Obstetric Violence despite society's consent

We know there is obstetric violence in many hospitals around the world today. It is a branch of violence against women. In fact, it is violence, full stop.I have never experienced obstetric violence at first hand. I have had three amazing births with three amazing midwives, the first at a London hospital and the last two at home.I am Spanish and even though I moved to the UK twenty years ago remain very connected with my own country and a great part of my matriactivism is involved in trying to change the birth situation in Spain.
This is not an easy task.
To give some recent examples of the attitudes that currently govern birthing practises in Spain and the problems facing those attempting to initiate positive change, I list the following:Despite understanding that the relationship between obstetricians, midwives and women in Spain was far from a healthy one, the biggest evidence of this for me recently was the publication in SEGO (the Spanish Society of Gynecologists and Obstetricians) of a comic strip in their medical journal depicting obstetric violence as a joke while also taking the opportunity to laugh at several distressing conditions and womens’ bodies in general. In response I funded the online platform The Roses Revolution, but despite various global actions in protest, the author and president of SEGO have to date failed to apologise. On the contrary, they issued statements complaining about women not having a sense of humour (El Mundo, 2011).In Spain we have a tradition of eating grapes during the bells on New Years Eve. It’s an old tradition thought to bring good luck for the forthcoming year and is taken very seriously by Spaniards.
Also on New Year’s Eve programmes often feature news of the first babies born and this year depicted a maternity theatre where a forceps delivery inbetween doctors and midwives standing around eating grapes in time with the chimes. The legs of a woman in stirrups were evident in the background (images from the father’s mobile) as this important event also recorded the obstetrician narrating his grape eating whilst inserting forceps in a competition to deliver the first baby of the year. The impression left were of mother and baby as objects; the container (the mother) appeared irrelevant, the content (the baby) a trophy.Thanks to the patience, diligence and hard work of associations such as El Parto Es Nuestro and some governmental initiatives like the Observatorio De La Mujer, Spain has gradually implemented some renewed protocols regarding intrapartum care, the latest being the Strategy For The Care Of Normal Birth (2008,Ministerio de Sanidad y Consumo), a document that finally wanted to bring Spanish obstetric care into the 21st century. It can be seen as evidence of just how far behind they were in many of their practices. In it they suggest to desist from the use of enemas (however it is still stated: only if the woman requests one and only then after being properly informed), and not to rasurate pubic hair. The strategy even proposes concepts such as continuous support and providing women with informed choice. The word doula is not mentioned however. Doulas in Spain are more common in pre and postnatal settings than they are at the birth where they are afforded no professional consideration.When this strategy was presented there was hope and intent. Then came the comic strip. And then the grapes. And now Baby Boom...
Which is the latest and strongest indication that from paper to practice is still a very long road indeed. Baby Boom is a primetime programme recorded at one of the busiest maternity hospitals in Madrid, Gregorio Marañon. The aim is to show birth as it happens.It copies the model of the UK show, One Born Every Minute. In the Spanish version however, all birthing women are forced to lay on their backs, Kristeller Manoeuvres are witnessed and epidurals are a routine. The treatment of women from the majority of the midwives is of infantilisation. They are seen laughing at how heavy or scared the women are. They scold them, shouting at them to shut up, and complain directly to the camera about how difficult the women can be. Some scenes are presented as humorous, with whimsical comedic musical accompaniment. The language used was an astonishing demonstration of disempowerment. One expression used repetedly could be translated as, “I will make you birth now”. A midwife tells a nurse to, “lean on her (the mother) a bit to see if that works”.I found it difficult to watch even 15 minutes of it. As a member of Birth Crisis (Sheila Kitzinger’s helpline) I recall many stories of women who felt completely out of control in situations like this and have suffered traumas as a consequence. I had the same physical response to watching the programme as I’ve had on the, thankfully, few occasions I’ve witnessed violence in any form, with a sickness in my stomach and a sense of extreme discomfort. The big question for me is why there are only few of us reacting this way in Spain. Parents appear in the throes of something akin to Stockholm Syndrome, grateful to the professionals despite the violence and abuse while the production company in Baby Boom explain through various platforms that their programme is simply a representation of what birth is like in Spain. The effect all this has is to ensure a big section of society accuses the horrified minority of exaggeration and hysteria and of being humourless hippies, weirdos and crazy pronatural risk takers.How can women expect to be anything other than an inactive part of this situation? To answer these questions I think it’s necessary to understand the huge social changes that Spain has undergone in the last 40 years. I am 37 years old and my grandmothers birthed a total of 24 children between them, all of them at home, and yet that generation became almost instantly subservient to medical authority, conditioned by subjugation from Franco, the Catholic church and the rise of medical technology (Linares Abad, M et al. 2012) together with a general increase of affluence and a in many cases a lack of education to the extent that the amazing wisdom of village midwives and matriarchal figures about ourselves as just another mammal in rural life became an anathema, an embarrassment, and quickly transformed into ignorance towards the old ways of the poor that we needed to move away from.

