In the fifth post of the Birth Trauma takeover, Laura O’Donovan illuminates the injustice experienced by many birthing people- not being heard.
Over recent years a number of reports into maternity care services in the UK have been published (Ockenden 2022; Birthrights, 2022; Kirkup, 2022; All-Party Parliamentary Group (APPG) on Birth Trauma, (Thomas, 2024) with further enquiries ongoing (Ockenden, 2022). These reports collectively identify the myriad ways in which birthing women and people, and their babies, have been failed by the very services supposed to care for, support, and treat them.
Far from being an isolated problem at one or two hospitals, the Birth Trauma Report (2024) exposed a catalogue of failures across the NHS maternity system in the UK. Common themes emerging from the Report include a failure to listen; a lack of informed consent; poor communication; a lack of pain relief; and a lack of kindness. The effects of these failings have been wide ranging- including physical harm, psychological harm, and very sadly in some cases, maternal death, stillbirth, and neonatal death. What is clear from some of the harrowing stories detailed in each of these reports is that there is a pervasive problem with the delivery and quality of maternity care in the UK. Reflecting and building upon research I am currently undertaking with colleagues at Manchester University, which explores misogyny, racism and epistemic injustice in healthcare, this essay focuses in particular on one of the themes arising from these reports – failure to listen – and asks why is it that healthcare professionals (HCPs) are not ‘listen[ing] to mums’ (Thomas, 2024)?
Feeling Unheard
No doubt some of you reading this essay will have had the experience of telling someone something and feeling that, while the person you’re talking to might seem to hear you, they are not really listening. In some cases, the reason will be benign. The hearer is distracted or busy perhaps. However, in other cases, this might be because of some prejudice on the part of the hearer that negatively affects the way in which they perceive you, the speaker, leaving you feeling unheard. This is the concept of testimonial injustice: a type of discriminatory epistemic injustice, coined by the philosopher Miranda Fricker (2007).
Owing to some identity-regarding prejudice (implicitly or explicitly held), the hearer attributes a deflated level of credibility to the speaker which impacts upon their acceptance of what the speaker is saying such that they don’t really take on board their testimony (Fricker, 2007). Identity prejudice in this case might operate on several bases e.g. gender, race, age, socio-economic status etc. In the healthcare context generally, and in maternity care in particular, racist and gendered tropes and prejudices remain prevalent. Birthrights (2022), the UK charity dedicated to championing the rights of women and pregnant people during pregnancy and birth, has, for example, identified multiple examples of systemic racism and dehumanisation in maternity care. The issue of testimonial injustice and medical misogyny is also prevalent across the spectrum of ‘women’s health’ services.
Indeed, the male-as-default-position has been at the foundation of medical research, education and training since the emergence of modern medicine in Ancient Greece (Cleghorn, 2021). As such, women (and those with female anatomy) have typically been regarded as inferior, constrained by their reproductive organs to which most illnesses were historically attributed. While ‘hysteria’, or its official term, ‘hysterical neurosis’, may no longer be recognised in the Diagnostic and Statistical Manual of Mental Disorders (DSM), it continues to frame and influence biased characterisations of them as overly emotional, unreliable, anxious, and prone to over-react (Ipsos, 2023).
Added to this are stereotypes and biases applicable to ‘ill persons’ or ‘patients’ as a group. This includes characterisations of patients as emotionally compromised, anxious or dominated by their illnesses, such that their capacity and ability to recount their experiences is impaired (Kidd & Carel, 2017, p. 177-178). Like anyone and any organisation in society, health care professionals (HCPs) and the NHS as an institution are not immune from external prejudices. Furthermore, the position of patients as a social group situated within a hierarchical structural power relationship that favours the HCP may further exacerbate their vulnerability to testimonial injustice given the power imbalance. In the context of maternity care, labouring people are generally not a group who are necessarily ‘ill’ or even ‘patients’ in the same way that others are ‘patients’ when they engage with healthcare. However, admission to labour units and hospitals, and being brought within the healthcare institution, positions pregnant women and people within the hierarchical structural power relationship baked into the healthcare system. As such, they may be uniquely vulnerable to testimonial injustice for the same reason that ill persons are. Furthermore, the stereotypes that Ian Kidd and Havi Carel (2017) identify as applying to ‘patients’ as a group could easily also be said to apply to pregnant women and people.
The result of testimonial injustice is both primary and secondary harm to the speaker. The primary harm is that the speaker is undermined in their capacity as a knower. According to Fricker (2007), secondary harms consist of a range of associated disadvantages caused by the primary harm. In other words, they are harms consequential to the primary harm. In the medical context, this includes the possibility of misdiagnosis which may have serious health consequences for the patient.
Mother does(n’t) know best?
