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Exploring ‘obstetric violence’ and ‘birth rape’

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Recently, the wonderful Ibone Olza (Perinatal Psychiatrist and Childbirth Activist from Childbirth is Ours, Spain) contacted me about her work on obstetric violence, birth rape and professional trauma. After reading her papers and watching her present her work, I was compelled to document and reflect upon some of the issues raised, here.

The following points are made within the paper: Fernández, Ibone Olza. “PTSD and obstetric violence.” Midwifery today with international midwife 105 (2013): 48-9.

Birth trauma has been defined as “Actual or threatened injury or death to the mother or her baby” (Beck 2008). Yet such trauma lies in the eye of the beholder, therefore, any trauma experienced by either the mother, newborn or the birth attendant may be due to a subjective experience of stress which does not need to fit any particular criteria necessarily. This means that some traumatic events may be subjective in their nature, and as such, we cannot judge what may or may not cause another person trauma. It is a personal interpretation or perception.

A meta-ethnographic analysis of studies about women’s perceptions and experiences of a traumatic birth reported that women are often traumatized as a result of the actions or inactions of midwifery staff (Elmir et al. 2010). Whatever, such inactions or actions may be…women often use words such as ‘barbaric’, ‘intrusive’, ‘horrific’ and ‘degrading’ to describe their mistreatment (Thomson and Downe 2008).

For Hodges, drugging or cutting a pregnant woman with no medical indication is an act of violence, even when performed by a medical professional in a hospital. Inappropriate medical treatment is also clearly abusive, although few women are aware that this is deliberate mistreatment (Hodges 2009).

The term ‘birth rape’ has been used by women who feel that their bodies have been violated. Kitzinger highlighted that many women who have experienced a traumatic birth display similar symptoms to rape survivors (Kitzinger 2006). The video below explores these issues in greater detail, as we can hear the lovely  Ibone Olza  sharing this work.

 

One of the things I was most encouraged about, was that  Ibone Olza  considers the wellbeing of the midwifery staff in her work. Birth attendants are often also traumatized by these acts, and may feel powerless to intervene. In a recent study by Beck, 26% of obstetric nurses met all the diagnostic criteria for screening positive for PTSD due to exposure to their patients who were traumatized (Beck and Gable 2012). Being present at  abusive deliveries can magnify staffs’ exposure to birth trauma.

staff use phrases such as…

“the physician violated her”

“a perfect delivery turned violent”

“unnecessary roughness with her perineum”

“felt like an accomplice to a crime”

“I felt like I was watching a rape.”

….to describe the guilt that ensued when they felt like they had failed women or they did not speak up and challenge/question…

Article 51 establishes that: The following acts implemented by health personnel are considered acts of obstetric violence:

  1. Untimely and ineffective attention of obstetric emergencies
  2. Forcing the woman to give birth in a supine position, with legs raised, when the necessary means to perform a vertical delivery are available
  3. Impeding the early attachment of the child with his/her mother without a medical cause thus preventing the early attachment and blocking the possibility of holding, nursing or breastfeeding immediately after birth
  4. Altering the natural process of low-risk delivery by using acceleration
    techniques, without obtaining voluntary, expressed and informed consent of the woman
  5. Performing delivery via cesarean section, when natural childbirth is possible, without obtaining voluntary, expressed, and informed consent from the woman

(D’Gregorio 2010)

trauma

Yet whilst people do bad things, it is important to remember that they are not necessarily bad people…

This work explains how professionals may exert obstetric violence due to:

  • Lack of technical skills to deal with emotional and sexual aspects of childbirth.
  • Unsolved trauma. The medicalization of childbirth produces more severe iatrogenic
    complications (Johanson, Newburn and Macfarlane 2002; Belghiti et al. 2011). If the
    professionals do not have a supportive space to reflect or to deal with this aspect of iatrogenic care, they may fall into a spiral of continuously increased medicalization as a defensive strategy. Childbirth is then perceived as a very dangerous event, “a bomb ready to explode,” without realizing that interventions cause more unnecessary interventions and pain.
  • Professional burnout in birth attendants will lead to increased dehumanized care and therefore never-ending figures of women experiencing childbirth as very traumatic.

..and so the challenge will be to identify and address these root causes to ensure that maternity staff are able to provide excellence in midwifery care. My work explores how we might support the psychological wellbeing of health care staff may increase levels of humanity and compassion in care. I hope to keep in touch with Ibone Olza and many others around the world who share the same passion for this work. Together we may collectively work towards a time where maternity workers are psychologically safer, and therefore better able to provide the excellence in care they strive to give.

If you would like to follow the progress of my work going forward..

