Cruelty in Maternity Wards: Fifty Years Later

Transcription

1 Cruelty in Maternity Wars: Fifty Years Later Henci Goer ABSTRACT Fifty years have passe since a scanal broke over inhumane treatment of laboring women in U.S. hospitals, yet first-person an eyewitness reports ocument that meical care proviers continue to subject chilbearing women to verbal an physical abuse an even to what woul constitute sexual assault in any other context. Women frequently are enie their right to make informe ecisions about care an may be punishe for attempting to assert their right to refusal. Mistreatment is not uncommon an persists because of factors inherent to hospital social culture. Concerte action on the part of all stakeholers will be require to bring about systemic reform. The Journal of Perinatal Eucation, 19(3), 33 42, oi: / X Keywors: abuse of chilbearing women, ysfunctional hospital social systems, patient safety, post-traumatic stress isorer Cruelty in Maternity Wars was the title of a shocking article publishe just over 50 years ago in Laies Home Journal in which nurses an women tol stories of inhumane treatment in labor an elivery wars uring chilbirth (Schultz, 1958). Stories inclue women being strappe own for hours in the lithotomy position, a woman having her legs tie together to prevent birth while her obstetrician ha inner, women being struck an threatene with the possibility of giving birth to a ea or brain amage baby for crying out in pain, an a octor cutting an suturing episiotomies without anesthetic (he ha once nearly lost a patient to an overose) while having the nurse stifle the woman s cries with a mask. The article shook the country an triggere a tsunami of chilbirth reform that inclue the founing of the American Society for Psychoprophylaxis in Obstetrics, now known as Lamaze International. Nonetheless, as Susan Hoges (2009) recently note in her guest eitorial publishe in The Journal of Perinatal Eucation, espite enormous ifferences in labor an elivery management, ecaes later, inhumane treatment remains istressingly common. American chilbearing women still suffer mistreatment at the hans of care proviers, ranging from failure to provie supportive care to isrespect an insensitivity to enial of women s right to make informe ecisions to common use of harmful meical interventions to outright verbal, physical, an even sexual assault. Furthermore, the more extreme examples are not aberrations but merely the far en of the spectrum. Abuse, moreover, results from factors inherent to the system, which increases the ifficulties of implementing reforms. ABUSE IN CHILDBIRTH: PARALLELS WITH DOMESTIC ABUSE Accoring to omesticviolence.org (an online resource evote to helping iniviuals recognize, aress, an prevent omestic violence), omestic violence an emotional abuse encompass namecalling or putowns, keeping a partner from Join Henci Goer in iscussions an questions about obstetric care at her online forum, Ask Henci, on the Lamaze website ( Cruelty in Maternity Wars Goer 33

2 contacting their family or friens, actual or threatene physical harm, intimiation, an sexual assault ( Domestic Violence Definition, 2009, para. 2). In all cases, the intent is to gain power over an control the victim. One coul a that perpetrators, obstetric staff or otherwise, feel entitle to exert this control on grouns of the victim s inferior position vis-à-vis the perpetrator as the following illustrate: [The octor claime there] is no supporting evience that says tearing is better, the articles weren t written by octors who eliver babies, an I m in no moo to sit aroun wasting my time because I have to sew you up. (Doula V, personal communication, May 24, 2007) When I [pregnant woman] attempte to iscuss the birth plan with you [obstetrician], you became efensive..., saying, If I want to o something to you I will o it an you will not interfere. I have elivere hunres of babies an you have not elivere any. (Zeller, 2004, p. 5) Perpetrators also justify controlling the woman on the basis that it is for her or her baby s own goo, as illustrate in these excerpts from a Texas obstetrician s birth plan reporte on the TheUnnecesarean. com blog (Jill, 2009e): Continuous monitoring of your baby s heart rate...is manatory.... This is the only way I can be sure that your baby is tolerating every contraction. Labor positions that hiner my ability to continuously monitor your baby s heart rate are not allowe. (para. 11) Depening on the size of the baby s hea an the egree of flexibility of the vaginal tissue, an episiotomy may become necessary at my iscretion to minimize the risk of trauma to you an your baby. (para. 15) The rate of maternal an fetal complications increases rapily after 39 weeks. For this reason, I recommen elivering your baby at aroun weeks of pregnancy. (para. 17) A c-section may become necessary at any time uring labor.... The ecision as to whether an when to perform this proceure is mae at my iscretion an it is not negotiable, especially when one for fetal