Righting wrongs: The humanization of birth and obstetric violence

The global mobilization for human rights in childbirth is intimately bound to the complex and subtle problematics of reproductive rights in maternal health that radically critique the dominant clinical/pathological or technocratic (Davis-Floyd 2001, 2018a) view. For decades now, global midwifery organizations and midwifery activists have tried to challenge this view by exposing the problems related to this technocratic paradigm, whose practitioners intrude on women’s bodies and self-determination and cause increased risks via over-intervening in births. The late birth activist Sheila Kitzinger (2006) has noted that women who are distressed after birth use the same language as survivors of rape—e.g. “I was violated.” Within medical anthropology, there is now a long tradition linked to studies of birth, reproductive life and midwifery, which have shown the problematics of the Western pathological understanding of birth as the dominant authoritative knowledge system—although, as Davis-Floyd (2003) has been careful to show, many women buy into that system and feel safer under technocratic care. These studies have also explained midwives’ empirical knowledge on women’s health and how the philosophy of this practice strongly differs from that of medical care (Rothman 1989, Kitzinger 2006, Jordan 1993, Davis-Floyd and Sargent 1997; Davis-Floyd 2018b). This literature constitutes a serious critique of the Western biomedical system and a revaluation of birth knowledge systems emerging from the Global South.

However, frequently the movement has been at odds with classic Western feminists, who have promoted the dominant, clinical view of reproductive rights because they intensely dislike being “ ‘essentialized” to their reproductive functions (see Craven 2010). As mentioned in Chapter 2, in the case of North America, the mobilization for midwifery and human rights in childbirth has shifted toward a discourse on consumer rights and midwifery as a “choice” for women, which has enabled women from different political backgrounds (meaning left- and right-leaning) to unite in the struggle. However, framing the struggle in terms of “consumer rights” presents the problem of excluding women from lower socio-economic backgrounds, which is why activists of color prefer the previously mentioned reproductive justice frame.

Nevertheless, currently this global mobilization has expanded and articulated itself rather from the viewpoint of human rights in childbirth, which combines midwifery activism with reproductive rights in maternal health. Sarelin (2014b) demonstrates that women now are using human rights as legal and political tools to demand change in childbirth. According to Sarelin (2014b), viewing childbirth mainly as an issue of access to healthcare

Post colonial midwifery 183 is changing and subject to a new set of questions: who decides how a baby is born? Who chooses where birth takes place? Who bears the ultimate responsibility for the outcome of a birth? What are the legal rights of birthing women? What are the responsibilities of the caregivers—doctors, midwives, nurses and other attendants? What are the rights and interests of the unborn and how do we protect them during childbirth without subsuming the needs of the mother to the perceived needs of the child? Sarelin (2014b) argues that the global human rights in childbirth movement: (1) seeks a system in which women own their own births; (2) demands women-centered care instead of practitioner-centered care, which usually implies prioritizing midwifery care; and (3) demands that women be respected as decision makers in birth.

There are numerous associations, organizations and actors involved in this mobilization. For example, the global organization Human Rights in Childbirth (HRiC) was established in 2012.3 HRiC notes on its website that every day it receives reports of rights violations related to birth around the globe. The organization is compiling these stories to raise awareness of the routine nature of obstetric violence against women at birth. According to HRiC, a woman does not lose her fundamental human rights when she becomes pregnant, including the right to informed consent, the right to refuse medical treatment, the right to evidence-based healthcare, the right to equal treatment, the right to privacy and the right to life. HRiC has detailed eight forms of violence in childbirth, including physical abuse, disrespect, non-confidential care, non-consensual care, misinformed care, depersonalized care, discriminatory care and abandonment of care.

Two networks have a special emphasis on midwifery. One, Sisters in Chains, is a network that exists to secure the human rights of all mothers.4 However, it has a special focus on supporting persecuted midwives, doctors and families. This organization also seeks to support mothers and families who have chosen a different type of care or assistant in birth (for example, a midwife) and are variously sanctioned or judged by persons or entities for choosing this option. The second, the White Ribbon Alliance (WRA), unites citizens to demand the right to safe birth with a local, community focus. While this alliance is less radical in its approach to the dominant, clinical view, it does campaign for the promotion of midwifery. Its members view midwifery care as a path to safe childbirth, which requires, among other things, a change in the public perception of midwives, and improvements in their working conditions and training. The WRA also campaigns for respectful maternal care, zeroing in on the mistreatment suffered by many pregnant women and birthing women, and noting that “Evidence is now emerging that this fear of being badly treated and abused in health facilities is holding women back from seeking help. It is proving to be as big a deterrent as cost of care and transport.”5

