To the reader: We are proud to say that we recognize and appreciate the many doctors, nurses, midwives, and other professionals who practice and promote respectful, evidence-based care. We do not believe that these cases of abuse against women represent "most" or "all" care providers--but where this abuse exists, it cannot be ignored any longer. We ask that you join us in calling for compassionate care of all women in all birth settings.
This article is one installment in our #breakthesilence campaign about abuse and trauma in maternity care, together with the trauma toolkit and trauma resources for mothers and providers, "How to File a Complaint for Mistreatment in Maternity Care," and the photo campaign here.
* TRIGGER WARNING *
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Beginning to Break the Silence
“I didn’t give birth! The doctor cut me and pulled my baby out.”
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“I don’t want anyone else to go through what I went through.”
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What Do Doctors Say About Kelly's Treatment?
"Dr. A came into the room and after two pushes he had scissors in his hands and told the nurse that he was going to perform as episiotomy. I said why? ... I pushed two more times and he was going to cut and I said “No, Don’t Cut Me”. Then I said "why, why can’t we try?” He said why you don’t go home and try or go to Kentucky! So then after he yelled at me he cut my Vagina twelve times. So before the episiotomy the nurse said it’s only going to be a little cut. A little cut turned into Dr. A’s horrific rage against me as a human being and against my will to begin with. I wanted to cry so badly and I was so horrified while he was cutting me."
The paragraph above is from a letter sent to a California hospital from Kelly*, a first-time mom who endured a forced episiotomy (enlargement of the vagina with scissors or scalpel) at the birth of her son in 2013.
Kelly’s experience is not an isolated incident. The authors of the national Listening to Mothers II Survey (2006) said, “[T]he great majority of mothers who had experienced episiotomy (73%) stated that they had not had a choice in this decision.” Indeed, Improving Birth has heard from dozens of women who say their vaginas were cut against their will—women who said, “No, don’t cut me!” and many of whom said they attempted to move away from the person coming at them with a sharp object (see one series of comments here). Routine episiotomy has been discredited by science for over 20 years. Top
Since the beginning of August, Improving Birth has received hundreds of photos, messages, comments, and stories from women from across the country about the abuse and trauma they have experienced in maternity care. Women are sharing these stories as part of our #breakthesilence campaign, which was inspired by the messages, emails, and phone calls we get year-round from our volunteers and from women giving birth in almost every state in the U.S. (Read Dara's story, Kai's story, and Ashlee's story.)
Over and over throughout this public campaign, we’ve seen the same skeptical comments and questions:
• If this really happened, she would have sued!
• Those procedures were unfortunate, but surely they were medically necessary?
• Didn’t the doctor do what he/she had to do? There must be more to this story!
• Childbirth is unpredictable; your expectations are too high.
• You have a healthy baby, and that’s all that matters.
These are the kinds of things women hear all the time when they come forward with stories of abuse in their maternity care. The stories are so unbelievable and the treatment so inhumane, many people automatically question or justify what they’re hearing. Top
During the birth of her son in 2013, Kelly endured what many women have described through photos this month: coercion, manipulation, bullying, and a total disregard of informed consent—enabling poor care that created health complications. It's important to note the prevalence of non-evidence-based care and health complications (especially for black women) in American maternity care, when we consider that at least some mothers are not being given a choice about their care. For Kelly, this ended in a traumatic, forced episiotomy, a recurrence of post-traumatic stress disorder (PTSD), and need for further treatment of the cuts made to her vaginal area.
So, what sets Kelly’s story apart? In her case, there is no question about the facts she relayed. We can confirm her story, because it was captured on video (see "The Birth" below). Kelly’s mother filmed her grandson’s birth (with the full knowledge of the doctor in attendance) to share it among family members, but what she recorded was life-changing for Kelly in quite another way. Top
Kelly told us that when she hand-delivered her complaint six months ago, she spoke with the hospital’s Director of Women’s Services for 45 minutes about what had happened.
She says she never received a response, even after inquiring several times about what was being done or what the next steps were. To compound this dismissal, when she returned to ask for help, as the assault had triggered symptoms of previous PTSD and she was experiencing complications from twelve cuts to her vagina, she says that she was told she would get over it in time.
After it became clear she was not going to receive a response to her letter, Kelly tried to find a lawyer to help her bring a claim for a forced procedure. She received several denials from lawyers who expressed sympathy, but were unable to see the value in a case where there were no permanent damages or deaths. Improving Birth and Human Rights in Childbirth also tried to help Kelly find a lawyer in California, without success. UPDATE, April 2015: See "We Will Not Be Silenced: An Update on Kelly's Story"
As far as we know, this doctor is still attending women and babies at this hospital. UPDATE, April 2015: We believe the doctor has been suspended from the hospital, but the hospital will not confirm this.
