Childbirth, Vulnerability and Law

Exploring Issues of Violence and Control

Camilla Pickles, Jonathan Herring, Camilla Pickles, Jonathan Herring

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429812903
• Edition: 1
• Topic: Medicina
• Subtopic: Ginecología, obstetricia y partería

This book is inspired by a statement released by the World Health Organization directed at preventing and eliminating disrespectful and abusive treatment during facility-based childbirth.

Exploring the nature of vulnerability during childbirth, and the factors which make childbirth a site for violence and control, the book looks at the role of law in the regulation of professional intervention in childbirth. The WHO statement and other published work on 'mistreatment', 'obstetric violence', 'birth trauma', 'birth rape', and 'dehumanised care' all point to the presence of vulnerability, violence, and control in childbirth. This collected edition explores these issues in the experience of those giving birth, and for those providing obstetric services. It further offers insights regarding legal avenues of redress in the context of this emerging area of concern. Using violence, vulnerability, and control as a lens through which to consider multiple facets of the law, the book brings together innovative research from an interdisciplinary selection of authors.

The book will appeal to scholars of law and legal academics, specifically in relation to tort, criminal law, medical law, and human rights. It will also be of interest to postgraduate scholars of medical ethics and those concerned with gender studies more broadly.

1 ‘Amigas, sisters: we’re being gaslighted’

Obstetric violence and epistemic injustice

Sara Cohen Shabot

Introduction

In ‘Making Loud Bodies “Feminine”’, I focused on how women live with and experience obstetric violence and why it is frequently described not only in terms of violence in general but specifically in terms of gender violence: as violence directed at women because they are women.¹ For this purpose, I used feminist phenomenology to explain and account for the feelings that many victims of this violence experience and report, including those of embodied oppression, of the diminishment of self, and of physical and emotional infantilisation.

In this chapter, I examine such feelings of diminishment of self and infantilisation through the epistemic aspects of the phenomenon of obstetric violence, mainly by observing it from the perspective of recent theories on epistemic injustice and specifically through the concept of ‘gaslighting’. I argue that a central part of obstetric violence involves labouring women being disbelieved, distrusted, and (unjustifiably) questioned about their violent labouring experiences and, more pressingly, even being made to doubt their own experiences of violence and to feel deprived of epistemic authority altogether. I show that the distrust shown towards labouring women operates both during the experience of labour and afterwards, when they attempt to tell others about their (violent) labouring experiences and to obtain epistemic recognition from them. I emphasise that this experience of deep distrust needs to be understood not simply as a response to the phenomenon of obstetric violence but must be recognised as a core part of the phenomenon itself.

The idea of ‘gaslighting’ has recently been used to account for specific cases of epistemic injustice, where the victim is intentionally or unintentionally made to doubt and distrust her own experience and testimony, since her interlocutor (often her supposedly ally) heavily questions their truth. Thus, in this chapter, I argue that to be a victim of obstetric violence means (also) to be continuously gaslighted: first by the medical staff involved and then by those who listen to the victim’s story.

1 Sara Cohen Shabot, ‘Making Loud Bodies “Feminine”: A Feminist-Phenomenological Analysis of Obstetric Violence’ (2016) 39 Human Studies 231, emphasis added.

‘But you cannot know for sure, can you?’

Last year, I went through several miscarriages. During one of them, I started bleeding at six weeks and five days into the pregnancy. I went to the hospital and was welcomed by a gynaecologist, a young woman. She seemed to be truly empathetic and kind. One of the first things she proceeded to do, after briefly conversing with me and my partner, was to examine me via ultrasound. She saw a tiny sac, with an approximately four-week-old embryo, a discovery she communicated to me optimistically. ‘You are four weeks pregnant’, she said, ‘and you are bleeding, like so many women at this stage. Everything seems to be all right, do not worry too much’. ‘But there is no heartbeat’, I countered. ‘Of course there is not’, she replied, immutable: ‘At four weeks we still cannot see any heartbeat’. Then I started impatiently explaining to her, for a second time now, that I was, in fact, not four, but rather almost seven weeks pregnant, and that this was surely an embryo that had stopped developing at four weeks (a situation similar to what had happened to me during several past pregnancies). It was then that a patronising dialogue of distrust began.

