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Monday, September 2, 2019

Reproductive coercion outside the domestic relationship

The image at left is designed to set the scene for what reproductive coercion might look like between a man and a woman in a romantic relationship. It’s fairly easy to define what that looks like, right? But what happens when the person doing the manipulating isn’t the romantic partner, but the care provider? Is it as easy to identify then? Are we hesitant to call it what it is? 

“We’ve all heard this scenario: mom receives the happy news that she’s pregnant and all is well until the anomaly scan. A little too early to tell, could be something, might not be. As much as you like your doctor, you aren’t comfortable with making a decision before you have all the facts and he is going on about how your baby surely won’t have any quality of life and you feel pressured to terminate. You’re not sure what to do - you mention seeking a second opinion and he gets mad, which makes you feel even more pressure to make a decision. What if he’s right? More importantly, what if he isn’t?”


“We’ve all heard the scenario: mom is getting close to delivery and just wants this baby out! She agrees to a cervical check to see how things are going, but this one is super painful and feels different than all the others. Later she experiences some light bleeding and loses her mucus plug, which scares her. Afterward, she realizes her doctor did a membrane sweep without her permission, without so much as a word of explaining what she was doing ahead of time.” 

According to ACOG, “Reproductive coercion is a form of domestic violence where behavior concerning reproductive health is used to maintain power, control, and domination within a relationship.” 

Reproductive coercion in a romantic relationship can be defined as:
  • poking holes in the condoms to increase the likelihood of pregnancy (and can be done by either the male or the female partner)
  • refusing to wear a condom or lying about birth control use 
  • otherwise tampering with birth control
It also involves manipulating in some way the outcome of her pregnancy and includes:
  • pressuring her to remain pregnant
  • pressuring her to terminate a pregnancy 

But did you know that it can also happen outside of the domestic relationship and often takes place in the doctor’s examination room and in hospital maternity wards every single day. While many women have been pressured by their partners to terminate pregnancies, unfortunately it’s not unheard of for doctors to do it to patients, too, especially when a terminal fetal diagnosis is involved. 

Don’t be afraid to seek a second opinion. If you’re facing a tough diagnosis but aren’t absolutely sure if you want to terminate, go somewhere else. If your doctor balks at this idea, it is a RED FLAG. 

Since reproductive coercion in a romantic relationship includes altering the outcome of a pregnancy, I think it’s safe to say that this is probably the most common form you’ll see in a doctor-patient relationship. Why are we not seeing it for what it is? If it’s considered manipulation for a woman’s boyfriend to alter the outcome of her pregnancy in a way she doesn’t want, why not a doctor? 