If you are or know of a California lawyer who might be able to help Kelly, contact us here.
It seems incredible that such a violation would not be immediately investigated by the hospital once it was reported, but we have yet to meet a mother whose complaint about mistreatment to her doctor, hospital, or state licensing board was taken as seriously as it was made. Improving Birth has worked and spoken with a number of women who have gone through the process, all of whom were initially ignored or dismissed. Some women say they were met with outright hostility when they tried to make complaints about bullying, coercion, and forced procedures.
For women violated in childbirth, there does not appear to be any meaningful process for recourse or enforcement—even when their rights to informed consent and refusal were disregarded and/or they believe that assault and battery occurred. Jenn Noell of Outer Banks, North Carolina attempted to report to the police that, during an unmedicated birth, the on-call doctor manually penetrated her with both hands while she was pushing, ignored her shouts of, “No!”, intentionally tore her vagina with his fingers, forcibly removed her placenta, and then began stitching her perineum after birth without using a local anesthetic. Local law enforcement declined to pursue charges after the district attorney’s office opined that the doctor’s "duties" included “invad[ing] certain areas." Neither was this woman able to find a lawyer to take her case for a civil action.
Most women never get to that point, though, simply because these abuses are considered part of childbirth in some places. When they attempt to speak up, family members, friends, care providers, and others often dismiss them with some of the statements we listed above. For a traumatized woman busy caring for a newborn, the idea of speaking up in the face of such skepticism can be overwhelming.
In Covington, Louisiana, Andrea Davis told us that she can’t think about her most recent birth “without crying and becoming physically ill at times” after, she says, the doctor manually removed her placenta and performed a uterine sweep following the birth, ignoring her distress and actually refusing to speak to her. She said, “I have never had someone put their arm up inside of me in my three previous births, let alone without telling me what they were doing first, and without asking permission. [The doctor] had zero respect or regard for me as a human being.”
When she spoke to a friend in private about what had happened to her, she said that rather than receiving support, she was met with coolness. She was warned “that if I keep talking about the OB who was abusive to me I could be sued for slander. I’m sick to my stomach thinking that she could harm us again.... and enraged that I could be harmed by telling the TRUTH about what she did to me.”
Improving Birth and Human Rights in Childbirth have worked together since 2012 on an unofficial hotline for women needing support in these situations. From those efforts was born the Birth Rights Bar Association, the U.S. legal network launching in August 2014 to educate, train, and organize lawyers around issues related to childbirth. Top
Kelly has been coping with a recurrence of PTSD since her son’s birth, as well as complications from her medical treatment. It was emotionally difficult for her to revisit the trauma of her son’s birth in order to document it and make a complaint; the lack of response to her complaint has been devastating.
Kelly has chosen not to be a victim. She made the brave decision to share her story and video (see "The Birth") because she doesn’t want anyone else to experience this kind of treatment. Top
Unfortunately, it’s not just about episiotomies--although routine episiotomy is still very much alive in some places, despite decades-old evidence against it. As an example, one Lexington, Kentucky hospital had an episiotomy rate of over 15% in 2011, while another Lexington hospital five miles away, serving the same population of women, had a rate of less than 1%. In the Westchester, New York area, two hospitals ten miles apart have episiotomy rates of 64.7% and 9.5% for the year 2012.
We regularly hear from women about violations like this:
- Forced vaginal exams during labor
- Being told they are not allowed out of bed, to use the bathroom, or to leave the hospital
- Being ignored or yelled at when they ask questions about their care
- Being told they are not allowed to give birth vaginally
- Being forcibly placed and restrained onto their backs during birth when they want to assume a more comfortable position
- Manual removal of the placenta without notification or permission
- Being given high-risk medications to hurry labor along without notification or consent
- Manual breaking of the membranes to accelerate labor without notification or consent
- Having membranes stripped (a way of inducing labor) without notification or consent at a routine prenatal appointment
Almost every one of these procedures and practices, done as a matter of routine, creates or increases risks of injury, complications, and even death. Please note that while the vast majority of the violations we hear about are associated with hospital birth, they can happen in any setting, with any provider.
