Obstetric iatrogenesis in the United States: the spectrum of unintentional harm, disrespect, violence, and abuse

Abstract

‘Medical iatrogenesis’ was first defined by Illich as injuries ‘done to patients by ineffective, unsafe, and erroneous treatments’. Following Lokumage’s original usage of the term, this paper explores ‘obstetric iatrogenesis’ along a spectrum ranging from unintentional harm (UH) to overt disrespect, violence, and abuse (DVA), employing the acronym ‘UHDVA’ for this spectrum. This paper draws attention to the systemic maltreatment rooted in the technocratic model of birth, which includes UH normalized forms of mistreatment that childbearers and providers may not recognize as abusive. Equally, this paper assesses how obstetric iatrogenesis disproportionately impacts Black, Indigenous, and People of Color (BIPOC), contributing to worse perinatal outcomes for BIPOC childbearers. Much of the work on ‘obstetric violence’ that documents the most detrimental end of the UHDVA spectrum has focused on low-to-middle income countries in Latin America and the Caribbean. Based on a dataset of 62 interviews and on our personal observations, this paper shows that significant UHDVA also occurs in the high-income U.S., provide concrete examples, and suggest humanistic solutions.

Keywords:

• Birth
• obstetrics
• obstetric violence
• disrespect
• and abuse
• obstetricians
• midwives
• obstetric iatrogenesis

Acknowledgments

We thank Ashish Premkumar, Elizabeth Nalepa, and our editors and anonymous reviewers for their helpful edits and comments on this paper. We also thank Maria Dana, Emily Garcia, Victoria Keenan and Susanna Snyder for their help.

Ethical approval

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study. The study was approved by the Oregon State University IRB protocol #6645.

Disclosure statement

We confirm the authors have no financial or personal relationships that might bias the work being submitted.

Notes

1 Transgender and gender non-binary people have reproductive health needs and experiences that can be similar to, but also unique from, those of cisgender women. To reflect this inclusivity, we employ a mix of words: “women,” “people,” “persons,” “childbearers,” and “mothers”.

2 The technocratic model is also associated with substantially higher costs (e.g., $12,516 for an uncomplicated vaginal birth in the U.S. and between $14,099 and $28,617 for a cesarean birth, depending on the state [Childbirth Connection 2013]), and worse outcomes. Studies have suggested that, if only 10% more U.S. births took place in homes and freestanding birth centers, nearly $11 billion could be saved annually (Daviss, Anderson, and Johnson 2021).

3 There are no documented data on how many cervical exams have been performed without consent, but one survey found that a majority of medical students had performed such exams on unconscious patients, and in nearly 3 of 4 instances, they believed that informed consent had not been obtained. These examples of iatrogenesis highlight how technocratic birth and the educational interests of residents often supercede the autonomy of the laboring person.