concerns. (para. 18) The same Texas obstetrician also isolates women from views other than his (see above: keeping a partner from contacting their family or friens ), stating, Doulas an labor coaches...may be aske to leave if their presence or recommenations hiner my ability to monitor your labor or your baby s well-being (Jill, 2009e, para. 9), an a Colorao obstetrician group oes the same, as illustrate in this sign poste at the group s clinic: Because the Physicians at [name of women s center elete] care about the quality of their patient s eliveries an are very concerne about the welfare an health of your unborn chil, we will not participate in: a Birth Contract, a Doulah [sic] Assiste, or a Braley Metho elivery. (Jill, 2009e, para. 23) Likewise, a nurse at a Virginia hospital that bans oulas states, From a nursing stanpoint, too many [oulas] crosse the line an interfere with my job (Paul, 2008, para. 11). TYPES OF ABUSE Perpetrators of abuse also feel justifie in using whatever means necessary to overcome resistance or to punish perceive infringements of the perpetrator s prerogatives or real or imagine challenges to the abuser s ominance or worlview. Coercion may take the form of verbal abuse, as in these examples: He [octor] storme in aghast that I was a VBAC [vaginal birth after cesarean] an ha been laboring twelve hours. He lecture me on the angers I was incurring.... He informe me that IF I got an epiural an IF I mae progress over the next two hours, he woul let me continue. If not, he woul [cesarean] section me stat. (Bax, 2007, The Short an Long of It, para. 8) After a long an painful inuction,...he [octor] sat on the couch an complaine that watching her [laboring woman] push her ea baby out [antepartum emise at 36 weeks] was like watching paint ry, an left to see patients in the office. (Nurse K, personal communication, In some cases, verbal abuse may be combine with physical abuse, as can be seen in this labor an elivery nurse s account: The octor...stoo over the patient s be an yelle into her face, You can kill your baby, you can lose your uterus, but if you want to o something stupi, I guess I can t stop you. So let s get on with it. He then jerke back the covers, 34 The Journal of Perinatal Eucation Summer 2010, Volume 19, Number 3

3 pulle the patient s legs apart an proceee to perform a rough vaginal exam. (Nurse K, personal communication, Sometimes, verbal abuse has blatant sexual overtones, as these accounts illustrate: I have witnesse many physicians say egraing things to women in natural labor, as if punishing them for not getting pain control in orer to be more passive patients, incluing I on t want to hear any noise from you, Come on, you nee to open your legs, obviously you in t min that nine months ago. (Nurse K, personal communication, She was crying out of fear of the [vaginal] exam, [because it] was being one by a male (very ifficult for most Muslim women).... Dr. tells her that if she is that scare an tense alreay, she ll never get the baby out naturally.... With each subsequent exam he woul then...conesceningly comment on how much better she was oing with her vaginal tension. (Doula S, personal communication, October 16, 2005) He tol her to ajust her bottom so she was straight, he says We want this smile to match that smile, heh heh...if you ha an episiotomy, I only have to sew up a straight line. What the F**K, are you kiing me...? She is nake, on her back, in a submissive position, at this octor s mercy. I wante to cry! (Doula V, personal communication, May 24, 2007) Abuseoflaboringwomenmaytaketheclassicform of physical harm an pain, as in these examples: You re the one who in t want an epiural, this is the price you pay this is often when they refuse to give the patient aequate local anesthetic for laceration repair, espite the fact that the patient is crying out for it an I am staning there holing it out to them. I have seen this too many times to count. The physician s answer is often I only have a few more stitches left. (Nurse K, personal communication, I saw one of my prenatal patients whose [cesareansection] incision opene when her staples were remove Monay. We calle the [octor], an he pulle on the tissue until it opene own to the fascia. He then scrubbe the woun with gauze an H202, an packe it. The patient receive no pain meication. (Miwife D, personal communication, August 27, 2003) Physical harm an pain inflicte on chilbearing women also inclues cesarean surgery without anesthesia. For example, in a publication title Cesarean Voices by the International Cesarean Awareness Network, one woman recounts: My epiural wore off uring surgery an the anesthesiologist in t believe me.... I coul feel the stitching an then the stapling. Finally, to stop my screaming, the anesthesiologist pretty much put me completely out, but only because the surgeon tol him to. (Scott, Huson, MacCorkle, & Uy, 2007, p. 4) Accoring to a stuy by Paech, Gokin, an Webster (1998), 1 in 200 cesareans are converte to general anesthesia