Later on these generations saw how women in Spain were virtually overnight gaining independence through work, divorce and voting rights while remembering that in their youth they weren’t even able to watch certain movies without the church’s permission or to leave the country without their husband’s consent (Nash, M. y Tavera, S. 1995) . So the daughters of those women became free and outspoken by standing on their own two feet and hospitalised birth was included in this new modernity, their mothers now too embarrassed to suggest some of the old ways may have been better.So today we have women who are very industrious, influential and informed. They are strong, independent, modern women yet curiously continue to remain subservient to authority in birth, still lying on their backs and still suffering epidurals as routine. They are told what to do at all times, are tied up in lithotomy, cut, given enemas, abused. And the whole of Spain watches this and believes it to be an accurate representation of birth. There are major governmental campaigns opposed to violence against women as there remains an alarming rate of women killed at the hands of their partners, almost 11% of women have suffered some kind of gender violence (Ministerio de Igualdad, 2012). Many attempts have been made at a cosmetic level such as changing the traditional male neutrality of the language to a less gender specific option and the previous administration’s policy of ministerial gender equality. I personally feel these are symptoms of a condition. I think that if so many efforts are needed it is because despite major external influences, at its core Spain remains deeply machist, and the proof to me was the SEGO comic strip. In certain aspects, especially in sexuality, birth and breastfeeding, Spanish women are still insecure and in the last 40 years, the experts in those fields remain men instructing women what to do. This has created a climate in which a programme such as Baby Boom is watched and defended as normality. As I see it, there are several ‘abusive’ relationships at work: the media towards the audience; the obstetricians towards the midwives; the obstetricians and midwives towards the women; and women towards themselves. All control information released as a process of disempowerment towards their ‘victims’. If we believe that is just how it is and any alternative is dangerous, we tolerate abuse.To me as a childbirth educator, education is the only true mode of empowerment that can help the present situation. I do not believe that any of the professionals in the programme are even aware that current practises and procedures are in any way wrong, and the same can be said for the mothers who approach the maternity services. So the professionals cannot understand the anger some of us harbour and the parents cannot understand there could be any other alternative.
Violence is still violence whether or not it is socially disapproved. Simply because there’s no general reaction against it, doesn’t mean it’s invalid or unreal.
We have plenty of examples in history that show this to be the case, e.g. pre-civil rights racial discrimination or in cultures where women are considered second class citizens.
Violence is often accepted by the victim or even defended. Such behaviour can be observed in many abusive relationships, but it is still violence.
And in the case of obstetric violence there’s little difference.
Where it does differ perhaps is that it occurs within the framework of an institution. However, rather than use this fact as an excuse to permit its continuation, we should look at it as our collective responsibility to eradicate it.
Today I’m writing about Spain, but obstetric violence is a global issue.
Indeed, it is a human rights issue.


Jesusa Ricoy-Olariaga
Matriactivist, Antenatal Educator Dip HE, Hypnobirthing practitioner, Doula and Placenta Encapsulation Specialist

Note: As I submit this article, women are planning a march in Madrid on Sunday 27th,May to reject obstetric violence and demand dignity at birth. It will be called The March of Mothers.



References:

Linares Abad, M., Moral Gutiérrez, I., Alvarez Nieto, C., Grande Gascón,
ML., Pancorbo Hidalgo (2012)
Gender-based social relationships of midwives in a rural district in Spain
(Relaciones sociales de género de matronas en un distrito rural en España)
Revista Enfermeria Global, Universidad de Murcia.

Nash, M. y Tavera, S. (1995) Experiencias desiguales: conflictos sociales y respuestas colectivas( Siglo XIX) Madrid, Ed. Síntesis.

Ministerio de Sanidad y Consumo (2008). Estrategia de parto normal. Available from: http://www.msc.es/organizacion/sns/planCalidadSNS/pdf/equidad/estrategiaPartoEnero2008.pdf. [Accessed 24th May 2012].

Ministerio de Asuntos Sociales e igualdad (2012) Macroencuesta 2011 .Available from: http://www.seigualdad.gob.es/violenciaGenero/documentacion/pdf/Macroencuesta2011_Principales_resultados.pdf. [Accesed 24th May 2012]

El Mundo Newspaper (2011) La Sociedad de Ginecología anuncia que está analizando sus polémicas viñetas. Available from: http://www.elmundo.es/elmundo/2011/09/23/espana/1316775194.html [Accesed 24th May 2012]