Accounts of what is arguably testimonial injustice are detailed throughout the reports into maternity services noted above. A clear example of this can, I suggest, be seen in the Report (2024, p. 15):
‘I was concerned that my baby was looking ‘yellow’ and asked the midwife. She told me I was being overly anxious and he was fine. She wrote in my notes that I was an overly anxious mother and my baby was NOT jaundiced. My husband intervened and a doctor confirmed my baby was jaundiced and he was treated. The next day the page written by the midwife had been torn out.’ [sic]
This mother, testifying her worries for her baby’s health to her midwife, arguably received a deflated level of credibility owing to some prejudice affecting the judgement of the midwife. Here, both gendered stereotypes that characterise women as anxious, unreliable, and prone to over-reaction, and negative stereotypes against users of the healthcare system, seem to be at play. Categorising the woman as ‘an overly anxious mother’ resulted in the midwife discounting her testimony and treating her as an unreliable witness. The mother was undermined in her capacity as a knower (primary harm) while her son’s jaundice was undiagnosed and untreated until the patient’s husband sought a second opinion (secondary or consequential harm).
Unfortunately, the experience of “not being listened to” recounted by this mother is not an isolated one and, I argue, evidence of testimonial injustice is to be found throughout the multiple reports into maternity care services published over recent years. This ranges from mothers/patients not being believed when experiencing pain, to the point that they were left screaming in agony without any pain relief (Birthrights, 2022, p. 54), to mothers/patients whose symptoms, including perineal symptoms and personal care issues, were dismissed, leaving them with undiagnosed complications and injuries following ‘significant birth trauma’ (Ockenden, 2022, p. 107, 117).
Misdiagnosis or not receiving any diagnosis and treatment is undoubtedly a significant harm to the patient. However, those responsible for the delivery of healthcare should also be concerned about the potential erosion of trust between doctor and patient as a consequence of testimonial injustice. Indeed, the therapeutic relationship depends on the patient’s ability to trust the person treating them (British Medical Association, 2024).
The need to better understand why HCPs are failing to listen
The Report concludes by putting forward a vision for what ‘good’ looks like in maternity care. It suggests that this would include “listening to women,” taking their concerns seriously, providing pain relief when it is requested, and not assuming that women are being over-anxious or over-dramatic when they express concerns (2024, p. 66). I don’t think anyone would disagree with these care aims and standards. However, ‘failure to listen’ is a theme arising in all of the reports cited above, which suggests that despite recognition that the problem exists, there is not a full understanding of why it keeps happening and how it might be prevented moving forward.
The policy response to a “failure to listen” has to be more than “there is a need to listen”. If the UK Government and NHS executives are serious about improving maternity care for women and birthing people, babies, and families, then seeking to understand how and why testimonial injustice occurs should be a priority. Listening to the patient is, after all, a vital aspect of good health care. Emphasising this in his report on maternity and neonatal services in East Kent, Dr Bill Kirkup (2022, p. 5) recalls the words of William Osler, who, over 100 years ago encouraged clinicians to ‘listen to the patient, [they are] telling you the diagnosis’. To this, I would add: and the future of the HCP-patient relationship in maternity care and the NHS more broadly depends on it .
Endnote
*This blog post reflects and builds on some of the research I am currently undertaking with Sarah Devaney and Alex Mullock (University of Manchester) exploring misogyny, racism and epistemic injustice in women’s healthcare more broadly.
About the Author
Laura O’Donovan (she/her) is a socio-legal researcher with a particular interest in reproduction, pregnancy and gendered experiences of healthcare. She has a PhD from the University of Manchester and currently works as a Lecturer in Law at the University of Sheffield. Previously, she worked as a Research Associate at Lancaster University on the Wellcome project, ‘The Future of Human Reproduction – Transformative Agendas and Methods for the Humanities and Social Sciences’. You can follow her on Twitter/X at @lauraaodonovan
References
All-Party Parliamentary Group on Birth Trauma. 2024. Listen to Mums: Ending the Postcode Lottery on Perinatal Care. 13 May 2024. London.
Birthrights, “Systemic Racism Not Broken Bodies – An Inquiry into Racial Injustice and Human Rights in UK Maternity Care” (2022)
British Medical Association, “Ethics Toolkit – The Doctor-Patient Relationship” (2024). Online.
Cleghorn, Elinor. Unwell Women: A Journey Through Medicine and Myth in a Man-Made World. W&N, 2021.
Fricker, Miranda. Epistemic Injustice: Power and the Ethics of Knowing. OUP, 2007.
Ipsos, “Hysterical Health, Unpicking the Cultural Beliefs That Shape Women’s Healthcare” (2023)
Kidd, Ian J. & Carel, Havi “Epistemic Injustice and Illness” Journal of Applied Philosophy. 34, no. 2 (2017): 172-190.
Kirkup, Bill. “Reading the Signals – Maternity and Neonatal Services in East Kent – The Report of the Independent Investigation” HC 681 (2022)
Ockenden, Donna. “Findings, Conclusions and Essential Actions from the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust” HC 1219 (2022)