because of a faile epiural. However, as Nurse K attests, not all inaequate epiurals are aresse before surgery begins: I have seen...cesareans when a patient s epiural becomes inaequate uring surgery. Despite her crying out Ouch, I can feel that, that feels sharp! That hurts! she is ignore, tol No, it s just pressure, I m not even oing anything that shoul hurt... or I m almost one. I have seen this probably 8 10 times in four years at two ifferent hospitals. (Nurse K, personal communication, Physical abuse may not be obvious to laboring women because it happens behin the scenes or is conceale, as reveale in reports by labor an elivery nurses: Many of the obstetricians that I work with are eager to get her elivere as quickly as possible. There is also pit to istress... in other wors, keep cranking that pitocin up until the baby crumps into fetal istress an the obstetrician oes a stat c- section all so the octor can be one, an get out of the hospital. (Jill, 2009a, para. 19) The...physician...was not satisfie with how quickly the patient was elivering (though she ha been pushing less than an hour an the baby was in no istress) an so she inserte two fingers into the patient s rectum an attempte to hook the baby s chin so that the hea woul eliver more rapily (without mentioning any of this to the Cruelty in Maternity Wars Goer 35

4 patient, who ha an epiural). Her fingers tore right through the sphincter an the patient sustaine a 4th-egree laceration. The only thing the OB tol the patient about it was that because she ha such a big baby (7lbs), she woul recommen inucing at 37 weeks next time so she in t tear so baly. (Nurse K, personal communication, Abuse in the labor an elivery unit also inclues actions that, ha they occurre outsie of the unit, woul be consiere sexual assault, as in the following example: First the oc oes an exam says there s a [cervical] lip.... Next thing I know, the nurse has her han in there, holing the cervix while mom is screaming, get out, OUCH, get out, THAT HURTS I look the nurse in the eye, tell her AT LEAST 10 times, she ASKED you to stop she oes NOT consent to this. So now, she s pushing..., but this DAMN octor, kept trying to stretch [the vaginal opening] with his flipping fingers an she kept screaming how ba it hurt. I kept saying to him OVER AND OVER, can you PLEASE stop?!?! The only time she screams is when YOU DO THAT. (Doula M, personal communication, April 2, 2003) An Illinois woman s story contains all of the types of abuse escribe above verbal, physical, sexual, an threats of physical harm that women may encounter in labor an elivery units. As reporte on the TheUnnecesarean.com blog, the woman s octor: refuse to let her have pain meication, telling the nurse that the woman eserve to feel pain because she ha not calle before coming in an that pain is the best teacher (Jill, 2008, Pain is the Best Teacher, para. 1; Jill, 2009b, para. 28); place her in stirrups with toes turne in so that her buttocks were not on the table, an force her to remain in that position until after the birth, which took over an hour (Jill, 2008, 2009b); repeately tol her, Shut up, close your mouth, an push... an there is only one voice in this room an it is mine (Jill, 2008, para. 18 an 29; Jill, 2009b, para. 9 an 18); performe a rough vaginal exam uring a contraction, causing extreme pain, while she sai, No. Stop! (Jill, 2008, para. 20; Jill, 2009b, para. 10); inserte a catheter uring a contraction, causing extreme pain, espite her asking to wait (Jill, 2008, 2009b); repeately tol the woman she was going to hemorrhage an that that she an the baby might ie, which was especially terrifying because she ha experience a prior stillbirth (Jill, 2008, 2009b); took a cell phone call from a resient an spoke at length about an abortion that he was going to perform that ay (Jill, 2008, 2009b); tol a nurse not to help her (Jill, 2008, 2009b); suture her without aequate anesthesia an ha her husban hol her own when she squirme in pain (Jill, 2008, 2009b); an refuse to let her or her husban hol the baby (Jill, 2008). The cases escribe above are reaily recognizable as abuse, but because of the intimacy an sexuality of chilbirth, treatment that an observer woul think no worse than brusque or insensitive what Elizabeth Smythe calle the violence of the everyay in healthcare (Thomson & Downe, 2008, p. 270) can inflict severe psychological trauma, in this case by triggering memories of past traumatic events: Because of the epiural,... when it was time to push, the nurse an the miwife kept yelling at me to keep my feet in the stirrups, but my legs were numb, so they just kept falling own to the floor.... They grabbe my hips an forcefully move me aroun into the position they wante me in, without asking. They just i it. An they kept yelling at me to keep my legs up, but I couln t. So they move me aroun like a rag oll an my feet just kept falling off the table onto the floor. I was so scare, an I felt like I was oing everything wrong. They i not try to calm me, or even ask how I was oing. They just kept yelling, This is what you have to o if you want to get your baby out! Keep your legs up! This forceful manipulation of my boy triggere a memory in me of being gang-rape at 15 years ol. During the rape, one of the boys hel me own, with my hips at the ege of the be, while the other boy rape me. He kept grabbing my hips an yanking me closer to him an my legs just felt like 50 lb weights. They just kept falling to the floor. He kept yelling, Keep your legs up, bitch! an I couln t. I couln t move. It was as if I was numb. During my son s birth, the wors that the nurse an miwife 36 The Journal of Perinatal Eucation Summer 2010, Volume 19, Number 3

