Experienced disrespect & abuse during childbirth and associated birth characteristics: a cross-sectional survey in the Netherlands

BACKGROUND

Experiencing upsetting disrespect and abuse (D&A) during labour and birth negatively affects women's birth experiences. Knowing in what circumstances of birth women experience upsetting situations of D&A can create general awareness and help healthcare providers judge the need for extra attention in their care to help reduce these experiences. However, little is known about how different birth characteristics relate to the experience of D&A. Previous studies showed differences in birth experiences and experienced D&A between primiparous and multiparous women. This study explores, stratified for parity, (1) how often D&A are experienced in the Netherlands and are considered upsetting, and (2) which birth characteristics are associated with these upsetting experiences of D&A.

METHODS

For this cross-sectional study, an online questionnaire was set up and disseminated among women over 16 years of age who gave birth in the Netherlands between 2015 and 2020. D&A was divided into seven categories: emotional pressure, unfriendly behaviour/verbal abuse, use of force/physical violence, communication issues, lack of support, lack of consent and discrimination. Stratified for parity, univariable and multivariable logistic regression analyses were performed to examine which birth characteristics were associated with the upsetting experiences of different categories of D&A.

RESULTS

Of all 11,520 women included in this study, 45.1% of primiparous and 27.0% of multiparous women reported at least one upsetting experience of D&A. Lack of consent was reported most frequently, followed by communication issues. For both primiparous and multiparous women, especially transfer from midwife-led to obstetrician-led care, giving birth in a hospital, assisted vaginal birth, and unplanned cesarean section were important factors that increased the odds of experiencing upsetting situations of D&A. Among primiparous women, the use of medical pain relief was also associated with upsetting experiences of D&A.

CONCLUSION

A significant number of women experience upsetting disrespectful and abusive care during birth, particularly when medical interventions are needed after the onset of labour, when care is transferred during birth, and when birth takes place in a hospital. This study emphasizes the need for improving quality of verbal and non-verbal communication, support and adequate decision-making and consent procedures, especially before, during, and after the situations of birth that are associated with D&A.

The ethics of consent during labour and birth: episiotomies

Unconsented episiotomies and other procedures during labour are commonly reported by women in several countries, and often highlighted in birth activism. Yet, forced caesarean sections aside, the ethics of consent during labour has received little attention. Focusing on episiotomies, this paper addresses whether and how consent in labour should be obtained. We briefly review the rationale for informed consent, distinguishing its intrinsic and instrumental relevance for respecting autonomy. We also emphasise two non-explicit ways of giving consent: implied and opt-out consent. We then discuss challenges and opportunities for obtaining consent in labour and birth, given its unique position in medicine.We argue that consent for procedures in labour is always necessary, but this consent does not always have to be fully informed or explicit. We recommend an individualised approach where the antenatal period is used to exchange information and explore values and preferences with respect to the relevant procedures. Explicit consent should always be sought at the point of intervening, unless women antenatally insist otherwise. We caution against implied consent. However, if a woman does not give a conclusive response during labour and the stakes are high, care providers can move to clearly communicated opt-out consent. Our discussion is focused on episiotomies, but also provides a useful starting point for addressing the ethics of consent for other procedures during labour, as well as general time-critical medical procedures.

Consent and refusal of procedures during labour and birth: a survey among 11 418 women in the Netherlands

BACKGROUND

Informed consent for medical interventions is ethically and legally required; an important aspect of quality and safety in healthcare; and essential to person-centred care. During labour and birth, respecting consent requirements, including respecting refusal, can contribute to a higher sense of choice and control for labouring women. This study examines (1) to what extent and for which procedures during labour and birth women report that consent requirements were not met and/or inadequate information was provided, (2) how frequently women consider consent requirements not being met upsetting and (3) which personal characteristics are associated with the latter.

METHODS

A national cross-sectional survey was conducted in the Netherlands among women who gave birth up to 5 years previously. Respondents were recruited through social media with the help of influencers and organisations. The survey focused on 10 common procedures during labour and birth, investigating for each procedure if respondents were offered the procedure, if they consented or refused, if the information provision was sufficient and if they underwent unconsented procedures, whether they found this upsetting.

RESULTS

13 359 women started the survey and 11 418 met the inclusion and exclusion criteria. Consent not asked was most often reported by respondents who underwent postpartum oxytocin (47.5%) and episiotomy (41.7%). Refusal was most often over-ruled when performing augmentation of labour (2.2%) and episiotomy (1.9%). Information provision was reported inadequate more often when consent requirements were not met compared with when they were met. Multiparous women had decreased odds of reporting unmet consent requirements compared with primiparous (adjusted ORs 0.54-0.85). There was considerable variation across procedures in how frequently not meeting consent requirements was considered upsetting.

