In the sixth post of our Birth Trauma takeover Frances Hand and Anna Nelson explore what is missing from the UK Government Report, including the systematic harms reported during experiences of maternity care.
The Report (2024) amalgamated hundreds of women’s stories of birth trauma. These stories matter, and we commend the report for platforming them. We are hopeful that this Report will contribute meaningfully towards combating maternity violence. However, we believe that it is important to acknowledge what is missing from the Report, as well as what is present. For us, one thing that stood out, both within this report and several of its predecessors, is the failure to name any of the systemic harms that women continue to report in maternity care for what they are: violence. Here, we explore the significance of this failure and highlight some of the questions this raises.
Softening Violence to a ‘Lack of Kindness’
The Birth Trauma Inquiry received over 1300 submissions, detailing experiences of traumatic birth. Aspects of this were challenging for us, as researchers, to engage with, on account of their obvious violence:
During her 36-hour labour, she was…denied an epidural because her platelets were too low. She remembers being violently sick…She sustained a third-degree tear: “Without an epidural the pain was intense, but the midwife nonetheless chastised me for flinching in pain when he had a go at stitching me up when in fact surgery was necessary.” (Birth Trauma Report, p. 17)
I could not stand or walk. I had a catheter. I was covered in blood and my own faeces but there was no one to help me wash…Around midnight I was woken up by a woman (I don’t know who she was? A nurse? A midwife?) who reprimanded me for not feeding my baby. (Birth Trauma Report, pp. 17-18)
Yet, throughout the Report, these stories are examined under headings which do little to capture the gravity of the harm being described, such as ‘lack of pain relief’ (p. 17), or to our minds the most disheartening, ‘lack of kindness’ (pp. 17-18). We argue that this treatment is not merely unkind; it is violent and should be named as such.
The topic of obstetric violence, which has its origins in Latin American feminist activism, is not without its controversies. Opponents to the terminology (most notably from the medical community) argue that the use of the term ‘obstetric violence’ is “inflammatory” (Cluver et al., 2023) and falsely implies that medical practitioners frequently commit intentional, malicious inflictions of bodily force (Chervenak et al., 2023). However, we argue that to discount the terminology of ‘obstetric violence’ on the grounds of a presumption of intentionality fails to consider years of feminist literature which has worked to undo this rigid definition of violence. We, instead, recognise that violence can be experienced regardless of the intentionality of the perpetrator. The use of the language of ‘obstetric violence’ to describe the harms experienced by women in maternity wards is an important form of epistemic rupture (Chadwick 2021, p. 109), forcing us to recognise the intensity of the harm women experience. Furthermore, ‘obstetric violence’ specifically points to the institutional and gendered nature of this violence, highlighting the systems of oppression which enable and underpin it (Sadler et al., 2016).
With this ongoing debate in mind, the oversight within the Report could be considered more forgivable, perhaps, if the authors did not engage with the violence narrative at all. This is not the case. The topic of obstetric violence is mentioned in the Report. However, these mentions are all confined to Chapter 2, entitled ‘What we can learn from other countries’ (p. 30). The positioning of violence as something which happens elsewhere is stark. For instance, the Report frequently references the disproportionately high rates of obstetric violence experienced by indigenous groups in Australia. Yet, it positions the arguably parallel statistics around the fact that Black women in the UK are four times more likely to die in childbirth than white women (p. 58), under the neutral heading of ‘maternal outcomes’, without drawing any relationships between this and the violence that a disproportionate number of Black birthing people experience.
Naming Violence: Language Matters
Language matters: “to refuse to name is a refusal of acknowledgement. It is to obscure, to ignore, and to dismiss…When the problem is not named it remains invisible and therefore almost impossible to solve” (Boudreaux, 2019). The failure to adequately label these traumatic birth experiences as violent hampers efforts to address the systemic and institutional forces which foster and enable this violence. Accuracy of language matters here, because in order to meaningfully tackle a problem “we need to know what we’re talking about” (Vorobej, 2016, 1). We argue that failing to incisively name the experiences within the The Report as obstetric violence is damaging and counterproductive to the overall goal of improving maternity care, as it “maintains the invisibility of a harmful social phenomenon” (Pickles, 2023, p. 634) and of the social-cultural and structural problems underpinning this. This chimes with the arguments made by Mahmoud in her post earlier in the series which interrogates the use of the term ‘trauma’ in the Report; indeed, that we have each picked up on different aspects of the language as problematic and worthy of comment perhaps itself underscores the importance of language.
A Pattern of Softening Violence: Ockenden as an example
Our criticism cannot be confined to this particular report. Rather, this report reflects a pattern of ‘softening’ which can be seen across a range of UK inquiries related to birth violence. For instance, the Ockenden Report was published on 30 March 2022, and provided an in-depth account into the systemic harms experienced by over 1500 families within the Shrewsbury and Telford NHS Trusts between 2000 and 2019. Again, their section entitled ‘Compassion and Kindness’ detailed several highly traumatic experiences, including situations where women and their children were placed at significant risk:
In 2008 a woman reported her distress about the care she received on the postnatal ward…‘There was no communication at all. I was shouted at, ordered about and forgotten…I was made to feel like an inadequate mother and made to feel like I was making up how poorly I was and like I shouldn’t have rung the bell or asked for help’. (Ockenden Report, 2022, p. 116)
In 2014 a mother reported , whose baby was on the neonatal unit, that she was ‘told off’ for ‘worrying about her pain too much’ [sic]…she was told by staff ‘what we tend to find is that those women who have babies next to them have more important things to think about. People like you who do not, are only concerned with themselves’. (Ockenden Report, 2022, p. 116).
