Guest post by Kari A Radoff CNM, Clinical Instructor, Boston University School of Medicine Department of Obstetrics and Gynecology, Midwives of Boston Medical Center

Childbearing women around the globe are confronted with harsh environments in which to give birth. Neglect, along with verbal, physical and sexual abuse have been documented throughout various cultures and countries. The roots of these abuses likely include poverty, gender inequality,  racism, classism, and other inequities. The creation of the Millennium Development Goals has promoted facility-based birth, where women can receive skilled attendance during birth as a means to reduce maternal mortality. The caveat is that most documented cases of abuse against childbearing women occur in facilities. If we are to encourage women to birth with skilled attendants we must also emphasize an environment of culturally appropriate, humanized, and compassionate care.

Why abuse women in labor? 

One of the answers may lie in the training of skilled birth attendants. There is a generalized lack of awareness regarding evidence-based obstetric practices and failure to implement these practices in developing countries. Medicalization of the birth process without a focus on evidence has brought with it practices that do not support the physiologic nature of birth and may be perceived as abusive by childbearing women. In addition, inadequate training of skilled birth providers may instigate the problem of non-evidence based practice. For example, in a hospital in Nicaragua births are attended, unsupervised, by social service doctors who may be attending their first births, with limited understanding of birth’s physiologic processes.

“I finished medical school and the first birth I ever attended was when they sent me to my social service site.” — a Cuban trained doctor in Nicaragua.

Common practices that have been observed that may be perceived as abusive and are generally considered harmful or controversial include: lack of informed consent; misuse of oxytocin; lack of auscultation of fetal heart tones; use of fundal pressure; routine use of episiotomy; and birth in the lithotomy position. A poor understanding of the normal progression of labor contributes to a snowball of interventions that are not proven beneficial to mother or baby and may be perceived as abusive. Birthing women may feel disempowered as they are forced to lay flat on their backs while a nurse or physician exerts extreme pressure on her abdomen [fundal pressure] to force the baby out while simultaneously cutting an episiotomy and shouting at the woman “you’re not cooperating! If your baby dies it will be your fault for not cooperating.” There is no knowledge of fetal status at this time, only a desire to deliver the newborn as swiftly as possible without an understanding of the physiologic nature of the second stage of labor.

The importance of evidence-based practice must be instilled in practitioners to provide the safest perinatal care with the most appropriate use of interventions. With a desire to increase facility-based birth, training must be focused on skilled attendants to not only provide care in obstetric emergencies but to deliver culturally appropriate, humanized, and compassionate care, promoting an environment of safety and acceptance by childbearing women.

For more, click here to read Kari A. Radoff, Amy Levi, and Lisa M. Thompson. “From Home to Hospital: Mistreatment of Childbearing Women and Barriers to Facility-based Birth in Nicaragua.” International Journal of Childbirth