CONCLUSIONS

Consent for performing a procedure is frequently absent in Dutch maternity care. In some instances, procedures were performed in spite of the woman's refusal. More awareness is needed on meeting necessary consent requirements in order to achieve person-centred and high-quality care during labour and birth.

Nine Months

When did we begin to exist? Barry Smith and Berit Brogaard argue that a new human organism comes into existence neither earlier nor later than the moment of gastrulation: 16 days after conception. Several critics have responded that the onset of the organism must happen earlier; closer to conception. This article makes a radically different claim: if we accept Smith and Brogaard's ontological commitments, then human organisms start, on average, roughly nine months after conception. The main point of contention is whether the fetus is or is not part of the maternal organism. Smith and Brogaard argue that it is not; I demonstrate that it is. This claim in combination with Smith and Brogaard's own criteria commits to the view that human organisms begin, precisely, at birth.

Harming one to benefit another: The paradox of autonomy and consent in maternity care

This paper critically analyses 'the paradox of autonomy and consent in maternity care'. It argues that maternity care has certain features that increase the need for explicit attention to, and respect for, both autonomy and rigorous informed consent processes. And, moreover, that the resulting need is considerably greater than in almost all other areas of medicine. These features are as follows: (1) maternity care involves particularly socially sensitive body parts that are regularly implicated in consent-centred procedures, as well as in unconsented interventions, in ordinary, non-medical life; and (2) much of maternity care (especially intervening in childbirth) is medically unique, in that it harms one patient (the mother) not primarily for the promotion of her own health but for the benefit of another (the baby). The apt comparison, within medicine, is therefore with non-therapeutic research and transplantation medicine-both of which have elevated consent requirements characterized by very rigorous consent processes. At the same time-and this delivers the titular paradox-the importance of autonomy and consent in maternity care is at particular risk of being denied or disregarded. Jointly, these considerations make a very strong case for change: attention to and respect for autonomy and consent should be (1) core values; (2) key points of practical attention in the years ahead; and (3) central quality indicators in maternity care.

Client-care provider interaction during labour and birth as experienced by women: Respect, communication, confidentiality and autonomy

INTRODUCTION

Respectful Maternity Care is important for achieving a positive labour and birth experience. Client-care provider interaction-specifically respect, communication, confidentiality and autonomy-is an important aspect of Respectful Maternity Care. The aim of this study was twofold: (1) to assess Dutch women's experience of respect, communication, confidentiality and autonomy during labour and birth and (2) to identify which client characteristics are associated with experiencing optimal respect, communication, confidentiality and autonomy.

METHODS

Pregnant women and women who recently gave birth in the Netherlands were recruited to fill out a validated web-based questionnaire (ReproQ). Mean scores per domain (scale 1-4) were calculated. Domains were dichotomised in non-optimal (score 1, 2,3) and optimal client-care provider interaction (score 4), and a multivariable logistic regression analysis was performed.

RESULTS

Of the 1367 recruited women, 804 respondents completed the questionnaire and 767 respondents completed enough questions to be included for analysis. Each domain had a mean score above 3.5. The domain confidentiality had the highest proportion of optimal scores (64.0%), followed by respect (53.3%), communication (45.1%) and autonomy (36.2%). In all four domains, women who gave birth at home with a community midwife had a higher proportion of optimal scores than women who gave birth in the hospital with a (resident) obstetrician or hospital-based midwife. Lower education level, being multiparous and giving birth spontaneously were also significantly associated with a higher proportion of optimal scores in (one of) the domains.

DISCUSSION

This study shows that on average women scored high on experienced client-care provider interaction in the domains respect, communication, confidentiality and autonomy. At the same time, client-care provider interaction in the Netherlands still fell short of being optimal for a large number of women, in particular regarding women's autonomy. These results show there is still room for improvement in client-care provider interaction during labour and birth.

Ethical Development of Artificial Amniotic Sac and Placenta Technology: A Roadmap

In this paper we present an initial roadmap for the ethical development and eventual implementation of artificial amniotic sac and placenta technology in clinical practice. We consider four elements of attention: (1) framing and societal dialogue; (2) value sensitive design, (3) research ethics and (4) ethical and legal research resulting in the development of an adequate moral and legal framework. Attention to all elements is a necessary requirement for ethically responsible development of this technology. The first element concerns the importance of framing and societal dialogue. This should involve all relevant stakeholders as well as the general public. We also identify the need to consider carefully the use of terminology and how this influences the understanding of the technology. Second, we elaborate on value sensitive design: the technology should be designed based upon the principles and values that emerge in the first step: societal dialogue. Third, research ethics deserves attention: for proceeding with first-in-human research with the technology, the process of recruiting and counseling eventual study participants and assuring their informed consent deserves careful attention. Fourth, ethical and legal research should concern the status of the subject in the AAPT. An eventual robust moral and legal framework for developing and implementing the technology in a research setting should combine all previous elements. With this roadmap, we emphasize the importance of stakeholder engagement throughout the process of developing and implementing the technology; this will contribute to ethically and responsibly innovating health care.