Follow me via @SallyPezaroThe Academic MidwifeThis blog

Until next time…Look after yourselves and each other 💚💙💜❤

References and further reading

  • Soet JE, Brack GA, DiIorio C. Prevalence and predictors of women’s experience of psychological trauma during childbirth. Birth 2003 Mar;30(1):36-46.
  • Creedy DK, Shochet IM, Horsfall J. Childbirth and the development of acute trauma symptoms: incidence and contributing factors. Birth 2000 Jun;27(2):104-111.
  • Ayers S, Pickering AD. Do women get post traumatic stress disorder as a result of childbirth? A prospective study of incidence. Birth 2001 Jun;28(2):111-118.
  • Beck CT, Gable RK, Sakala C, Declercq ER. Post traumatic stress disorder in new mothers: results from a two stage U.S. national survey. Birth 2011 Sep;38(3):216-227.
  • Allen S. A qualitative analysis of the process, mediating variables and impact of traumatic childbirth. Journal of Reproductive and Infant Psychology 1998;16(2-3):107-131.
  • Beck CT, Watson S. Impact of birth trauma on breast-feeding: a tale of two pathways. Nurs Res 2008 Jul-Aug;57(4):228-236.
  • Beck CT. Post-traumatic stress disorder due to childbirth: the aftermath. Nurs Res 2004 Jul-Aug;53(4):216-224.
  • Beck CT. Birth trauma: in the eye of the beholder. Nurs Res 2004 Jan-Feb;53(1):28-35.
  • Ayers S. Delivery as a traumatic event: prevalence, risk factors, and treatment for postnatal posttraumatic stress disorder. Clin Obstet Gynecol 2004 Sep;47(3):552-567.
  • Olde E, van der Hart O, Kleber R, van Son M. Posttraumatic stress following childbirth: a review. Clin Psychol Rev 2006 Jan;26(1):1-16.
  • Elmir R, Schmied V, Wilkes L, Jackson D. Women’s perceptions and experiences of a traumatic birth: a meta-ethnography. J Adv Nurs 2010 Oct;66(10):2142-2153.
  • Nicholls K, Ayers S. Childbirth-related post-traumatic stress disorder in couples: a qualitative study. Br J Health Psychol 2007 Nov;12(Pt 4):491-509.
  • Ayers S. Thoughts and emotions during traumatic birth: a qualitative study. Birth 2007 Sep;34(3):253-263.
  • Thomson G, Downe S. Widening the trauma discourse: the link between childbirth and experiences of abuse. J Psychosom Obstet Gynaecol 2008 Dec;29(4):268-273.
  • Goldbort JG. Women’s lived experience of their unexpected birthing process. MCN Am J Matern Child Nurs 2009 Jan-Feb;34(1):57-62.
  • Sawyer A, Ayers S. Post-traumatic growth in women after childbirth. Psychol Health 2009 Apr;24(4):457-471.
  • Hodges S. Abuse in hospital-based birth settings? J Perinat Educ 2009 Fall;18(4):8-11.
  • Kitzinger S. Birth as rape: There must be an end to ‘just in case’ obstetrics. British Journal of Midwifery 2006;14(9):544-545.
  • Beck CT. The anniversary of birth trauma: failure to rescue. Nurs Res 2006 Nov-Dec;55(6):381-390.
  • Beck CT, Gable RK. A Mixed Methods Study of Secondary Traumatic Stress in Labor and Delivery Nurses. J Obstet Gynecol Neonatal Nurs 2012 Jul 12.
  • Perez D’Gregorio R. Obstetric violence: a new legal term introduced in Venezuela. Int J Gynaecol Obstet 2010 Dec;111(3):201-202.
  • Callister LC. Making meaning: women’s birth narratives. J Obstet Gynecol Neonatal Nurs 2004 Jul-Aug;33(4):508-518.
  • Johanson R, Newburn M, Macfarlane A. Has the medicalisation of childbirth gone too far? BMJ 2002 Apr 13;324(7342):892-895.
  • Belghiti J, Kayem G, Dupont C, Rudigoz RC, Bouvier-Colle MH, Deneux-Tharaux C. Oxytocin during labour and risk of severe postpartum haemorrhage: a population-based, cohort-nested case-control study. BMJ Open 2011 Dec 21;1(2):e000514.

 

 

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How to conduct research: A dummy’s guide to conducting research

Image result for quote "I do research because"

Seminars held by the worlds top universities generally present the most up to date and respected ideas in relation to conducting research. Recently, I was lucky enough to attend a conference where several seminars were held over a one week period…How very convenient!…These seminars in combination were able to map out a broad blue print of how to conduct research for their audiences (myself and other chums).

As a result of attending these wonderful seminars, I am now able to translate what was shared into this dummy’s guide to conducting research. I write here not only to refresh my own knowledge in this area, but also in the hope that it may be of use to the readers of this post. Wish me luck!…

research

So why do we do research?…Because we have an idea?, a problem to solve?, or an area where a lack of knowledge resides?..(See ) …These are all valid reasons to conduct research within reason, but…What is research?…

Image result for quote on research is formalised curiosity

OK, so we need to define a research question…What question, need or idea are we trying to answer?..What itch do we have to scratch? We need to formulate a research question….and also formulate a research problem.