It probably looks a little like this:
  • The pregnancy has been going textbook perfect and delivery is imminent. Suddenly there are a million things going wrong, she is literally one day overdue, and before she knows it she’s been booked in for an induction she said she didn’t want but feels like she has no choice in the matter. 
  • Mom is being induced and isn’t sure why and the doctor won’t really answer her questions about it. She also has no idea what to expect or what they’re going to do to her. 
  • The pregnancy has been going great and the doctor has assured her she can walk around in labor, go into labor on her own, and will try her best to honor everything on mom’s birth plan. Then suddenly mom is pressured to induce, is told that she can’t get up out of bed, can’t walk around, and none of her birth plan wishes are honored. 
  • The doctor pressures mom repeatedly during the pregnancy to induce, even in the absence of any medical condition, gives conflicting or confusing advice about what could be happening, and uses intentional language to scare, manipulate or coerce the patient. 
This poor woman's doctor is coercing
her into an induction with confusing
fluid level measurements, is arguing with
her about her due date and refuses to change
it even though by the mom's calculations
it's significantly off, and has even
gone so far as to involve her family
physician to manipulate her into
consenting. She went on to have a lovely
birth after standing her ground
and stated that the only augmentation
she had was having her water broken. 
Just like in a romantic relationship, it can include:
  • getting angry, impatient or condescending when you ask questions, want more information or time to think it over or express a desire to seek a second opinion 
  • pressuring you to terminate when you don't want to or aren't sure, and using manipulative, condescending or threatening language if you refuse, want to wait or seek a second opinion
  • pressuring you to consent to a cesarean when you have reasonable requests to avoid one and threatening you if you don't 
  • pressuring you to consent to vaginal exams when you don't want them, and threatening you if you refuse 
  • pressuring you to make a decision without all the facts and refusing to give you unbiased information to make the best decision for you 
  • refusing to administer permanent birth control because of age, marital and childbearing status even when you have expressed a clear desire to not have children or are done having children
  • being forced to have a court-ordered induction or cesarean when you are of sound body and mind and have refused 
Threats can look like:
I can’t tell you how many times I’ve heard this scenario happen: moms who have no idea why they were induced and they felt like they had absolutely no choice in the matter. You often see these people on internet forums, asking other moms “is this right? Is this normal?” 
“I am almost 39 weeks and at my last OB visit the doctor said my cervix is only finger tip and the baby is floating. The doctor also told me that there is an 80% chance of a c-section because the baby is not engaging and my pelvis may be too small. This is my first child and I really do not want a c-section.” - prncssjenjenn
“I am currently 38 weeks and 4 days pregnant. My little girl is 7.5 pounds. I am 1.5 cm dilated and experiencing no contractions of any sort…I had a doctor appointment on Wednesday and she told me that if I did not go into labor by September 12 (my due date) they would induce the same night or the morning of the 13th.” - AutumnRMcG
“I am 40 weeks pregnant and my doctor is already talking about inducing labor at week 41 if there is no baby. I object to this as I have no medical problems thus far and during my non-stress test, the baby is doing perfectly. I am not understanding her reasoning…I do not want to get into a boxing match with my doctor, but my husband and I both feel that when the baby is ready she will come. Again, I have had a perfect pregnancy and no reason to be talking about an induction. What is the best way to handle this?” - palesa2678
The underlying emotion in all of these comments (and many more in addition to these) is stress. It becomes a game of “how can I trick this baby into coming as soon as possible to avoid making my care provider mad/being asked one more time to induce/made to feel guilty/basically being forced into something I don’t want to do?” It’s stressful enough just to read their comments; it’s even worse when you have to live it and think about it 24/7 until your baby finally arrives and every appointment potentially turns into a battle of wills. Why is just saying no not an option? Why is it so hard? 

The point is, no one can predict what can happen: sometimes things unfortunately do happen and no one could predict or prevent it. Sometimes none of your fears or the doctor’s threats come to fruition, thank goodness. But the time it takes to get through that event can really mess with your head and coercion, manipulation and bullying don’t help. No one has a crystal ball, not even your doctor. 

If ACOG can readily define what reproductive coercion looks like in a romantic relationship, why can't they do it in a patient/doctor one? At best they offer platitudes about "guidelines," "recommendations" (which do not translate into "rules and regulations," contrary to popular opinion) and patient autonomy, and essentially give doctors a choice as to whether or not they choose to follow them. Unfortunately, it would seem the patient herself is not afforded the same luxury. 

More reading: ACOG Practice Bulletin 664, Committee Opinion on Refusal of Medically Recommended Treatment During Pregnancy 

Thursday, August 29, 2019

Are you in an abusive relationship with your OB?

Originally published May 2010 
Edited August 2019

I am convinced that some women are in abusive relationships and don't even know it.

Studies show that one in six women report being mistreated,
but I suspect that number is actually much higher.
Most people automatically think of romantic relationships. You may say you'd never tolerate emotional or psychological abuse from a partner, yet you may put up with it for nine months from one of the people who is supposed to care about you the most: your obstetrician.

I have heard some pretty awful stuff over the years (many screenshots have been taken). I don't think it's too difficult to draw some comparisons between an abusive spousal relationship and one between doctor and patient. I've taken some basic points from websites that detail spousal abuse and replaced the word 'partner' with OB.