While kindness and compassion are clearly missing from these scenarios, to frame the problem in these terms alone softens the reality of these behaviours, which put women and birthing people at significant risk of harm.
NHS Exceptionalism and the Denial of Violence
This leads us to ask why is the UK, both within The Report and more broadly, so unwilling to accept violence on its own shores, when it is happy to recognise it elsewhere? We question whether this is reflective of a uniquely British cultural protectionism towards “our” NHS (Arnold-Foster & Gainty 2021, p. 57). There is no denying that the NHS is perceived as a bedrock of Britain, illustrated powerfully by the celebration of the service during the opening ceremony of Great Britain’s 2012 Olympic Games (Konstantaki et al., 2016, p. 50), and by the ‘Clap for Carers’ during the COVID-19 pandemic, where families would routinely congregate on Thursdays at 8pm to clap for frontline NHS staff. The NHS is unquestionably heralded by many as a unique and proud attribute of the UK (Cowan 2020, p. 134). Public bodies are not immune to this mentality. However, where this love of the NHS results in individual and institutional unwillingness to critically engage with, and highlight the flaws of, this national organisation – as distinct from our admiration for the essential workers within it – we risk creating the conditions for the downfall of the very system we seek to protect. Agnes Arnold-Forster and Caitjan Gainty note, speaking to the NHS more broadly, the “privileging of sentiment over scrutiny is dangerous; it obscures structural failings and precludes progressive reform” (2021, p. 53). We suggest that the approach to obstetric violence in The Report is a reflection of this broader trend.
Conclusion
On the whole, we are encouraged by the fact that the UK government, and independent inquiries, are beginning to take notice of the wide-spread and structurally embedded harms that women experience in UK maternity wards. The gathering of information is important, though one has to wonder how many more reports do we need before we start to see meaningful improvements? We are critical of the way in which this research is framed, and the implications of this for responses going forward. Without the recognition of these harms as forms of violence, we fear that the severity of these experiences will not be appreciated. For the UK to turn a real corner with their responses to these harms, they must first accept that violence can, and does on a routine basis, occur within NHS maternity wards. It is only through this that pressure can be placed on the state to take positive, intentional action to combat these harms.
About the Authors
Frances Hand is a PhD candidate at the University of Oxford. Her thesis reconceptualises violent practice in UK maternity wards. She is also a Guest Lecturer at the University of Oxford specialising in Obstetric Violence, and the founder of the Medical and Family Law Student Collaborative Hub. You can follow her on Twitter/X at @FrancesHand_
Anna Nelson (she/her), is a socio-legal researcher, with a primary research focus on the way that (gendered) socio-medical realities shape experiences of consent and care during labour and childbirth. She has a PhD in Bioethics and Medical Jurisprudence from the University of Manchester and has worked as a Research Associate on a wide range of projects. You can follow her on Twitter/X at @Anna_Nelson95, or Bluesky at @annanelson95.bsky.social.
References
All-Party Parliamentary Group on Birth Trauma. 2024. Listen to Mums: Ending the Postcode Lottery on Perinatal Care. 13 May. Online.
Arnold-Forster, Agnes and Caitjan Gainty. 2021. To save the NHS we need to stop loving it. Renewal 29(4): 53-61
Boudreaux, JoAnne. 2019. Naming Obstetric Violence; Coercion, Bullying, and Intimidation in Non-Evidence Based Childbirth Interventions. The Journal of Mother Studies 4.
Chadwick, Rachelle. 2021. Breaking the Frame: Obstetric Violence and Epistemic Rupture. Agenda 35(3): 104-115.
Chervenak, Frank et al. 2023. Obstetric Violence is a Misnomer.
Cluver, Catherine et al. 2023. The need for appropriate language in the debate on medicalisation of pregnancy. The Lancet: Correspondence 401(10379): 818-819.
Cowan, Hannah. 2020. Taking the National(ism) out of the National Health Service: re-locating agency to amongst ourselves. Critical Public Health 31(2): 134-143.
Konstantaki, Maria, Eugenia Wickens, and Feng Yi Perris. 2016. Themes and content of the London 2012 Olympic Games Opening Ceremony: A comparison between pre-Games perspectives of British residents and actual ceremonial elements. Tourism & Hospitality Research 19(1): 40-53.
Ockenden, Donna. 2022. Final report of the Ockenden review. Department of Health & Social Care. 30 Mar. Online.
Pickles, Camilla. 2023. “Obstetric Violence,” “Mistreatment,” and “Disrespect and Abuse”: Reflections on the Politics of Naming Violations During Facility-Based Childbirth. Hypatia 38(3): 628–649
Sadler, Michelle et al. 2016. Moving beyond disrespect and abuse: addressing the structural dimensions of obstetric violence. Reproductive Health Matters 24(47): 47-55.
Vorobej, Mark. 2016. The Concept of Violence. London: Routledge.
