procedures.
[14:22] These are examples of obstetric violence. And you might be sitting there listening to this as a care provider and think, whoa, actually, I do often put my hands on women without asking, manipulate their body, yell at them sometimes.
[14:37] You know, I've heard midwives yell at women. Women are like saying, I'm trying. And the midwife yelled back, no, you're not. I mean, at the time it was shocking, but these are examples of real life things. And whether or not you're out there thinking, yep, that's violent or not, women are experiencing it as mistreatment and or violence. And I want to.
[15:00] Although the terminology says obstetric violence, any maternity care provider, a nurse, obstetrician, midwife, anaesthetist, pediatrician could be the perpetrator. These, don't let the words fool you, this is not isolated to obstetricians. And the other thing to note is that depending on where you live in low, middle or high income countries, violence looks different. So in this 2025 paper that I'm working from, it explains that in low to middle income countries, the violence looks more overt or obvious. So some lower income countries have an acknowledged culture of physical or verbal violence against women as I explained earlier with the hitting and slapping and pinching and some countries have come to understand that during childbirth women may be hit and yelled at as part of the usual care and the clinicians and to a degree the women have come to accept it. However, studies from the higher income countries, they noted that the violence against women was more covert or more hidden. It was less obvious. And for this reason, it's harder to name it and identify that it's happening in higher income countries. And that's contributed to the perception that violence during birth doesn't happen here.
[16:17] That's for the lower middle income countries. But the current research that's emerging over the last 10 years, at least, it's showing differently. And so while some violence may be obvious, yelling, hitting.
[16:32] These kinds of things, doing things to women that they said no to or not giving adequate pain relief during procedures, it's clear violence. However, what the research is saying is in the higher income countries, it's harder to define and describe what violence looks like. And there is one paper in the resource folder for the podcast, if you're on the mailing list.
[16:57] And you've got access to that and it pulled data from many studies to try and answer the question of how prevalent or how common is obstetric violence in high-income countries. And the authors said that our findings are concerning as physical, verbal and psychosocial obstetric violence were all found to be highly prevalent in high-income countries. In this paper, they report overall when they pooled the data together for high-income countries that 45.3% of births included one or more forms of violence against women.
[17:39] 45.3% of births included one or more forms of violence against women when they pooled the research data for high-income countries. That's almost one in two. And I wish this was inaccurate. But when you look at that paper and see what they've included as the violent actions, I think that number feels accurate.
[18:11] I'll encourage you to go and read the paper if it's of interest to you. I don't want to focus too heavily on how common it is because I want to get to some solutions. But the paper is called Prevalence of Obstetric Violence in High-Income Countries, a Systematic Review of Mixed Studies and Meta-Analysis of Quantitative Studies.
[18:30] And that's in the resource folder. You can click through in the show notes to get access to that. So you might be wondering, why do maternity care providers perpetrate violence against women? Aren't they supposed to be looking after us? So in this paper from 2025 that I've been speaking through, it's explained that some clinicians will justify their behavior because they believe they're acting in the best interest of the baby and trying to help the woman.
[18:58] But that doesn't really excuse abusive behaviors. So obstetric violence includes verbal assaults and threats like you can't push your baby out in the next few contractions I'm going to give you an episiotomy or insulting the woman threatening her intimidating language all of that is counted and this can be more common in low-income countries but women around the world aren't immune to this and I've witnessed the behavior firsthand And particularly for women who are non-compliant or are difficult. Now, for those women who want to question their care provider or decline care, you might be labelled as non-compliant or difficult. And these women are more at risk of being verbally abused or called names or treated differently in an effort to try and elicit some compliance or punish them. And that speaks to the fact that obstetric violence is rooted in a power imbalance and a struggle for power.
[20:07] And whatever you call it, obstetric violence or obstetric mistreatment, there is acknowledgement from women, maternity care providers and academic researchers that when you have a baby, there is a risk that you'll be abused by your maternity care provider. And you need to know that. And your support team need to know that too because the story that you are safe in birth is not true. You are at risk of mistreatment. And this is an additional risk on top of whichever complications might be presented to you in childbirth. And I'm not saying this to scare you. I'm saying this to prepare you. If the behaviours of your care provider don't feel right to you and you feel violated and mistreated, you might be experiencing obstetric violence and your support team need to protect you from that. You might not be able to expect protection from the other staff members because the violent behaviors are sometimes normalized within facilities and the staff are desensitized or they don't have the courage to call it out.
[21:12] There is a lot of incidental trauma that goes on for care providers around that witness women being abused in childbirth and they feel powerless to do anything about it. And that is a whole other discussion. there is a raft of research about what witnessing obstetric abuse does to care providers in the workplace. But that's a topic for another day. So one of the roots of obstetric violence is to try and elicit compliance. And so another example of violence is to withhold care from women or neglect them until they comply. And this withholding of care was a circumstance in this research paper across low, middle and high income countries where if the woman was non-compliant or appeared to be disrespectful to their care provider.