5 yelle at me, an the ways they manipulate my boy were so similar, it was as if the rape was happening all over again. I was terrifie. (Rose, personal communication, September 22, 2007) In a secon example, we see the harm of staff insensitivity to the violence of the everyay in a octor s story of events after her birth tol from her viewpoint an juxtapose with her meical chart notes (Pil, 2010): Patient: Seven hours [after birth], I suenly feel weak, izzy, an nauseate.... The next minute, I m hemorrhaging. There is bloo spurting everywhere, clots the size of frying pans. I think I am going to ie. Panicky nurses an resients crow the room.... I am being stuck everywhere for an IV.... My unerwear is cut off, injections slamme into my buttocks, my legs are force open an someboy shoves an entire forearm into my uterus an pulls out clots. Three times. I scream an scream an scream. The pain is unbearable, an I feel brutally violate. (para. 14) Chart: 7:30 am: Calle to see patient passing clots....bloo pressure 110/ / / Bimanual evacuation lower uterine segment with 3 large clots. Orers: IV, Pitocin IV, [etc.]. Discusse with Doctor B. Intern (para. 15) Patient: Everyone flees the room. I am curle in a fetal position, crying an shaking. No one comes to explain why, how or what has just happene....[no staff members] ever ask if I am all right. (para. 17) Chart: 7:40 am: BP 90/58. Will continue to observe. Night Nurse B 8:00 am: IV running. Patient meicate with Zofran for nausea. Resting comfortably. Will monitor. Day Nurse C (para. 18) Patient: Doctor B makes rouns. You octors make the worst patients. (para. 20) Pil s resultant PTSD renere her unable to return to clinical practice. Health care environments were too much of a trigger. ABUSES UNIQUE TO CHILDBIRTH The treatment of pregnant an laboring women opens up new categories of abuse not falling uner conventional efinitions. One category of abuse is enial of the right to informe choice through giving chilbearing women insufficient information, no information, or misinformation about their options. In the Listening to Mothers II survey, women were aske to agree or isagree with four statements on cesarean surgery s averse effects (Declercq, Sakala, Corry, & Applebaum, 2006). Three-quarters of the responents on every question were either not sure how to respon or respone incorrectly. Women who ha cesareans were no more likely to know the right answer than women who i not have cesareans. A secon category of abuse among chilbearing women is elective primary cesarean initiate by the physician. A survey at one hospital reveale that 13% of intrapartum cesareans were at physician request accoring to the obstetrician s self-report (Kalish, McCullough, Gupta, Thaler, & Chervenak, 2004). An aitional 3% were, accoring to the obstetrician, a joint ecision with the woman, but consiering the power imbalance in the relationship, it is not unreasonable to inclue these in the physician request category. That makes 1 in 6 intrapartum cesareans at this hospital. Subjecting women to unnecessary surgery is, of course, a form of physical abuse. A thir category of abuse is enial of the right to refuse invasive meical proceures an especially to refuse surgery. Results from the Listening to Mothers II survey foun that over half (56%) the women who wante VBAC were enie that option (Declercq et al., 2006), an a 2009 survey of 2,850 U.S. hospitals reveale that half of the hospitals ha an outright or e facto ban against VBAC, the latter meaning the hospital ha no official policy against VBAC, but no obstetrician woul allow one (International Cesarean Awareness Network, 2009). Vaginal breech birth an vaginal twin birth are almost impossible to obtain. Refusing vaginal birth forces women to agree to surgery or forgo meical care. A fourth category is abuse of chilbearing women by the legal system. Legal system abuses arise from meical staff an societal perception that the fetus s rights supersee the rights of the woman. In this respect, women are worse off than they were with omestic violence before the women s rights movement. Before, women coul expect no relief from legal authorities or social services; now, they are calle in on the sie of the abuser. Cases inclue The treatment of pregnant an laboring women opens up new categories of abuse not falling uner conventional efinitions. Cruelty in Maternity Wars Goer 37