Many more women report being bullied into or forced to have a Cesarean section. The cases of Rinat Dray – the New York mother whose doctor wrote that he “decided to override her refusal to have a C-section” – and Jennifer Goodall in Florida – whose hospital wrote to her that she would receive a Cesarean “with or without your consent” if she presented in labor – are the most extreme recent examples of something we hear about at the rate of about one a month.
Neither is it about just force. Mothers and birth professionals from all over the country report that, more commonly, "consent" is obtained through inaccurate, incomplete information (no discussion about the risks of a procedure, for example) or under duress ("The doctor won't come in until you let me give you another vaginal exam.").
Lisa Sandhusen in New Jersey said, "As a postpartum doula for six years, I often see how new mothers who are struggling with the conflicting emotions of coming to terms with how they were treated during labor and birth and the desire to be loving attentive mothers to their newborn babies. Often times the experiences and feelings are brushed away or justified with the phrase, ‘At least the baby is healthy.’
“It breaks my heart to see women disregarding their own experience to enter into motherhood with wounded hearts and bodies. My job has evolved into gently coaching these women through trauma at a time when they should be enjoying the time learning about their newborns. The women that I work with are educated and fortunate in that they can afford the services and support of someone like me. Imagine what the average woman goes through."
Almost one in ten American women leaves childbirth meeting criteria for PTSD. While nature can certainly create a traumatic birth, so much of the trauma we hear about has nothing to do with medical circumstances and everything to do with how a woman was spoken to, listened to, and respected. Much of this trauma seems to be entirely preventable.
A recent study from University of North Dakota researcher Sarah Edwards, Ph.D. found a strong link between coercion and post-partum PTSD. “We investigated what factors predicted whether women developed PTSD after childbirth, including risk factors like having a history of physical or sexual abuse or domestic violence, low socioeconomic status, age, and education level of the mother. First, we were surprised to find that 34% of our sample of 1,125 mothers reported PTSD symptoms related to their births. Then, we were really surprised when we found it the strongest predictor of developing PTSD after labor was not a history of trauma, but rather the level of coercion the women experienced during their labor and delivery. This makes it clear how important it is that women are treated with respect, dignity, and care when giving birth, to prevent serious mental health complications post-partum.” Top
Kelly’s birth story and video are very graphic and may be difficult for some readers/viewers, especially those who have experienced sexual assault and/or trauma in childbirth. For legal and privacy reasons, we are not revealing the names of anyone involved.
Below are a link to the video itself and a detailed narrative of the events written by Human Rights in Childbirth founder and birth lawyer Hermine Hayes-Klein. Ms. Hayes-Klein has also written an excellent analysis of some the legal, human rights, and liability factors at play here. Top
Narrative by Hermine Hayes-Klein
The scene opens with a woman on her back in a hospital room. Her feet and legs are up above her in gynecological stirrups. You can’t see her face; camera is angled from below, so you see her exposed haunches, her vagina and anus. The camera is held by the woman’s mother, let’s call her Grandmother. You don’t see Grandmother’s face during the video either; you only hear her voice from behind the camera.
The birthing woman, Kelly, has a tube running to her pubis, a urethral catheter that was part of the epidural process. She received the epidural after telling the nurses, as she told her prenatal providers, that she had been raped and sodomized twice, that she was feeling scared, that she needed them to be gentle and to ask her, step by step, every detail of what was going to be done. The hospital staff gave her a drug to calm her, and an epidural.
Kelly is a healthy young woman having her first baby. Her pregnancy and labor have been normal. She has a partner holding her left hand, and the nurse on her right. The nurse says, “Cinco de Mayo baby. It’s going to come out with a sombrero. Just kidding.” The nurse watches the monitor until she sees a contraction coming on. Then she loudly directs Kelly to push push push, talking nonstop for the length of the contraction. Kelly pushes hard; you can hear her exertion, working against gravity because this position makes her have to push her baby up into the air. Slowly the baby starts to crown. The baby’s head is just opening the labia; not yet out far enough to stretch the perineum.
A man in a white coat has been sitting on a stool between Kelly’s legs. During her contraction, while she’s pushing, he stands and holds up a long, sharp pair of scissors. He mumbles toward the nurse, “I’m going to do the episiotomy now.”
Kelly cranes her head up and says, “What’s up, doctor?”
He says, “I said I’m going to do the episiotomy now.”
Kelly objects: “What? Why? We haven’t even tried.”
The doctor explains: “Listen, dear. You are pushing, baby’s head comes down and doesn’t come out because there is no space here to come out.” He stands now between her legs, gesturing with his hands, one of which holds the scissors. “OK? Baby’s head about that big and your vagina is only that much. Ok?”