In defence of gestatelings: response to Colgrove

Ectogestation-that is, 'artificial' or extramammalian pregnancy-may soon be within technological reach. This confronts us with questions about the correct moral and legal attitude towards the subjects of this technology, which are called 'gestatelings'. Colgrove argues that gestatelings are a kind of newborn, and consequently should have the same moral and legal protections as newborns. This paper responds that both claims are unsupported by his arguments, which equivocate on two understandings of the term 'newborn'. Questions about the appropriate moral and legal status of gestatelings are therefore (once again, and correctly) left unanswered, but in the course of attempting to answer them, we are well advised to continue using the term gestateling.

Parental obligation and compelled caesarean section: careful analogies and reliable reasoning about individual cases

Whether it is morally permissible to compel women to undergo a caesarean section is a topic of longstanding debate. Despite plenty of arguments against the moral permissibility of a forced caesarean section, the question keeps cropping up. This paper seeks to scrutinise a particular moral argument in favour of compulsion: the appeal to parental obligation. We present what we take to be a distillation of the basic form of this argument. We then argue that, in the absence of an exhaustive theory of parental obligation, the question of whether a labouring woman is morally obliged to undergo emergency surgery-and especially the further question of it is morally permissible for third parties to compel this-cannot be answered via ready-made theory. We propose that the most viable option for settling both questions is by analogy. We follow earlier writers in presenting an analogous case-that of fathers being compelled to undergo non-consensual invasive surgery to save their children-but expand the analogy by considering objections that appeal to the ownership of the fetus. We offer two lines of response: (1) the parthood view of pregnancy and (2) chimaera dad. We argue that it is clear in the analogous case that compulsion cannot be justified. We also offer this analogy as a useful tool for assessing whether mothers have a moral duty to undergo caesarean sections, both in general and in particular cases, even if such a duty is insufficient to warrant compulsion.

Left powerless: A qualitative social media content analysis of the Dutch #breakthesilence campaign on negative and traumatic experiences of labour and birth

INTRODUCTION

Disrespect and abuse during labour and birth are increasingly reported all over the world. In 2016, a Dutch client organization initiated an online campaign, #genoeggezwegen (#breakthesilence) which encouraged women to share negative and traumatic maternity care experiences. This study aimed (1) to determine what types of disrespect and abuse were described in #genoeggezwegen and (2) to gain a more detailed understanding of these experiences.

METHODS

A qualitative social media content analysis was carried out in two phases. (1) A deductive coding procedure was carried out to identify types of disrespect and abuse, using Bohren et al.'s existing typology of mistreatment during childbirth. (2) A separate, inductive coding procedure was performed to gain further understanding of the data.

RESULTS

438 #genoeggezwegen stories were included. Based on the typology of mistreatment during childbirth, it was found that situations of ineffective communication, loss of autonomy and lack of informed consent and confidentiality were most often described. The inductive analysis revealed five major themes: ''lack of informed consent"; ''not being taken seriously and not being listened to"; ''lack of compassion"; ''use of force"; and ''short and long term consequences". "Left powerless" was identified as an overarching theme that occurred throughout all five main themes.

CONCLUSION

This study gives insight into the negative and traumatic maternity care experiences of Dutch women participating in the #genoeggezwegen campaign. This may indicate that disrespect and abuse during labour and birth do happen in the Netherlands, although the current study gives no insight into prevalence. The findings of this study may increase awareness amongst maternity care providers and the community of the existence of disrespect and abuse in Dutch maternity care, and encourage joint effort on improving care both individually and systemically/institutionally.