6 It is important to note that the vast majority of maternity care proviers are not abusers. Nonetheless, abuse continues to flourish. a California woman whose octor threatene to report her to Chil Protective Services for resisting inuction for postates (Doula E, personal communication, September 11, 2003); an Arizona woman with a prior cesarean tol if she showe up in labor an refuse automatic surgery, the hospital woul get a court orer an perform cesarean surgery anyway (Jill, 2009); a Floria woman confine by the court to hospital berest for preterm contractions at 25 weeks, enie access to a secon opinion, an orere to submit to any treatment her octor eeme necessary, incluing cesarean surgery (Appel, 2010); an a New Jersey woman previously iagnose with post-traumatic stress isorer (PTSD) an epression eprive of custoy of her chil at birth because she refuse to sign a blanket consent at hospital amission for cesarean surgery, an act cite as evience she was too mentally ill to be a fit mother (Jill, 2009c). ABUSE AND THE TOLL ON VICTIMS Preictors of psychological trauma resulting from chilbirth inclue a history of sexual assault, feelings of powerlessness, negative interactions with meical staff, failure to meet expectations, meical interventions, an unplanne cesarean surgery (Soet, Brack, & Dilorio, 2003), although trauma can also occur in spontaneous vaginal births (Soerquist, Wijma, & Wijma, 2002). Given the ubiquity of these experiences, it shoul not be surprising that sizeable percentages of women experience psychological trauma following chilbirth. An Australian survey of women 4 to 6 weeks postpartum foun that one thir of responents reporte a traumatic birth event in conjunction with three or more symptoms of emotional trauma (Creey, Shochet, & Horsfall, 2000). Listening to Mothers II survey investigators conucte a follow-up survey that inclue questions iagnostic of chilbirth-relate PTSD (Declercq, Sakala, Corry, & Applebaum, 2008). Nearly 1 in 5 (18%) women were experiencing some symptoms, an 1 in 10 (9%) met the full PTSD iagnostic criteria. Worse yet, symptoms are longlive: Women were surveye 6 to 18 months postpartum an aske about symptoms in the past month. Women also specifically report experiencing their chilbirth treatment as an assault: It was like being torture because I was...screaming,...begging, really, really begging for [the Syntocin] rip to be turne off ; Don t feel I gave birth an ha a baby on that ay. I just felt I went into a room an was just assaulte ; an It was violent an brutal (Thomson & Downe, 2008, p. 270). The consequences can be severe an long-lasting, as conveye in the following comments from women: I was left feeling like a total failure. I left the hospital thinking that I was a horrible mom....i in t even want to hol my baby an I was terrifie of being alone with him. (Rose, personal communication, September 22, 2007) I on t remember my baby s first 6 months, I was so mire in epression an post-traumatic stress flashbacks, nightmares, sweating panics.... You in t only take my birth, though. I lost more than my son s infancy. For a long time, I lost myself. (Bax, 2007, The Short an Long of It, para. 17 an 18) I still have nightmares six years later. (Scott et al., 2007, p. 4) It is important to note that the vast majority of maternity care proviers are not abusers. Nonetheless, abuse continues to flourish. Why isn t it stoppe? To answer this question, we must look at factors inherent to the system. OBSTACLES TO REFORM Most hospital social systems are rigi hierarchies. Because authoritarian social systems allow some iniviuals unrestraine ominance over others, mistreatment an abuse are likely to follow. For example, as a labor an elivery nurse recounts: He aske me for an Amnihook to rupture the patient s membranes, an when I pointe out that accoring to my exam, the cervix was still close an the baby was still high..., he yelle at me to get out of the room an that he wante another nurse an I was no longer allowe to take care of his patients. (Nurse K, personal communication, Consier the authoritarian family an its organizing principles, as escribe by Virginia Satir (1988): There is one right way, an the person with most power has it, There is always someone who knows what is best for you, Self-worth is seconary to power an performance, Actions are 38 The Journal of Perinatal Eucation Summer 2010, Volume 19, Number 3