Some of the biggest ones are:

• Does your OB frequently criticize you, humiliate you, or undermine your self-esteem?

Examples I've heard include medical staff making inappropriate comments about the baby's father, (if they all have the same father, or assuming that you don't know who he is);  when women are harassed and mistreated after home-birth transfers and it's assumed you've had no prenatal care even if you have; being treated like a child or talked down to. Sadly, in my experience the worst of this came from female physicians.

• Are you afraid of your OB?

This one reminds me of a woman who was about to be induced with Cytotec, but had read warnings about uterine rupture and was very nervous. She decided to stand her ground about the induction, but yet was "afraid of making her OB mad."

I still remember the nervousness I felt when I decided at 37 weeks to change my plan to a VBAC. I was afraid of making my OB angry so I took my husband with me for support, thinking the whole time how utterly ridiculous the whole thing was.

• Do you sometimes feel trapped in the relationship?

Is your doctor initially supportive and then changes his mind at the last minute? Makes you think you have no choice but to stay with him? Little do women know that they can find care late in a pregnancy - it can often be difficult and stressful, but it's not impossible.

Brainwashing and mind control are also hallmarks of emotional and psychological abuse. (Replace the word 'brainwasher' with OB)

• The OB keeps the patient (victim) unaware of what is going on and what changes are taking place.

I once heard a comment that basically amounted to, "Forget about reading those pregnancy books; I'll tell you everything you need to know." Limiting access to outside information by creating a false sense of security often convinces women that they don't need to research birth because their doctor will give them all the details. My doctor tried this with me when I asked him about having absolutely no urge to push. He basically said, "We'll help you when the time comes," and that was all that was said about it. Puzzled, I thought, That's not much of an answer, and left there feeling confused and doubtful.

My next favorite is "you can't always believe everything you read in blogs." I don't think I need to mention names of certain former physicians that shall remain nameless...

Other tactics include not explaining procedures before they happen but as they happen, when you basically feel like it's too late to say anything. Birth is such a chaotic, busy event that sometimes you don't even realize things are happening until much later.

 The OB creates in the patient (victim) a sense of powerlessness, fear and dependency.

In obstetrics this is often accomplished by threats (the dead baby card) and coercion to get you to comply. I've heard of women denied pain relief for episiotomy after a natural birth because it's assumed they don't want drugs for that part, either. I've also heard of nervous dads being manipulated to influence mom into compliance, which undermines her confidence.

Many women who seek a VBAC are also told "their doctor won't allow them," "I really want one but I can't," or "I trust my doctor when he says VBAC is a bad idea." Studies have shown that women are often swayed by their care provider's preference on whether to have a repeat cesarean or trial of labor, which means many women may be choosing a repeat cesarean when they don't even have to out of a feeling of complete powerlessness.

This often includes having your complaints of emotional distress or physical pain denied by gaslighting (how many of us have been told by our nurses, "it's not that bad!"). Studies have shown that both female and male doctors often do not take female pain seriously, which can be a major factor in maternal deaths when red flags are ignored.

And I think we've all heard the comment "I would've died had my OB not (fill in the blank)." While sometimes that is absolutely true, let's be honest - sometimes it's not. As women we often tend to overshare and don't skimp on details, and when you find out the patient thinks the doctor who basically caused all of her complications through his own actions really saved her life,  it's pretty cringeworthy.

• The OB puts forth a closed system of logic, and allows no real input or criticism.

"In other words, what he says goes." At the time of this edit, there has been much talk on Facebook about OB's who refuse doulas in the delivery room. Never mind that doulas have been shown to reduce your rate of cesarean.

While I don't doubt that some physicians have had bad experiences with doulas, a good doula realizes her place in the room: to solely support the mother, not to offer medical advice. Unfortunately the choice to ban them altogether means you're also doing a disservice both to the good doulas out there and to the patients who desperately need them.

• Your OB has a great capacity for self-deception. 