Kelly says, “But why can’t we just try?”
The doctor says, “Try? You’re trying all the time and it doesn’t come out. And if it comes out its going to rip the butt hole down clean.” He makes a slashing motion with the scissors toward her anus as he says this.
The nurse reassures Kelly: “We’re not going to feel it, remember? And you have the epidural.”
Another contraction comes. The nurse directs Kelly to pushpushpush gogogo. In the foreground, the doctor bustles with scissors and a medical cloth. He throws the cloth over Kelly’s lower belly, exposing her perineum below it, and approaches with the scissors.
Panting with the contraction, Kelly calls out desperately, “No, don’t cut me!” From behind the camera, Kelly’s mother chastises her in Spanish, telling her not to argue with the doctor, to let the doctor do his job. T
he doctor says, “Yes, tell her!” Kelly begs, “No! Why? Why can’t we try?”
The doctor’s voice is authoritative now, even angry, as he responds: “What do you mean, ‘Why?’ That’s my reason. Listen: I am the expert here.”
Kelly pleads, “But why can’t I try?”
The doctor answers, “ ‘Why can’t I try?’ You can go home and do it. You go to Kentucky.” [Kelly has never been to Kentucky.]
Grandmother and the nurse berate, chastise and urge Kelly to submit to the doctor. Grandmother says, “No, you can’t fight with the doctor. Just do it, doctor.”
The nurse says, “If you rip, you’ll rip more than a cut and it’s a lot more pain too. He said it’s only an inch. An inch isn’t that bad. Do you want to see an inch again?” A contraction comes. Kelly is pushing and breathless; she can’t speak.
Grandmother says, “Just do it, doctor.” The doctor starts to snip Kelly with the scissors. You can hear the scissors cut her flesh 12 times.
He reaches in and wrenches, twists, and pulls the baby out of her. Everybody around Kelly cheers throughout this delivery.
Kelly is silent. The nurse lifts her beautiful baby up to meet her. Kelly tries to smile.
Dr. Michael Klein, MD, CCFP, FCFP, FAAP (Neonatal/Perinatal), FCPS, is a pediatrician/neonatologist and family physician researcher and educator based at Children’s & Women’s Hospital and the Centre for Developmental Neurosciences & Child Health of the Child and Family Research Institute in Vancouver, British Columbia, Canada. Dr. Klein pioneered randomized controlled studies on episiotomy in the 1980s and 90s, conducting over ten years of research that reached some groundbreaking conclusions (see articles here, here, and here). Thanks to his work, we have known for over 20 years that while episiotomy can be appropriate in rare circumstances, when applied routinely, it “cause(s) the very trauma that it was supposed to prevent” (see article here).
Of Kelly’s case, Dr. Klein said, “The physician here applied a medio-lateral episiotomy unnecessarily early through thick tissue, but rather than making a single definitive cut, he makes a series of short cuts that cause unnecessary bleeding and will interfere with healing. The episiotomy was done so early that the perineal tissues did not have time to stretch, so that the tissues were thick and bloody, a situation that would not have pertained if the professionals had waited… Having decided in advance to do an episiotomy, the doctor apparently does not even know how to do one--how to time it to minimize trauma. This behavior makes it more likely that severe trauma will occur, including tearing into or through the rectum. Our research and the research of others show that it is episiotomy that is the cause of severe trauma, not the prevention of severe trauma….”
He went on to say that the “doctor and the nurses were simply unwilling to allow time for the perineum to stretch, so that episiotomy would be not needed…. The mother is clear that she does not want an episiotomy. Her wishes are ignored and the clearly planned episiotomy is simply justified in advance so that the professionals can do what they planned to do anyhow…. It was all about the impatience of the professionals who were not remotely interested in the values and needs of the mother. They just wanted the birth expedited. This is a picture that was often routine in the past, but since the early 1980s this approach cannot be justified, if it ever was.” (Emphasis added)
Dr. Klein concluded, “this video shows a woman assaulted by uncaring professionals who ought to be sanctioned.”
We also asked California obstetrician/gynecologist Dr. Nick Rubashkin, MD, MA, for his opinion. Dr. Rubashkin is a staff physician at the California Pacific Medical Center in San Francisco, and a former Fulbright Research Fellow at the Visiting Scholar Institute of Behavioral Sciences, Semmelweis University, in Budapest, Hungary.