‘But you do not really know exactly when you got pregnant, do you?’ ‘The truth is that I know the precise date’, I responded. ‘But you cannot know for sure’, she continued. ‘I do believe I can, though: I feel ovulation very clearly and I also used an ovulation predictor kit’. ‘Well, this is what I see in the ultrasound’, she said, attempting to bring this hierarchical conversation to a happy ending by using the ultimate silencing weapon: Technology.

‘You just do not believe me; you do not believe me at all, right?’ I desperately tried, one last time.

She wielded her final weapon, condescendingly: ‘Well, we cannot base a diagnosis on your intuition, can we?’. And then I just shut up. I knew that this was pointless. I would not be able to convince her. In her view, I was still pregnant. To me, it was clear that I was miscarrying. I had experience, and I had knowledge, but this knowledge was being silenced mercilessly and turned by the ‘epistemic authority’ into ‘pure intuition’, just another suspicious female hunch not to be trusted. This is how I, an adult woman in her 40s, a responsible professional, a professor of philosophy, was sent home and told not to worry, since in eight more months I would most probably become a mother for the third time.

I went home, and I miscarried. Everything was all right and I needed no further intervention. However, that meeting with the kind doctor demanded reflection. After I went home that night, before I miscarried, I had noted that there was something else awakening in me alongside my anger and desperation at being disbelieved. I felt self-distrust, an uneasy feeling of not being sure whether I might be four weeks pregnant after all and not seven. That is, I had a feeling of not being sure whether I knew anything at all. In the end, I thought, it would be nice if she was right, and maybe she was, and how could I really know, after all?²

2 The similarities between my case and the one described by McLeod in her chapter on miscarriages and self-distrust as part of her analysis of reproductive autonomy and self-trust are striking. She quotes a report by telling the story of Janet, who precisely and accurately charted her first pregnancy, and miscarried at seven and a half weeks of gestation:

Every morning the bleeding stopped and every afternoon it started and on the Wednesday we went back to our doctor. He felt, palpated, and prodded and questioned that I had ever been pregnant at all: ‘You told me you were pregnant and I believed you.’ And I, knowing that I had been pregnant, started to doubt myself and my knowledge of my body. I felt concerned for the doctor, that he felt he had made a mistake, and it was my fault. You are very willing to believe everything is your fault. … I was afraid that the whole episode had just been hysteria, and he (the GP) was thinking ‘neurotic woman.’ … [She then explained that she had an ultrasound which confirmed her pregnancy.] … I had known that I was pregnant, and I had doubted it, doubted me, doubted this little baby existence because some forms of knowledge are seen as more valid than others.

Valerie Hey and others, Hidden Loss: Miscarriage and Ectopic Pregnancy (2nd edn, Women’s Press 1996) 44–45 quoted in Carolyn McLeod, Self-Trust and Reproductive Autonomy (MIT Press 2002) 38, emphasis added