[21:59] Their care would be impacted. And I've seen this firsthand as well, when women will decline a recommendation made by their care provider and their care provider appears to retaliate by telling the woman that they're not willing to offer any other option. And so the woman is given no choice but to choose that one thing that the care provider is willing to offer. In fact, I've even offered to take women from one hospital to another hospital in order to get the care that she wanted and that was she was asking for but the care provider refused to provide it. Now this is defined as violent because it manipulates and forces the woman to choose something that they didn't want to do. It's obstetric violence and the other thing to be aware of is that anything that makes you vulnerable puts you at an increased risk of experiencing violence and mistreatment. So studies have shown that if you are socially marginalized, women who are impoverished or living in poverty, women who suffer from mental illness, if you're overweight, if you speak a different language to the venue that you're at, teens, women of colour, they're all more likely to be victims of violent behaviour.
[23:11] And black women in particular are at risk of discrimination and racism and violence as a result. So this highlights that a foundational cause of obstetric violence is the power imbalance and the intention to maintain a power imbalance and maintain authority over women in the birth space. And it's widely acknowledged in the literature that healthcare systems aim to regulate women's bodies so they perform and conform to medical expectations. And this can have a side effect and manifest as behaviours that seek to dominate and control women's bodies. And this just reflects the normal oppression that is experienced by women in society. We are not safe from violence in society without putting in some checks and balances to keep ourselves safe. And the same thing exists in birth. The power imbalance that exists against women in society is a contributor to obstetric violence. And for a long time, maternity care providers have justified their behaviors in the birth room and justified them to say that they were forceful or aggressive or abusive or provided unconsented to interventions for the safety and well-being of the mother and baby as if they were the ones who knew best or often their actions focus on just the well-being of the baby and they forget that the woman is a person too.
[24:40] But her treatment and bodily autonomy is sacrificed as the care provider prioritizes her baby over her. It appears to be well-intentioned. However, the impact is that the woman is perpetrated against. And I can understand that way of thinking. And some women will want this. Some women will be prepared to sacrifice their own well-being in favor of their baby.
[25:04] But that has to be the choice of the woman and not enforced upon her by her care provider. And I can hear you thinking out there, what type of mother would put herself above her baby? Well, the truth of that is that the shaming of women for not sacrificing themselves on the altar of motherhood is an outdated way of defining good motherhood. The priority in modern society is both the woman and the baby, not one over the other. And in fact, the priority in lower resource communities is often to prioritize the woman over the baby. What good are we to our children as mothers if we are incapable of caring for them due to our own injuries and poor health? So this idea of the good mother as being someone who sacrifices her own well-being for the sake of her baby is outdated and it's inappropriate because what's happening is we are sacrificing women through obstetric violence for the supposed good of their babies without even asking women what they want. And also, there is a focus on positive outcomes from care providers because they fear the repercussions of what might happen to them if there's a poor outcome for the baby.
[26:20] So while there might be many reasons for acting violently towards women or for mistreating them, good intentioned as it may be the reasons and excuses don't justify the behaviors and the other issue here is that the maternity care system and infrastructures around the world are perpetually understaffed under resourced and the staff are overworked underpaid and often work in violent workplaces where there's bullying a hierarchical power struggle and ongoing feelings of moral distress and burnout from maternity care workers. So these environments seem to curate a circumstance where there is an increased interest in the need for women to comply and for the outcomes to be positive. And this causes maternity care providers to care for women in a way that can be experienced by the women as violent. And what's worse is that in these workplaces where the culture might feel toxic or hierarchical, Where there is workplace bullying, maternity care providers feel that when they speak out or call out obstetric violence, they become whistleblowers and they become further ostracized and bullied.
[27:40] This is the context in which obstetric violence occurs and is allowed to flourish.
[27:47] Okay, let's shift gears. We've had a look at what obstetric violence and obstetric mistreatment could be. We know from some current research that a high number of women are exposed to violence during birth, with one paper suggesting that it's as high as 43.5% if we pooled the research for high-income countries together. And we know the reasons for this violence are multifactorial and the solutions to workplace issues need to be attended to by maternity care services. But how can you, the woman, or if you're listening as a partner or support person, how can you keep yourself safe and avoid becoming the victim of obstetric violence? There are some things that you can do to reduce the chances of you becoming a victim. So let's have a look at those.