In Latin America, the mobilization for human rights in childbirth has been organized around two concepts: the humanization of birth and obstetric violence. One of the driving forces has been the Latin American and Caribbean Network for the Humanization of Birth (Red Latinoamericana y de! Caribe

para la Humanización del Parto y el Nacimiento'. RELACAHUPAN).6 It is an alliance composed of national networks, groups and people seeking to humanize and to improve human rights in childbirth, and includes members from five Caribbean countries, four Mesoamerican countries, 10 Latin American countries and Spain, as well as Hispanics in the USA. It was formed as a result of the First International Congress on the Humanization of Birth in Brazil in 2000.7 This congress was attended by almost 2000 people, including midwives, doulas, humanistic obstetricians, doctors and gynecologists, and also by many public health and development professionals, as well as lactation consultants, childbirth educators, nurses and others seeking to exchange information as part of what later emerged as the continental campaign for the humanization of birth. The Congress stated in its declaration that the notion of the “humanization of birth” is intended to form “the center and base for development in a sustainable society nascent in the 21st century.” Brazil continues to form the focus of this mobilization, in part because in Brazil the movement also stems from within official agencies like the Ministry of Health, as some key proponents of the movement have positions there (Georges and Davis-Floyd 2018).

As the humanization of birth and obstetric violence are notions related to this Latin American mobilization, their definitions are subject to debate. The educational midwifery association Nueve Lunas in Oaxaca, Mexico, defines humanized birth in its informational portfolio as follows:

A nonviolent pregnancy and birth attendance practice ... ensures respect for fundamental rights, reproductive and sexual rights for women, couples and babies ... reduces perinatal complications, maternal mortality and costs of medical assistance. A “humanized birth” [parto humanizado, humanized delivery, referring to the birthing woman] refers to a model that takes into account explicitly and directly the opinions, necessities and emotional values of women and their families in the processes of attention during pregnancy, birth and puerperium; having as a fundamental aim that they are living a special moment and pleasurable lived experience in the conditions of human dignity where woman is the subject and protagonist of her own birth, acknowledging the right to freedom of women and couples to take decisions about where, how and with whom to give birth in the most poignant moments of their life. The term “humanized birth” [nacimiento humanizado, being born in humanized manner, referring to the newborn] opens more elements, giving an important weight to the impact that this attention has on the newborn and its future development, considering its necessities to receive alimentation and affect immediately at birth, in a loving and nonviolent context.8

Again, the opposite of humanized birth is considered to be “obstetric violence.” The Information Group on Chosen Reproduction in Mexico (El Grupo

Post colonia! midwifery 185 de Información en Reproducción Elegida-, GIRE (2013)) defines obstetric violence in the following way:

Obstetric violence is a specific form of violation of human rights and reproductive rights of women, including rights to equality, non-discrimination, information, integrity, health and reproductive autonomy. It is generated in the contexts of healthcare services in maternal care in pregnancy, birth and puerperium—public or private—and it is a product of a multi-factor framework in which institutional violence and gendered violence converge. During institutional attention to birth, the violation of human rights and women’s reproductive rights goes from scolds, jokes, derisions, irony, insults, threats, humiliation, manipulation of information and rejection of treatment without referring to other services to receive suitable care, postponement of urgent medical care, indifference to requests or complaints, no consulting or informing about decisions to be made during birth, to use a birthing woman as a didactic resource without respect to her human dignity, the management of pain during birth as a punishment and coercion to obtain “consent,” to different forms in which it is possible to verify deliberate damage caused to the health of the affected person, or falling into violating more seriously her rights.9

The campaign for the humanization of birth and against obstetric violence shows how the issues involved in women’s rights are contested terrain in Latin America. The campaign is radical in the sense of questioning the dominant clinical vision of reproductive rights in the Global South. As previously noted, the very existence of the humanization of birth movement highlights the ways in which the medical approach to reproductive rights (getting women into medical institutions) may actually jeopardize the reproductive rights of women in low-to-middle-income countries because of the obstetric violence they experience there.

Nevertheless, the terms “humanization of birth” and “obstetric violence” are also subject to debate within the movement itself. Some midwives in my study argued that the humanization of birth might be co-opted by the biomedical system, as have many other similar terms before, meaning that a humanized birth could simply come to mean “a nicely painted room” without any significant transformation in the violence-generating obstetric system (see also Davis-Floyd 2001). Such co-option would render the term “humanization” an empty signifier. Thus, in her delineation of “the technocratic, humanistic, and holistic paradigms of health and birth care,” Davis-Floyd (2001, 2018a) is careful to distinguish between “superficial humanism”—the nicely painted room—and “deep humanism”—in which the deep physiology of birth is honored and facilitated and the woman is the protagonist of her birth. Other midwives argued that the term “obstetric violence” is too radical and might jeopardize political collaboration between midwives and doctors,

as “nobody wants to be labeled inhumane.’’ These midwives expressed a fear that medical establishments might not receive emergency transport from midwives because of this labeling, which might make their personnel feel “criminalized.”

In the following, two autonomous midwives in Mexico narrate their her-stories in rural and Indigenous contexts in the country, and their complex relations to these women’s rights and mobilizations, particularly in terms of humanized birth and obstetric violence.

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