Reflecting on this experience in retrospect, I could not help but notice the similarities it had with some of the forms of obstetric violence I had undergone in my second childbirth, which I documented and analysed as examples of the broad experience of obstetric violence in my first paper on the subject. I suddenly understood that this experience of profound distrust and disbelief was a recurrent, aching theme in stories denouncing obstetric violence: women being infantilised and having our reports of pain or power – of knowing what our bodies were either suffering or enduring with strength during childbirth –dismissed by medical authorities (whether doctors or nurses) in the labour room³ and, even more stressfully, by well-meaning allies listening to our labour experiences after the fact. But there was something else: this experience too often developed into one of self-distrust; it was eventually tainted by a disempowering feeling of deep self-doubt and, in consequence, loss of autonomy.⁴ In other words, in addition to being condescendingly questioned regarding our most intimate embodied experiences, we were ultimately being convinced that ‘they knew better’; we were truly made to feel and to believe that we had been exaggerating. Furthermore, it even seemed somewhat reasonable to assume that – precisely because of the pain of childbirth, because of our vulnerable state during it, because we were probably a little ‘hysterical’ – we had been magnifying ‘what everybody goes through’ and making a fuss over a ‘normal’ experience.⁵ This is of course the ultimate silencing tool. It is one thing to know that our experiences are not trusted, but to be convinced that we are indeed wrong, exaggerating, crazy, or ultimately just not even capable of proper judgment: this is the most effective form of oppression. Such deep internalisation of self-distrust and of the idea of our selves not being worthy epistemic agents is certainly the ultimate tool through which hegemonic powers can continue unquestioned and untouched.

3 The Internet is full of such reports these days. For instance, Birth Monopoly’s Facebook page offers dozens of reports of women being mocked and patronised for bringing birth plans to their births. One such account reports:

My first birth I handed over my birth plan and the nurse literally LOL’d and said to the other nurse ‘Look. First time mom with a birth plan *laughs*’ I was openly disrespected. I should have walked right out of that hospital and checked in somewhere else. The nurse mocked me for going pain med free, didn’t believe me when I told her I was about to vomit, didn’t believe me when I told her my water had broken. She was awful. My OB was so respectful, though. I didn’t get anything in my birth plan (ended with a c-section after my cervix swelled), but I knew that was likely. That nurse made my birth experience traumatic. Not the c-section, the nurse did.

Birth Monopoly (Facebook, 14 November 2017)

4 On self-distrust as eventually leading to loss of autonomy, see McLeod (n 2) 6. McLeod considers self-trust in patients to be the result of an intersubjective, relational process in which the patient trusts her healthcare provider and in consequence trusts herself and is able to make autonomous decisions about her own health. Referring to one particular case, she writes:

Lee was not able to trust her health care providers to interpret the expression of her needs as legitimate, and as a result, she was not always able to trust herself to act in her own interests. Patients cannot trust themselves to be autonomous if they cannot trust physicians to give them room to express their autonomous desires, and also to inform them accurately about their health and health care options. Patient self-trust does not replace the need for trust between patients and practitioners.

5 For more on the phenomenon of distrusting women in medical settings, mainly with respect to the reproductive process, because of sexist assumptions that women are oversensitive, overly emotional, and epistemologically and morally incompetent in consequence, see, for instance, McLeod (n 2) 8–9. Added to these sexist assumptions about women are assumptions about parenthood being a stressful and vulnerable condition, all of which are put onto women as they are going through the processes involved in becoming or trying to become mothers. Goering writes, for instance, about the experience of new parents in France when their babies are being taken care of in the newborn intensive care unit: ‘[P]arents whose infants are in the NICU are often treated paternalistically, with the presumption that they are “too emotional to be able to decide” or without “their whole decision-making capabilities because they are too stressed, for instance”’. Sara Goering, ‘Postnatal Reproductive Autonomy: Promoting Relational Autonomy and Self-Trust in New Parents’ (2009) 23 Bioethics 9. Racism adds another set of pernicious assumptions and frequently plays a part when women are disbelieved in the labour room as well as being involved in epistemic accountability in general: see Miranda Fricker, Epistemic Injustice. Power and the Ethics of Knowing (OUP 2007); Luvell Anderson, ‘Epistemic Injustice and the Philosophy of Race’ in Ian James Kidd, José Medina, and Gaile Pohlhaus (eds), The Routledge Handbook of Epistemic Injustice (Routledge 2017). The story of Serena Williams, the famous African-American tennis player, is a recent powerful example. After Williams gave birth to her first baby by emergency caesarean section, she started to experience a shortness of breath. Williams as...