[28:41] So firstly, the opposite to violent and disrespectful care is respectful maternity care. And the most respectful maternity care, generally, is delivered to women in continuity of care models where you know your care provider. And this is because you have a relationship. And that relationship is somewhat protective against violence and disrespectful treatment. Of course, not all the time, but you are much safer with a clinician that you know and with whom you have a relationship than with whoever you happen to meet on the day. And we saw the results of that. This is expressed in the BEST study, which was run by Dr. Hazel Kittle and her team. So if you can get access to a continuity of care model with a known care provider, and And I know this is not accessible to everybody, but if you can access that, you reduce your chances of being exposed to obstetric violence purely because you've got a relationship with that care provider and that increases the chances that they will treat you respectfully.
[29:53] Number two is to have a support team around you. So I'm talking about the people who you have around you for your birth, your partner, maybe a robust friend, a doula, whoever you're taking.
[30:07] That they are vigilant and ready to support and defend you and that they understand that obstetric violence is a possibility. I would suggest having them listen to this podcast and remind them that any parts of care that intuitively don't feel right. Sometimes you don't really know, why don't I feel good about this? That's your intuition telling you something's not right here. And this is what we were talking about earlier, the overt versus covert obstetric violence. In higher income countries, the violence feels more covert. It's more hidden and maybe subtle and more coercive. So we sometimes have to tap into our intuition to fully understand what's going on. But if you're not being listened to, if someone is yelling or using coercive language or disrespectful language to you, or where your pain relief is not adequate, where you feel you need it to be, or where something is done to you without your consent, your care team needs to acknowledge that during labour you are vulnerable and that you're unable to defend yourself. They're going to need to step up and be hypervigilant, be willing to identify and name and put a stop to behaviours that feel violent or disrespectful.
[31:25] Now thirdly, choose a birthplace that you have researched well so you know what to expect. So there is less chance of obstetric violence at a home birth for example but really any setting where you're being cared for by a known care provider improves your chances of a respectful birth experience so do some research about your local services and about the services that are available to you or the one you've chosen so what are women saying about that facility is there some online commentary that might indicate that you are in more danger at one facility over another is there a particular obstetrician or a particular midwife who has a reputation for being a little bit more aggressive in their behaviors women and people talk and the hospitals and birth facilities will get reputations within the community and sometimes there are particular clinicians within those facilities that have a reputation for giving disrespectful or violent care and if you're a care provider out there listening you know which ones they are in your facility.
[32:29] You might see that the midwives in that facility or other care providers will be there trying to protect you from them or they'll give you a warning. So my suggestion is to carefully research the reputation and the place and birth in which you've chosen specific to you. So your local hospital, if that's where you're going, search and search for people's feedback, for commentary on it, just to see what you might be in for. You might find that your facility has a great reputation, in which case you might be able to tell your support team that they can stand down and be less hypervigilant, but you might be at a place that has a reputation for being particularly aggressive, in which case you know how to prepare. Now, number four, if you are in a scenario where you feel like violence is being perpetrated against you, if you feel unsafe, Say so and ask the person to leave. We have to name it to tame it or name it to shame it. You don't have to accept abusive care providers. If they won't leave, you can escalate your language. I don't feel safe around you. Find somebody else to look after me. Stop yelling at me. I don't like it. I do not consent. Don't do that.
[33:55] This is also where your care team comes in. You might not be in a position to be that forceful with your language, but your care team may need to be. And a quick note here, if you are the victim of obstetric violence and you feel unsafe and the person will not leave, you're currently engaged in a power struggle. Can I advise that you keep your cool, stay firm and calm and do not become violent yourself because the power struggle will not fall in your favor. There's been circumstances where security teams have been called to extract seemingly aggressive support people out of the room. So remain calm but firm.
[34:44] And if this is something that really worries you, I would suggest getting a doula to add another layer of protection. They can also be a source of information. They're usually familiar with the birthing facilities in the area and they know which care providers are more likely or less likely to act aggressively against you. Now, those are five things you can do as a woman and as a support person to
[35:11] protect yourself from obstetric violence during birth. And if you're a care provider and looking for resources to assist in understanding what you can do to prevent obstetric violence and avoid being the perpetrator yourself, I'm going to recommend the resource folder for this podcast, which has the White Ribbon Alliance Respectful Maternity Care Charter in there. And that is a list of the universal rights of women and their newborns. And the World Health Organization have a document called the Prevention and Elimination of Disrespect and Abuse During Childbirth. And the International Confederation of Midwife resources are also in the folder and they can help to educate and rehabilitate you and your workplace. Violence against women is never okay in or out of the birth room.
[36:01] That's this week's episode of the Great Birth Rebellion podcast. I'm Dr. Melanie Jackson and I will see you in next week's episode. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com and to support the work of this podcast, wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @Melaniethemidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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©2025 Melanie The Midwife
