Antonia Yunge

We come to the world crying, covered in blood and bodily fluids. Although it is usually romanticized, childbirth is a noisy, messy, violent—but natural—event. This kind of violence is unavoidable, it is part of the circle of life.

However, labor and childbirth is often also accompanied by a common, invisible, and avoidable type of unnatural violence: obstetric violence. A normalized set of practices that relegate birthing people to a secondary plane, focusing solely on the well-being of the baby while infringing on people’s fundamental rights of dignity and respect, making the experience of childbirth traumatic for many of those who go through it.

1/3 of pregnant people in the US report having been victims of obstetric violence.¹

In a society where medical practice is often shaped by efficiency rather than by care, giving birth, a normal physiological process, became highly medicalized. Over the years, the rates of cesarean section, use of oxytocin, episiotomy, epidural, enema, electronic fetal monitoring, intravenous infusions, among other medical practices, have increased and have even become routine.

Today, as high as 30% of childbirths in the US are C-Sections (double the World Health Organization recommendation), half of which are not medically necessary, putting patients in danger².

Furthermore, despite medical advances, the US has the highest rate of maternal deaths among developed countries³. Black women are three to four times more likely to die in childbirth than white women⁴regardless of education, income, or any other socio-economic factors.⁵

The causes of obstetric violence involve a complex system of factors, primarily related to gender discrimination, unequal power dynamics between patients and providers, a legal system set up to protect providers and medical systems instead of the patients they serve, lack of provider accountability, and misinformation or lack of education about birthing rights—both in patients and healthcare students & providers.

Gathering pregnancy and childbirth experiences—not only from patients, but also from their support network and service workers—provided a valuable framework to develop the project. Collaboration withPublic Health Solutions (PHS), theNational Advocates for Pregnant Women (NAPW), and a partnership with theBirth Justice Defenders (BJD) played very important roles throughout the project.

The Birth Justice Defenders is a community group formed mainly by Latin American women. They meet once a month to discuss challenges and ways of moving forward towards respectful childbirth. They constantly participate and organize events to educate different communities about birthing rights, increasing awareness about obstetric violence. Attending their monthly meetings and listening to their experiences, hopes, and fears provided the project with insightful and inspiring perspectives on the topic, especially from a community point of view. A small subgroup of the BDJ was also able to participate in a research workshop, where we got the chance to deeply explore their stories of pregnancy, labor, and birth.

Pregnancy and childbirth involve a wide network of stakeholders. In the clinical setting, pregnant people interact with obstetricians, midwives, doctors, nurses, technicians, and administrative staff. Outside of that area, stakeholders appear at the family and community levels. Within a pregnant person’s community, support groups, organizations, doulas, social workers, case workers, and nurses from different programs provide essential assistance to them and their families. Stakeholders at the family level greatly vary, but the support network can include partners, parents, siblings, other family members, neighbors and/or friends.

The complexity of this system is a fertile ground for design interventions that can improve the experience of people along their pregnancy and birth journeys. The process of making the systemic and cultural changes needed to effectively combat obstetric violence is long and complex, and requires a lot of resources and structural changes. A problem of this magnitude cannot be approached directly nor can it be changed by a single, simple intervention. There’s no magic solution to it.

The purpose of this thesis project is to understand the challenges and leverage points for tackling obstetric violence, and to empower pregnant people about their birthing process.

Obstetric violence can be tackled from different points of view, as many factors and stakeholders contribute to its existence. This complexity allows for design to intervene at different levels of the system, to start tearing down the structures in which violence supports and feeds itself.

When considering timespans as a first parameter to determine leverage points, there’s a clear distinction between what can be achieved in the short term and in the long term. Provider culture, ethics and behaviors need to change, but that transition needs to be supported by other systemic interventions. The creation of new laws that recognize obstetric violence could probably lead to increasing accountability and influence the redesign of health curriculums, training programs and hospital protocols, that could eventually lead to a better ethic of practice. Even if these are necessary milestones, they are situated in the long-term realm.

Providing information is a short-term intervention. However it has little influence in obstetric violence rates, as patients don’t have any power over providers and hospitals.

In this context, the importance of accessing information does not radicate in being an enabler for action, but in its capacity to help people be prepared to face events of disrespect and abuse. Preparation provides new tools for the pregnant person to combat these situations and reduce the negative effects that they might have.

Advocating against and reacting to obstetric violence are not easy things to accomplish. Pregnant people need support, but not of any kind: it needs to be one that leads to increased accountability in order to break the circle of abuse.

The research uncovered a diverse range of leverage points that would be key to achieving the right kind of support. The main three that guided the design process are: informed consent, the support person, and education & preparedness. These areas served also as a basis to define the design principles that helped develop the project.

The Respectful Birth Care program is conceived from the need to support pregnant and birthing people and of pushing for policy change. It provides free support and education on birth rights to pregnant people in New York City to decrease episodes of violence and ensure the best chances at having respectful care at birth.

The program is inspired by theStandards for Respectful Care at Birth, published in December 2018 by the Health Department’s Sexual and Reproductive Justice Community Engagement Group (SRJ CEG) in collaboration with NYC Health + Hospitals/Harlem.

Initiatives like this show a growing interest in addressing obstetric violence and providing better maternal care to pregnant people. In this context, the Respectful Birth Care program aims to expand what NYC already started by not only providing information, but also helping people recognize and react to abuse and violence.

The Respectful Birth Care program tries to fill this gap by providing support at different stages of pregnancy and birth. The program is divided in 4 phases:

The prenatal session is aimed at pregnant people and their support person, ideally during their second or early third trimester. The session introduces the program, its services, tools and resources. Participants go through different activities and role playing as they learn about their birth rights and how to manage the different situations that might arise during childbirth.

They also receive the respectful birth care package that contains the My Respectful Birth Care guide, a translation aid tool, stickers and wristbands to share information with providers, a pin that identifies the support person, and a deck of cards with prompts to role play at home.

The person facilitating the session will also act as the participants’ caseworker during the next phases.

After the prenatal session, the pregnant person and the support person continue to work together to complete the activities on the guide and prepare for childbirth. They should spend time discussing and deciding about the type of assistance the pregnant person is expecting, and defining the role of the support person. People from the program are available to answer questions by phone or online chat.

The program’s website, complementary to the guide, provides information, resources, videos and tools that participants can use to further expand their knowledge of respectful childbirth.

Once the pregnant person goes into labor and delivery, the program makes itself available to provide support mediating conflict situations, providing translation assistance, and contacting the hospital or birthing center directly, if an issue with providers cannot be resolved otherwise. To access this service, the pregnant person or their support person can call the program’s emergency phone number, available on the website.

The translation aid tool can also play an important role during this phase. If the pregnant person does not speak English, they can use the translation tool to communicate when arriving at the hospital or while waiting for a translator. The pregnant person can also use the stickers and bracelets provided to communicate their preferences to the staff and providers through their body.

After childbirth, the case manager will follow up with the participant to check in with them and provide connection to resources and support groups as needed. They will also discuss their experience during childbirth. If there was any disrespectful or abusive situation, the case manager will ask the participant if they’d like to file a report.

This information is collected in a database and later used to provide reports of the quality of care provided in different hospitals to help women choose the best place to give birth, and pressure hospitals into improving their policies and communication strategies.

If a hospital has recurring reports, they will receive a notification and be asked by the city government to report back with the measures they are going to take to prevent future situations.