Violence in Midwifery Part 2: Obstetric Violence

Posted by Katy Bones

Midwives deal with violence on a regular basis. Whether its violence experienced by the women we serve, violence within systems of health care, violence against women by providers, or violence within the community of midwives, violence should be looked at continuously in an attempt to understand it, cope with it, and curb it.

“Obstetric violence” is a legal term defined by the Venezuelan government that has been talked about a lot in the birth community since Dr. Perez D’Gregorio published an editorial describing the Venezuelan laws on obstetric violence in the Dec. 2010 issue of the International Journal of Gynecology and Obstetrics. There are several links to some wonderful blogs and articles at the end of this entry that describe the particulars of the legislation in Venezuela. These laws emphasize the role of individual providers in perpetuating and engaging in violence by holding individuals responsible for their actions. D’Gregorio also recognizes the importance of health care systems in contributing to or preventing violence. He notes the importance of training, specifically in regards to upright deliveries, in supporting the autonomy of women and in respecting the natural process of childbirth. Additionally, he recognizes the limitations of individual providers in resource-poor settings where “environmental” reasons necessitate separating the mother and baby shortly postpartum. In itself, the idea that laws can change violent practices points to the importance of system changes as well as individual changes in eliminating practices that undermine the ability of women to get both the best care and the care of their choosing.

As I begin the intrapartum clinicals in January, I feel grateful to have this opportunity to examine obstetric violence with clarity and intentionality before starting to guide women through labor and birth. The very specific acts delineated by the Venezuelan laws offer explicit components of care that must be handled with knowledge and deep respect for the woman. Specifically, I recognize the importance of learning to help women give birth vertically, a skill that I haven’t yet learned or been well familiarized with. I also intend to maintain consciousness of the ways that I am learning to be a midwife, to avoid violence and to gain trust in the process of childbirth that allows me to serve women in the best ways possible.

Salon.com on Obstetric Violence

Babble.com
The Unnecesarean

Orgasmicbirth.com on Obstetric Violence

Violence in Midwifery Part I: Intimate Partner Violence

Posted by Katy

Midwives deal with violence on a regular basis. Whether its violence experienced by the women we serve, violence within systems of health care, violence against women by providers, or violence within the community of midwives, violence should be looked at continuously in an attempt to understand it, cope with it, and curb it.

I’ve been seeing a patient in antepartum clinic that has a very interesting story suggestive of intimate partner violence (IPV). IPV is both affected by pregnancy and affects the course and outcomes of pregnancy. While the statistics of prevalence are fairly unknown, about 14% of pregnant women in the US experience IPV. IPV in pregnancy is associated with low weight gain, substance abuse, premature labor and birth, persistent STIs, anemia, vaginal bleeding, and complications associated with physical trauma. IPV is an important and relevant topic for midwives to be familiar with in order to best care for women. Intimate partner violence is challenging to fit into the process of diagnosis and management which makes midwives (and all providers) shirk away from the issue rather than dealing with it appropriately. This case study served as an important opportunity for me to become more competent in screening for and supporting women experiencing IPV.

This woman, let’s call her Josefina, came to the inner city hospital clinic where I’m doing clinicals for prenatal care. The first time I saw her she had bruises on her face that she said were from play fighting with her partner. She had been testing positive for chlamydia since the beginning of her pregnancy and had already been treated once. She said that her partner had not been treated and that they were still having sex without condoms, despite previous counseling on the importance of using condoms or abstinence to prevent reinfection. She withdrew with questioning about her social situation or the sexual relationship with her partner, and would not answer questions.

Midwifery and Public Health: A Sisterhood

Posted by Katy
There is an old fable told in the Public Health world that has been on my mind this week:

The villagers of Downstream lived peacefully by the river until one day, many years ago, a single man was found floating in the river. Good people, the villagers jumped to their feet, dragged the body from the river and were able to save the man. After the first bodies, many turned up in the river and quickly the rescuing mission became the primary work of many of the villagers. The villagers grew better at rescuing the bodies, swifter and wiser, and the village was very proud of their work. Despite their prowess at life saving, the number of people drowning in the river continued to increase until the villagers were not able to keep up and the numbers of dead bodies began to pile up. The villagers worked harder, learned more, trained more rescuers, put more resources into rescuing, but higher still the bodies piled. Until, one day the granddaughter of a wise old woman finally took the time to listen to her grandmother and began to hike upstream. The other villagers shook their heads at her and told her that people were dying while she chose not to help. It pained her to do nothing as the bodies floated by, but she was faithful to the wise woman and continued her journey until she reached the village of Upstream.