How to formulate a research problem

  • Explore the nature of the problem. Why is it a problem?..who does it affect?
  • Explore the context of the research problem. Where does it ‘sit’ among other things?
  • Define your variables. What would vary?…what can’t you control?…what would be the impact of that?
  • Think about what would happen if you didn’t address this problem. What would be the consequences of doing something else?
  • Define your objectives? What are you trying to achieve by doing this research?

How to formulate a research question

Think first…is your research question:

  • Interesting
  • Relevant
  • Focused
  • Answerable

Then…narrow your ideas down to develop a great research question.

Broad topic  Narrowed topic      Focused topic   Research Question
Children’s
health →
 Children and diabetes → School meals and sugar content→ Is there an association between sugar content in school meals and diabetes risk?
Walking → Walking related injury → Walking related injury and
adults→
How does Walking related injury affect
adults?
Bullying → Teenagers and
bullying →
Teen peer
pressure and aggressive behavior→
What role, if any, does
peer pressure play in the development of aggressive behavior
among teens?

                                          Image result for hypothesis

Image result for hypothesis

  1. Non directional hypothesis = Pregnant women will experience some change in their pattern of urination.
  2. Directional hypothesis = Pregnant women will urinate less frequently.
  3. Null hypothesis = A statistical assumption. e.g: There will be no difference in the frequency of urination for pregnant women who swim compared with those who do not swim.

And to test this theory…..(quasi-experimental or experimental study design)..we must ascertain the relationship between variables.

Components

Experimental group = Pregnant women swimming

Expected result = e.g Pregnant women will urinate less frequently

Comparison group = Pregnant women who do not swim

Image result for which research design

 

Image result for methods

Quantitative and qualitative research characteristics….

Characteristic Quantitative research Qualitative research
Philosophical origin Logical positivism Naturalistic/Interpretive
Focus

Reasoning

Concise and objective Broad and objective
Reasoning Logistic and deductive Dialectic and inductive
Basis of knowing Cause and effect relationships Meaning, discovery and understanding
Theoretical focus Tests theory Develops theory
Researcher involvement Control Shared interpretations
Methods of measurement Structured interviews, questionnaires, observations, scales or measurements Unstructured interviews and observations
Data Numbers Words
Analysis Statistical analysis Individual interpretations
Findings Generalisation, accept or reject theoretical propositions Uniqueness, understanding of new phenomena and/or theory

Image source and further reading = Crowe, Michael, and Lorraine Sheppard. “Qualitative and quantitative research designs are more similar than different.” Internet Journal of Allied Health Sciences and Practice 8.4 (2010): 5.

Image result for research designs

Image result for data analysis

Quantitative data analysis methods Qualitative data analysis methods
Involve statistics/number analysis Text analysis
Seek deductive interences Seek inductive inferences
Focus on quantifiable phenomena (comparisons, differences, trends and relationships) Focus on meanings (themes)
Involve data clustering analysis for relationships in non-hypothesis testing Involve data structuring and coding into themes and groups.
Involve systematic predetermined analysis Involve in-depth fluid analysis
Value-free enquiry Considers the impact a researcher may have on others’ values
Objective Subjective
Narrow and specific General and broad

Image result for variables

Variable = Anything that varies

Independent variable = does not depend on that of another. Can be introduced or withdrawn by the researcher

Dependent variable = Depends on the independent variables and it’s out come variable e.g: Trauma, bleeding, symptom changes.

Extraneous variable = Unwanted influence that may interfere with either the dependent and/or independent variables.

Demographic variable = Age, gender, race etc.

Top tips:

  • We can ask..’What is the relationship between two or more variables?’ However, we cannot infer ’cause and effect’.
  • Experimental study designed (hypothesis testing) is considered to be the ‘Gold standard’ for evidence. However, you can gather a multitude of this type of evidence via systematic review and/or meta analysis (See more information on these here or in the image below).
  • Ethical considerations should be revisited throughout the study, as well as before commencement.
  • Take control of any extraneous variables by random sampling (from a larger sample base), random assignment (into either a control or experimental group), selecting a homogeneous (similar on an important variable) sample and by matching the control to the experimental group on important variables.

In conducting a systematic review, you can also arrive at new research problems and questions…meaning that the possibilities of conducting research are endless!..

 

But why do all of this hard work if you are not going to share what you have found, analysed, discussed and then concluded?

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It is important to publish and share your work at both a high and low level, so that new knowledge is available to everyone!…Students and professors alike should publish. It is never too soon or early in your career to get started on this. If you are not confident about writing or publishing your work, contact me and I will be happy to partner with you throughout the process.

Not sure how to do this?…see my post…’Why Midwifery and Nursing Students Should Publish their Work and How’ for further info.

Image result for methods of research data analysis

If you would like to follow the progress of my work going forward..

Follow me via @SallyPezaroThe Academic MidwifeThis blog

Until next time…Look after yourselves and each other 💚💙💜❤