7 subject to the whims of the boss, an Change is resiste (p. 132). As a result, self-esteem is low; communication is inirect an incongruent; styles of interaction are blaming, placating, istracting; rules are unspoken, outate, an when inhumane, people aapt rather than change them. As authoritarian families provie fertile groun for violence an abuse at the micro level, so authoritarian institutions o the same on the macro level. They enable what has been calle a culture of impunity in which there is no accountability for abuses an in which its members are at risk to become sometimes unwilling, sometimes unwitting, an sometimes neither participants in, if not perpetrators of, abuse. For example, nurses may enforce abusive policies an practices: If [her partner] has been aske to leave the room uring a proceure or something, I try to let them know that it s not because we on t want them there. There are certain policies to be followe an it s the octor s ecision. (Gale, Fothergill- Bourbonnais, & Chamberlain, 2001, p. 268) Nurses may also collue in abuse: Woman uring prolonge vaginal exam: That hurts my gut. Dr.: That hurts to o that? [surprise] Woman: Yes! Just on t o it no more....no more. Please! [to husban] It hurts, it hurts. I no more, please no more. [Vaginal exam continues] Nurse: Just squeeze his han. There you go. [Doesn t help]. (Bergstrom, Roberts, Skillman, & Seiel, 1992, p. 15) Nurses may feel compelle to conceal abuse: I o everything I can so she ll hurry up an eliver, even though ethically I feel horrible about it. I can t tell her, Your octor s got a golf game...an that s why I m oing this to you. (Sleutel, 2000, p. 40) An because nurses rank higher in the hierarchy than laboring women, they may engage in abusive behaviors themselves: Frequently nurses on t want to take the time to work with ifficult patients an...go along with the ecision to section early in the labor process. (Sleutel, Schultz, & Wyble, 2007, p. 206) From the very beginning the nurse was very overpowering an just...took away everything that we wante to o. (Mozingo, Davis, Thomas, & Droppleman, 2002, p. 346) Even so, many iniviuals working in institutions with authoritarian cultures are concerne about patient well-being, yet abuse continues unchecke. How oes this happen? One theory is that nurses are usually women, an women are socialize to efer to authority. Traitional nursing training an hospital culture may reinforce this blanket eference without regar to potential conflicts with the woman s rights or her best interest. A secon theory is that authoritarian systems often lack effective mechanisms for calling abusers to account, as illustrate in this labor an elivery nurse s account: This patient s family subsequently file a complaint with the hospital (to match the literally 100s of complaints file by nurses in the past 25 years) an he was suspene for one ay before his privileges were returne an he was given the option to retire six months later. The next ay he returne to the unit an sat at the nurses station leaing a iscussion with 4 other OBs (incluing the chief of staff) saying how angerous the nurses were an that someay one of them is going to kill someboy because they on t get it that their job is just to follow orers. (Nurse K, personal communication, As the nurse s experience also illustrates, iniviuals who attempt calling abusers to account may expose themselves to intimiation an retaliation, up to an incluing losing their job. A thir reason why abuse continues unchecke is that the lack of accountability often enables abusive octors to use their power to trap nurses into nowin positions. For example, as this labor an elivery nurse reports: A female obstetrician on our unit is notorious for punishing the nurse for failing to push Pitocin har enough to get patients elivere by the en of the work ay, by taking the patient back for a Cesarean. She then tells the nurse Have it your way, but it s your fault she ene up with a section. Cruelty in Maternity Wars Goer 39

8 (Nurse K, personal communication, October 16, 2009) A fourth reason for continue abuse may be because iniviuals who are high enough in the hierarchy to make change are unlikely to o so. During resiency, octors traine in authoritarian systems are likely to internalize as normative a moel of interaction with unerlings an patients that esensitizes them to problem behaviors if not converts them into outright abusers themselves. Once in practice, octors woul rarely witness their colleagues abuses firsthan. Confronte with the more egregious nurse or patient complaints, the instinct woul be to close ranks against a perceive attack from iniviuals below them in the hierarchy an to iscount or ismiss them. Moreover, close systems create a conspiracy of silence. As Marsen Wagner (2006) notes, We may talk to one another about the terrible way a certain...member practices obstetrics, but only in private (pp ). He goes on to relate an anecote of speaking at a meeting attene by octors from a number of local hospitals at which he presente ata on their hospitals cesarean rates. Rates were as high as 60%. The next ay, the obstetric community was in an uproar not about the shamefully high cesarean rates, but over who ha given Wagner the ata who ha broken the hospital omertá? Whistle-blowers in authoritarian systems run the of risk social ostracism, a powerful isincentive to taking action against peers. What about the other sie of the equation? Why o women tamely submit an o nothing even after the fact? For one