Reproductive coercion outside the domestic relationship

Image: joinonelove.org

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?”

Or….

“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:

• calling the police to have "welfare checks" without serious justifiable cause
• calling the police to have you forcibly removed from your home
• threatening to call CPS on you if you refuse interventions 
• threatening to drop you from their practice even though you're making perfectly reasonable requests 

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