He can not only fool you into thinking he supports you and your wishes, but also convinces himself that what he does is not wrong, but required and very necessary - even to the point of putting mother and baby at increased risk. (Unnecessary inductions and unnceseareans are a prime example.) Jennifer Block brings this up in Pushed: A doctor did for a cesarean because the patient's fluid levels were low, and afterwards cheerfully announced when Block asked, "Oh, her levels were fine!" Another example: Block asks the doctor if he thinks the induction will work, and he says, "No." So why are you doing it?

A friend of mine recently recounted her birth story of her only child, and when she asked about walking around and other coping techniques, her doctor told her it would be no problem. That all went out the window when it was time to deliver, and later she realized her doctor had absolutely lied to her. Basically they did everything to her they said they wouldn't.

• He/she projects the blame for his (relationship) difficulties onto his patient (partner).

I see this a lot in comments (from both medical professionals and the general public) about mothers dying in childbirth, because they're "fat, old and unhealthy." Unfortunately this is not always the case, and even so, does not account for so many maternal deaths.
"I think we've been inadvertently placing blame on mothers for these outcomes, and I hope this kind of work helps shift that narrative." - Stephanie Leonard, PhD
And just like in abusive romantic relationships, the patient/OB relationship can sometimes culminate in obstetrical violence. Kimberly Turbin is a mother who sued her physician for a forced episiotomy despite the fact that she had barely started pushing and repeatedly told him to stop. Remarkably the entire event was videotaped and the physician ended up surrendering his license. Ironically Turbin herself is a two-time rape survivor who already told staff ahead of time that she wanted permission before they touched her.

Caroline Malatesta also successfully sued an Alabama birth center after the violent birth of her child in 2012. Among her complaints were that the birth center had billed itself as a natural birth-friendly facility when it was anything but. Malatesta said that she was forcibly held down by a nurse and the baby was prevented from being delivered until the doctor arrived, despite her screams to stop. As a result she experienced permanent nerve damage and chronic, debilitating pain.

Demi Ruben Dominguez died after her doctor forcibly removed her placenta, despite her obvious pain and distress.
"The nursing staff documented that during the placenta extraction, the patient was screaming in pain and moving around in bed, and in his note, [the physician] described her as 'agitated,' and did not consider or record consideration summoning the anesthesiologist to add medication to the patient's epidural infusion prior to attempting to extract the placenta." - People Magazine, August 27, 2019
Her doctor had manually tried to remove the placenta and perforated her uterus, after which nurses noted that she was losing blood and looked pale - but the doctor refused to act. Both the patient
and her baby later died.

Other examples may include forced cesareans and membrane sweeps without consent (that some women may discern feels different than a normal vaginal delivery but otherwise are not informed that's actually what's taking place).

A controversial topic to many, this type of physical abuse has led to the term "birth rape."  It's extremely important to note that rape does not always have a sexual connotation, but can mean several things:
  1. To seize, take, or carry off by force
  2. an act of plunder (to rob, despoil or fleece), violent seizure, or abuse; despoliation (stripping or taking by force); violation.
Synonyms listed include "violate," "strip," or "ravage."

Some sexual assault victims do not agree with this terminology; some absolutely do and felt that their traumatic birth was like reliving their rape all over again. Unfortunately some women have still experienced mistreatment despite fully informing their care providers that they were sexual assault victims.

While some criticize those who use the term 'birth rape,' we are forgetting that abuse comes in many forms, and are devaluing the traumatic experiences that these women had - much like abuse deniers try to devalue the trauma of sex abuse. 

I'm not even sure how to tell women to avoid an abusive OB, because it's easier said than done to just switch providers. Often the new doctor is just as bad or worse than the first one. Gaining knowledge, information and perspective on your situation can be helpful in encouraging you emotionally and physically, as well as knowing when your doctor is giving you a line of BS. And speaking up when you feel violated, unsafe, patronized or mistreated in any way is absolutely crucial. 

Even after three pregnancies, I'm still learning how to do this.