thing, women in general, not just nurses, are socialize not to challenge authority. For another, women traumatize in birth isplay the same prisoner/victim mentality for the same reasons as victims of violent crime or abuse: Systemic change will require long-term, concerte effort by likemine groups an organizations from both within an without its institutions. There were similarities in relation to the belief that eath was imminent because of the severity of pain, suffering, an trauma; in sensations of isconnection, alienation, an isolation from social relationships; in the imbalance of power between the victim an the abusing authoritative others; an in the inucement of passivity, helplessness an epenency through rituals an proceures. (Thomson & Downe, 2008, p. 270) Female physiology may be at work as well. Taylor an colleagues (2000) ispute that fight or flight is the preominant response to stress in women an that belief in its being so originates in almost all stuies having been one in males. They argue that fight or flight will be evolutionarily counterprouctive in females in mammalian species who bear young with limite or no mobility. They propose an alternative: ten an befrien. In support of their hypothesis, they cite numerous stuies in animals, primates, an humans showing that stressful events trigger nurturing behavior in females. When irecte towar offspring, tening calms an soothes, promoting health an well-being. Tening behaviors also reuce stress in the ones oing the tening, not just the recipients, an tening behaviors are not solely irecte towar young. Tening facilitates formation of social networks among females, which ensures mutual assistance when a member is threatene. Unlike fight or flight, which is meiate by the sympathetic nervous system, ten an befrien appears to be meiate by the parasympathetic nervous system, primarily by oxytocin. Ten an befrien coul explain why laboring women submit without protest to treatment that woul provoke outrage uner other circumstances. Women, of course, coul complain afterwars an some o but most abuse victims are likely to be recovering from surgery, an all have a newborn to care for. Traumatize women will have all they can o to cope with their symptoms an function as new mothers. Few will have the physical or emotional energy to o other than try to put events behin them an carry on. For those who o complain, the system that preispose to abuse in the first place ensures that complaints will fall on eaf ears. What, then, is to be one? Meaningful, longlasting change requires transforming the system. We nee a system that rewars those who practice mother-frienly care. We nee to introuce accountability for those who on t. Above all, we nee to convert authoritarian moels to collaborative social structures within which maternity care proviers oulas an eucators inclue are respecte for their spheres of expertise, an the mother-baby ya s physical an mental health an well-being come first. 40 The Journal of Perinatal Eucation Summer 2010, Volume 19, Number 3

9 Systemic change will require long-term, concerte effort by like-mine groups an organizations from both within an without its institutions. As we begin our next 50 years, it is time for birth professional an avocacy organizations to get raical, a wor whose original meaning is funamental, an to take the forefront in the campaign begun by the 1958 Laies Home Journal article, Cruelty in Maternity Wars. Unless an until eucators, nurses, oulas, miwives, physicians, reprouctive-rights activists, an chilbirth reformers join hans an rise up together, chilbearing women will go on having no other recourse than the kinness of strangers to protect them uring a supremely vulnerable time in their lives. REFERENCES Appel, J. M. (2010, January 24). Meical kinapping: Rogue obstetricians vs. pregnant women. Retrieve from Bax, J. (2007, September 15). ICAN enews, 43. Retrieve from 43-september Bergstrom, L., Roberts, J., Skillman, L., & Seiel, J. (1992). You ll feel me touching you, sweetie : Vaginal examinations uring the secon stage of labor. Birth (Berkeley, Calif.), 19(1), 10 18, iscussion Creey, D. K., Shochet, I. M., & Horsfall, J. (2000). Chilbirth an the evelopment of acute trauma symptoms: Incience an contributing factors. Birth (Berkeley, Calif.), 27(2), Declercq, E., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to mothers II: Report of the secon national U.S. survey of women s chilbearing experiences. New York: Chilbirth Connection. Declercq, E., Sakala, C., Corry, M. P., & Applebaum, S. (2008). New mothers speak out. National survey results highlight women s postpartum experiences. New York: Chilbirth Connection. Domestic Violence Definition. (2009). Retrieve from Gale, J., Fothergill-Bourbonnais, F., & Chamberlain, M. (2001). Measuring nursing support uring chilbirth. MCN. The American Journal of Maternal Chil Nursing, 26(5), Hoges, S. (2009). Abuse in hospital-base birth settings? The Journal of Perinatal Eucation, 18(4), International Cesarean