Female Circumscision

posted by Katy
 
During undergrad at Berkeley, I came across the topic of female circumcision (also called female genital cutting, female genital mutilation, FGC, or FGM) fairly frequently. The subject came up in Public Health classes, in Medical Anthropology, in Development Studies, and in classes my friends were taking about gender and race. It seemed to be everyone's favorite example of ways that culture and power effect health. I often got the strangest of looks if I pointed out the motifs of the Heart of Darkness story playing out as we discussed female circumcision, despite the fact that this was a very popular concept in other conversations. The key sources used in discussing female circumcision were white, American, faith-based organizations who were set to "save" African women from the horrors of female circumcision. Berkeley's much loved cultural relativity was not considered applicable to families, mostly women, who chose to have their daughters circumcised. The voice of women who were assumed rather than elicited. Needless to say, female circumcision did not seem like something I would ever experience in the US, it seemed like an "African Problem".

I was surprised to discover that the first patient I did a pelvic exam for was circumcised. She was not a meek woman who had no voice, the character suggested by Berkeley academics. She was strong and angry about pain during sex, which was the reason she had come to the clinic. The pain was not from circumcision however, but rather from an endometrial infection, presumably contracted from a colposcopy. She did not mention the circumcision and the midwife I was studying with also did not. The next day, though, I worked with a midwife who is currently doing ethnographic research on circumcised women in New York (this is one reason I love midwives!). We served another circumcised patient and the midwife responded in perfectly "I can see you've been cut, when was that done? Where? Have you had any problems with it? Do you have any questions or concerns?". She answered with validation and empowerment, opened the door for the woman to discuss the circumcision in a setting that was affirming and non-judgmental, or not as her choice may be. This was a moment where theory was biased while practice in the real world lived up to the opportunity to be honest, human, and completely present to serve a woman's needs.

People often ask me "Girl, what are you doing in New York?", often with about that much attitude-- usually I don't have an answer. "Its just the way the wind blew." Slowly though, I'm piecing together reasons and one of them is the diversity of patients. Having the opportunity to work with women who were circumcised is an opportunity to broaden my understanding of the experiences of womanhood and what it means to serve women. This is why I came to New York and why I chose a CNM program.

Storytelling

Posted by Katy 

The first day of the year, at orientation, we each shared our journey to the room that day. Even though I already knew everyone in the room, taking the time to listen to and tell our stories was quite powerful. There were a few common threads that are worth mentioning. Many of the students expressed the challenge of getting to midwifery school. Many students came to the profession of midwifery through academic and intellectual pursuits, a path that may be more common to university training programs.

Birth Stories in India

Posted by Katy
August means a much needed vacation from school and the toil of New York City. I'm spending the month with my boyfriend in the Himachal Pradesh region of India (that is very north). I decided to let this be a true vacation and not do any nursing or midwifery work, but I still have run across some interesting stories:

Mountaineering Mama- We went to the mountain institute outside of Manali for trekking information and met the nicest woman who gave us a map, directions, and advice. She is a mountaineer, guide, and teacher at the institute and was clearly incredibly knowledgeable about mountains. She asked what I did and when I explained midwifery she launched into her birth story (it seems to be a cross-cultural response)! She explained that she had a c-section for her first baby because the cord was wrapped around his neck. She tried to have a natural birth with the second baby, but when the labor pains started, they were so painful that she requested another c-section.

Inspiration to be a Nurse Midwife

Posted by Laurel

If men flee the female, we will survive, but if women themselves treat femaleness as a disease we are lost indeed. ~Germaine Greer

10 thoughts on why I am inspired to be a nurse midwife...
1. Women are not socialized to celebrate their bodies, let alone live in them and own their power... I want to help bring in generations of beings that celebrate women and the female body. I love my body!
2. No matter where a woman is at in her life cycle, I believe that she deserves the option and opportunity for midwifery are. Whether a woman wants to have children, is pregnant, is pregnant and does not want to be, is unable to have children for one reason or another or choses not to... they can benefit from a midwifery philosophy of care. No matter age, sexual orientation, race, religion, ethnicity, SES, marital status, class, motherhood status, education, nationality, able-bodiedment - the option of midwifery care should be available.