He said, “Informed consent is an ethical and legal imperative for all physicians, including obstetrician/gynecologists… Informed consent to this episiotomy did not happen. Kelly was simply told by her doctor, ‘I am going to do an episiotomy now.’ He did not respond to the patient’s clear requests for more information and for additional alternatives… This is unfortunate, because had the medical staff in the room listened to the mother, she might have avoided an unnecessary and painful procedure that may well result in future complications for her.”
We believe one of the best things we can do right now is to create awareness to “break the silence” around these abuses, and support each other in sharing our stories without fear. Here's what you can do.
#1 Support Kelly's case. Because Kelly has been unable to find legal representation, she is representing herself in filing a lawsuit by May 2015, before the statute of limitations runs out on her claim. At this point, her case is 100% funded by other women--many of whom have also seen or experienced violence or coercion in childbirth. Go here for an update on her story, and go here to contribute toward her legal fund.
#2 Sign and share the petition to California Attorney General Kamala Harris asking for help in holding care providers and hospitals accountable for abuses of laboring women. The petition is here.
#3 Use your social media reach to help get the message out to one million people by the end of this month (August)!
- Share a photo that’s meaningful to you from our #BreaktheSilence photo project or our "1 in 3" photo, using hashtags #breakthesilence and #improvingbirth. Feel free to tell your own story on your page when you share.
- Every photo you share will link back to this article, so each share brings more people here to learn about these issues.
- Change your profile picture to the Improving Birth logo, here.
Get your story on public record. Over 40 mothers have already submitted stories that have been shared with the court on behalf of Rinat Dray, the New York mother who brought a lawsuit for her forced Cesarean section. We are still collecting these stories to be shared in future cases. The intent is to illustrate for courts that an incident of bullying, coercion, or force in childbirth is not an anomaly. If you’d like to be counted in this important effort, spearheaded by lawyers with Human Rights in Childbirth, please share your story here. Top
If you are a mother or witness struggling with birth trauma, we hope our Trauma Toolkit may be of help to you. You may also find helpful "How to File a Complaint for Mistreatment in Childbirth," and please do not hesitate to contact us on your journey.
* Not her real name
Author Cristen Pascucci is vice president of Improving Birth and has been running its "hotline" for pregnant women with lawyers from Human Rights in Childbirth. She is also the founder of Birth Monopoly.
Declercq ER, Sakala C, Corry MP, Applebaum S. Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection, October 2006. <http://www.childbirthconnection.org/pdfs/LTMII_report.pdf>
Declercq ER, Sakala C, Corry MP, Applebaum S., New Mothers Speak Out: National Survey Results Highlight Women’s Postpartum Experiences. New York: Childbirth Connection, August 2008. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174380/>
Kentucky Cabinet for Health and Family Services. “Kentucky 2011 Quality Indicators.” <http://1.usa.gov/1oUCRhb>
Klein, M.C., Studying episiotomy: when beliefs conflict with science. Journal of Family Practice Nov. 1995: 483+. Academic OneFile. Web. 6 Sep. 2011. PDF: <http://bit.ly/VGl5BB>
Klein MC. From routine episiotomy to routine Cesarean section: how society came from rejecting one to embracing another. Bear Bones Publication of the Department of Family Practice University of British Columbia. 2010. Spring 10 (1): 12-17. <http://www2.cfpc.ca/local/user/files/%7B2F968A23-D9EE-4F6A-BEC7-6E8B991A5DAB%7D/BBones_Klein.pdf>
Klein, M.C., Gauthier, R.J., Jorgensen, S.H., Kaczorowski, J et al. Does episiotomy prevent perineal trauma and pelvic floor relaxation?[erratum appears in Online J Curr Clin Trials 1992 Sep 12;Doc No 20:[54 words; 1]. Online Journal of Current Clinical Trials 1992;Doc No 10:[6019 words; 65 paragraphs]. < http://www.ncbi.nlm.nih.gov/pubmed/1343606>
Klein, M.C., Gauthier, R.J., Robbins, J.M., Kaczorowski, J. et al. Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. American Journal of Obstetrics & Gynecology 1994;171:591-8. <http://www.ncbi.nlm.nih.gov/pubmed/8092203>
Klein, M.C., Kaczorowski, J., Robbins, J.M., Gauthier, R.J., Jorgense, S.H., Joshi, A.K. Physicians’ beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for women in their care. Canadian Medical Association Journal 1995;153:769-79. <http://www.biomedsearch.com/nih/Physicians-beliefs-behaviour-during-randomized/7664230.html>
New York State Department of Health. “Hospital Maternity-Related Procedures and Practices Statistics.” <http://www.health.ny.gov/statistics/facilities/hospital/maternity/>