Awareness Network. (2009, February 20). New survey shows shrinking options for women with prior cesarean. Retrieve from Jill. (2008, December 17). Re: More than just rue behavior: The rest of Catherine Skol s allegations [Web log message]. Retrieve from com/blog/2008/12/17/more-than-just-rue-behaviorthe-rest-of-catherine-skols-all.html?ssscrollposition¼ 237 Jill. (2009a, July 6). Re: Pit to istress : Your ticket to an emergency cesarean? [Web log message]. Retrieve from 6/pit-to-istress-your-ticket-to-an-emergency-cesarean. html Jill. (2009b, July 21). Re: Skol v. Pierce upate: Doctor fine an place on probation [Web log message]. Retrieve from 7/21/skol-v-pierce-upate-octor-fine-an-place-onprobation.html Jill. (2009c, July 23). Re: New Jersey cesarean refusal case: The system is schizophrenic [Web log message]. Retrieve from /7/23/new-jersey-cesarean-refusal-case-the-systemis-schizophrenic.html Jill. (2009, October 1). Re: Page hospital in Arizona threatens woman with court-orere cesarean [Web log message]. Retrieve from com/blog/2009/10/1/page-hospital-in-arizona-threatenswoman-with-court-orere.html?lastpage¼true#comment Jill. (2009e, October 18). Re: An OB s birth plan: Obstetrician s isclosure sent one mom running [Web log message]. Retrieve from com/blog/2009/10/18/an-obs-birth-plan-obstetriciansisclosure-sent-one-mom-runn.html Kalish, R. B., McCullough, L., Gupta, M., Thaler, H. T., & Chervenak, F. A. (2004). Intrapartum elective cesarean elivery: A previously unrecognize clinical entity. Obstetrics an Gynecology, 103(6), Mozingo,J.N.,Davis,M.W.,Thomas,S.P.,&Droppleman, P. G. (2002). I felt violate : Women s experience of chilbirth-associate anger. MCN. The American Journal of Maternal Chil Nursing, 27(6), Paech, M. J., Gokin, R., & Webster, S. (1998). Complications of obstetric epiural analgesia an anaesthesia: A prospective analysis of 10,995 cases. International Journal of Obstetric Anesthesia, 7(1), Paul, P. (2008, March 2). An the oula makes four. The New York Times. Retrieve from com/2008/03/02/fashion/02oula.html Pil, T. (2010, April 9). Babel: The voices of a meical trauma. Pulse. Retrieve from Archive_inex.cfm?content_i¼119 Satir, V. (1988). The new peoplemaking. Mountain View, CA: Science an Behavior Books, Inc. Schultz, G. D. (1958, May). Cruelty in maternity wars. Laies Home Journal, pp , Scott, C. C., Huson, L., MacCorkle, J., & Uy, P. (Es.). (2007). Cesarean voices. Reono Beach, CA: International Cesarean Awareness Network. Sleutel, M. R. (2000). Intrapartum nursing care: A case stuy of supportive interventions an ethical conflicts. Birth (Berkeley, Calif.), 27(1), Sleutel, M., Schultz, S., & Wyble, K. (2007). Nurses views of factors that help an hiner their intrapartum care. Journal of Obstetric, Gynecologic, an Neonatal Nursing, 36(3), Cruelty in Maternity Wars Goer 41

10 Lamaze International s research blog, Science & Sensibility, is intene to help chilbirth eucators an other birth professionals gain the skills necessary to econstruct the evience relate to current birth practices. Visit the Science & Sensibility website (www. scienceansensibility.org) to stay up to ate an comment on the latest evience that supports natural, safe, an healthy birth practices. Soerquist, J., Wijma, K., & Wijma, B. (2002). Traumatic stress after chilbirth: The role of obstetric variables. Journal of Psychosomatic Obstetrics an Gynaecology, 23(1), Soet, J. E., Brack, G. A., & Dilorio, C. (2003). Prevalence an preictors of women s experience of psychological trauma uring chilbirth. Birth (Berkeley, Calif.), 30(1), Taylor, S. E., Klein, L. C., Lewis, B. P., Gruenewal, T. L., Gurung, R. A., & Upegraff, J. A. (2000). Biobehavioral responses to stress in females: Ten-an-befrien, not fight-or-flight. Psychological Review, 107(3), Thomson, G., & Downe, S. (2008). Wiening the trauma iscourse: The link between chilbirth an experiences of abuse. Journal of Psychosomatic Obstetrics an Gynaecology, 29(4), Wagner, M. (2006). Born in the USA. Berkeley, CA: University of California Press. Zeller, R. (2004). It was all for nothing. The Clarion, 19(4), 5. HENCI GOER is the author of The Thinking Woman s Guie to a Better Birth an is at work on the secon eition of Obstetric Myths versus Research Realities, her highly acclaime resource for chilbirth professionals. She serve as project irector an Expert Work Group member for the Coalition for Improving Maternity Services Evience Basis for the Ten Steps of Mother- Frienly Care. Goer moerates Lamaze International s online Ask Henci Forum an contributes regularly to the Lamaze research blog, Science & Sensibility. Help make our vision a reality: A oula for every woman who wants one. DONA International offers birth an postpartum oula training, certi cation, ongoing support an eucation, an multiple membership bene ts Join DONA International toay! Atten our annual conference July 21-24, 2011 in Boston, Massachusetts [email protected] DONA (3662) 42 The Journal of Perinatal Eucation Summer 2010, Volume 19, Number 3