Neonatal incubator or artificial womb? Distinguishing ectogestation and ectogenesis using the metaphysics of pregnancy

A 2017 Nature report was widely touted as hailing the arrival of the artificial womb. But the scientists involved claim their technology is merely an improvement in neonatal care. This raises an under-considered question: what differentiates neonatal incubation from artificial womb technology? Considering the nature of gestation-or metaphysics of pregnancy-(a) identifies more profound differences between fetuses and neonates/babies than their location (in or outside the maternal body) alone: fetuses and neonates have different physiological and physical characteristics; (b) characterizes birth as a physiological, mereological and topological transformation as well as a (morally relevant) change of location; and (c) delivers a clear distinction between neonatal incubation and ectogestation: the former supports neonatal physiology; the latter preserves fetal physiology. This allows a detailed conceptual classification of ectogenetive and ectogestative technologies according to which the 2017 system is not just improved neonatal incubation, but genuine ectogestation. But it is not an artificial womb, which is a term that is better put to rest. The analysis reveals that any ethical discussion involving ectogestation must always involve considerations of possible risks to the mother as well as her autonomy and rights. It also adds a third and potentially important dimension to debates in reproductive ethics: the physiological transition from fetus/gestateling to baby/neonate.

Contemporary Accounts of Health

Contemporary philosophers of medicine have wrestled with the difficulty of defining health, and even over the basic question of whether this is a normative or descriptive concept. Both approaches seem to be prone to objections. The descriptive approach has difficulty defining health in a way that is not prey to counterexamples. Particular attention is given to the naturalistic accounts of Christopher Boorse and Jerome Wakefield. After the drawbacks of these accounts are discussed, it is suggested that normativism may be more promising but typically fails to meet two general conditions: isolating health from other normative states (the circumscription problem) and explaining how health relates to the value of a good life.

Conference report: interdisciplinary workshop in the philosophy of medicine: parentalism and trust

On 13 June 2014, the Centre for the Humanities and Health at King's College London hosted a 1-day workshop on 'parentalism and trust'. This workshop was the sixth in a series of workshops whose aim is to provide a new model for high-quality open interdisciplinary engagement between medical professionals and philosophers. This report briefly describes the workshop methodology and the discussions on the day.

Interdisciplinary workshop in the philosophy of medicine: medical knowledge, medical duties

On 27 September 2013, the Centre for the Humanities and Health (CHH) at King's College London hosted a 1-day workshop on 'Medical knowledge, Medical Duties'. This workshop was the fifth in a series of five workshops whose aim is to provide a new model for high-quality, open interdisciplinary engagement between medical professionals and philosophers. This report identifies the key points of discussion raised throughout the day and the methodology employed.

Naturalism about health and disease: adding nuance for progress

The literature on health and diseases is usually presented as an opposition between naturalism and normativism. This article argues that such a picture is too simplistic: there is not one opposition between naturalism and normativism, but many. I distinguish four different domains where naturalist and normativist claims can be contrasted: (1) ordinary usage, (2) conceptually clean versions of "health" and "disease," (3) the operationalization of dysfunction, and (4) the justification for that operationalization. In the process I present new arguments in response to Schwartz (2007) and Hausman (2012) and expose a link between the arguments made by Schwartz (2007) and Kingma (2010). Distinguishing naturalist claims at these four domains will allow us to make progress by (1) providing more nuanced, intermediate positions about a possible role for values in health and disease; and (2) assisting in the addressing of relativistic worries about the value-ladenness of health and disease.

What is it to be healthy?

According to Christopher Boorse's Bio-Statistical Theory (BST), 'health' is statistically normal function in a reference class, and 'health' and 'disease' are empirical, objective and value-free concepts. I demonstrate that the success of the BST depends on its choice of reference classes; different reference classes result in different accounts of health. I argue that nothing in nature empirically or objectively dictates the use of reference classes Boorse proposes. Reference classes in the BST, and the concept of health, are therefore not value-free. Nor is there a reason to favour the BST over accounts of health that use different reference classes.

Perception of Emotional Facial Expressions at Different Intensities in Early-Symptomatic Huntington’s Disease

BACKGROUND

While there is abundant evidence that patients with Huntington's disease (HD) have an impairment in the recognition of the emotional facial expression of disgust, previous studies have only examined emotion perception using full-blown facial expressions.

OBJECTIVE

The current study examines the perception of facial emotional expressions in HD at different levels of intensity to investigate whether more subtle deficits can be detected, possible also in other emotions.

METHOD

We compared early symptomatic HD patients with healthy matched controls on emotion perception, presenting short video clips of a neutral face changing into one of the six basic emotions (happiness, anger, fear, surprise, disgust and sadness) with increasing intensity. Overall face perception ability as well as depressive symptoms were taken into account.

RESULTS

A specific impairment in recognizing the emotions disgust and anger was found, which was present even at low emotion intensities.

CONCLUSION

These results extend previous findings and support the use of more sensitive emotion perception paradigms, which enable the detection of subtle neurobehavioral deficits even in the pre- and early symptomatic stages of the disease.