In Celebration of Nursing

Posted by Katy
I just passed the NCLEX, which is the nursing licensure exam! It took me a humbling first attempt and much more confident successful attempt but now I am officially a New York RN! Som with that really good, relieving news I want to take some time to share some of the things I've enjoyed in this year of nursing school, several of which are quite surprising!

(1) I have enjoyed meeting all of the wonderful people with diverse backgrounds who completed the program with me. I learned so much meeting people from all over the country with interest and expertises including transgender health, dance, massage, art, and community organizing! I gained an enourmous amount of knowledge from and respect for my peers, they enriched the learning environment.

The Art and Joy of Pelvic Exams

Posted by Katy

"Scoot Down. Relax your vagina. Why? So you can shove mean cold duck lips inside of it? I don't think so" -Vagina Monologues

This spring, two of the beautiful student midwives organized a bilingual rendition of the Vagina Monologues at the medical center here, involving nursing, medical, and physical therapy students, a professor, and women who work in the violence support center of Alianza Dominicana, a local community health organization. I performed the Angry Vagina monologue which railed on poorly performed pelvic exams. Now, I'm learning how to give pelvic exams, hopefully in a more empowering, de-mystifying, sensitive way!

An Introduction to my Student Midwifery Path

Posted by Katy

As an introduction, I will break down the university-based nurse midwifery program that I’m in. The program is intended for students who have completed a bachelors degree in another field and consists of a one year bachelors degree and certification in Nursing, followed by a year and a half masters degree and certification in Nurse Midwifery.

I moved to New York from Berkeley, CA last year specifically for the program. My sister (who is a marvelous doula), dad, and boyfriend all still live in the Bay Area and the rest of my family lives in Colorado, so living this far away is challenging. The program dominates my entire life right now which is overwhelming, but also seems like a good way to get a high volume of knowledge and skills that can be a strong foundation for developing a midwifery practice.

Robbie Davis-Floyd breaks down the pros and cons of university-based midwifery programs quite eloquently, so I’ll draw from some of her thoughts in “Types of Midwifery Training: An Anthropological Overview”. Davis-Floyd explains that university-based education provides an opportunity to become a midwife that is accepted in mainstream society and allows her the opportunity to teach, do research, and engage in politics as well as practice midwifery. A university education involves classes in a wide variety of subjects leading a midwife to be well-rounded in math, science, English, anthropology, etc. The program I am in includes a strong clinical component (classes 2 days a week and clinical 2-3 days a week), which connects the student midwife to a preceptor. The clinical placements are in a wide variety of settings, many of which focus on patients of underserved communities. This program gives attention to the individuality of the students and promotes creative, critical thinking.

Many of the challenges of the program are also articulated by Davis-Floyd. Davis-Floyd explains that experience of birth complications seen by student nurse midwives can contribute to a fear of birth rather than a confidence in the natural process. I am concerned about this happening, but I do not feel that I am in a position at this time to comment on this phenomenon. I hope that any birth complications I see will contribute to my body of knowledge in guiding women and babies through a safe birth, rather than promote fear or mistrust. Davis-Floyd also explains that student nurse midwives can become overly reliant on medical technology because of their training sites. I am also afraid of this happening, but I feel reassured that I am a flexible person and will continue to develop my midwifery practice throughout my life to adjust to what the women I’m serving need and want.

Perhaps the greatest critique of all is that university programs require student midwives to first complete nursing training. I feel that nursing training has taught me a lot about providing care for women and I think that many of the theories taught in nursing school are absolutely applicable to midwifery. However, the realities of nursing are antithetical of much of what my understanding of midwifery is and that difference makes nursing a huge barrier to becoming a nurse midwife.

Over all, I am unsure of what this year will be like, but I plan to take the good with the bad and use this year to begin the journey of becoming a phenomenal midwife.