By Daniela Drandić & Fleur van Leeuwen
“People — and their rights — must be front and center,” said the UN Secretary-General on 23 April 2020. Since the start of the COVID-19 pandemic, drastic measures have been taken by public bodies and health authorities to contain the spread of the virus. Many of these have had serious repercussions for internationally recognized human rights.
The position of the rights of women in childbirth is in this context a precarious one. Stories have emerged in mainstream media – supported by personal accounts received by global and European birthrights organizations – of women having their labor induced, being forced to have cesarean sections, giving birth alone, and being separated from their babies immediately after birth. For Human Rights in Childbirth (HRiC), Drandić (co-author of this piece) collected data on global experiences of childbirth during COVID-19. In this essay, we focus on accounts received by HRiC and reports in mainstream media coming from Europe that warn of serious infringements of women’s rights in childbirth.
By and large, the measures taken in maternal healthcare settings in response to COVID-19 are attributed to the need to “flatten the curve,” such as by protecting healthcare professionals, women in labour, and their newborn babies from the risk of contagion in hospital settings. Although they are presented as temporary – necessitated by and lasting only for the duration of the current pandemic – they follow decades of institutionalization of childbirth, deeply rooted structural inequality, patriarchy, and neoliberal austerity measures. Even prior to the pandemic, this had resulted in a situation in which disrespect and abuse in childbirth were common. This includes, for example, brutal or inexperienced vaginal palpation, episiotomies carried out without consent, fundal pressure, membrane stripping, condescending remarks, and refusal to allow women to choose how they want to give birth.
Current responses to the pandemic in maternal healthcare and the acceptance of these measures on the basis of “necessity” not only imply serious infringements of human rights but also present a serious risk that the precarious status of women’s rights in childbirth will become the new normal.
Reports on measures taken in response to COVID-19 indicate a closure of midwifery and community services in several European countries. These moves provide an impetus for a further institutionalization of childbirth. Since the 1950s, European countries have witnessed a shift in childbirth practices, from a traditionally female-led model that considers pregnancy and childbirth to be normal, physiological life events (known as “the midwifery model of care”), to typically male-led models of care in which the underlying presumption is that birth events are inherently pathological and need to be medically managed in specialized, centralized facilities (“the obstetric model of care”). As Johanson, Newburn and Macfarlane point out, obstetrician involvement and medical interventions have become routine in normal childbirth in most developed countries. Although it is in the best interest of expectant families that these models of care complement each other, respecting the differences in approach and necessity, this has often not been the case.
The shift from midwifery models of care to the obstetric model typically led to over-medicalization of pregnancy, childbirth and postpartum, characterized by the “active management of labour.” The practice is reflected in highly elevated cesarean rates and the use of medical interventions that are not based on evidence. Notably, as Oja and Yamin observe, over-medicalization can reduce women to objects of interventions without agency, just as neglect of women’s differential needs in pregnancy and delivery can harm them.
Following the 2008 financial crisis, many European governments drastically reduced public expenditures on health. Cuts in healthcare budgets have been associated with understaffing, high patient volume, low salaries, long hours, and lack of infrastructure. A study of the effects of austerity measures in European Union countries linked austerity measures to a likely increase in maternal deaths. A side-effect of austerity was the strengthening of existing systems, for better or worse, and decrease in the chances that new programs like midwifery-led services could be implemented or gain traction.
The measures taken in maternal healthcare settings in response to COVID-19, moreover, did not happen in a gender-neutral vacuum. Blasko and colleagues, for example, point to how the lack of gender balance in COVID-19 decision-making in Europe impacts the degree to which women’s specific needs are taken into consideration. And Sadler and colleagues reiterate that rather than being an effective response to COVID-19, many of the measures currently taken in maternal healthcare settings are a “cloaked manifestation of structural gender discrimination.”
Crucially, the developments in maternity services over the past few decades happened within a system of structural gender inequality, discrimination, and patriarchy. Feminist literature on childbirth points to patriarchy, where women are instructed that their suffering during labour has a purpose, and that their very existence is intrinsically linked to that purpose. Simonovic observes in this regard that “Women are told to be happy about a healthy baby – their own physical and emotional health is not valued.” And Blondin finds that gynecological and obstetric violence is “the result of the continued existence of a patriarchal culture within the medical sector, particularly in the training given to health care staff, and of persistent gender stereotypes in society.” Studies in this respect also focuses on the notion that the primary threat to fetal health comes from its “maternal environment.”
The institutionalization of childbirth and the erosion of maternal health and midwifery care, coupled with patriarchy and discrimination, have led to serious impacts on women’s rights in childbirth. COVID-19 has deepened this problematic situation.
Since the beginning of 2020, the international NGO HRiC has been collecting data on the changes in care provided to pregnant, birthing, and postpartum women and their newborns. These data reinforce the stories in mainstream media. Reports from the United Kingdom, Germany and Slovenia – for example – point to the (further) closure and limitation of community and midwifery care and to midwives being removed from their duties in maternity units to work with COVID patients. In Malta, patients are allegedly discouraged from having home births. These measures not only indicate a further restriction to the already limited availability of midwifery-led care but also severely restrict women’s rights to decide how and where to give birth. These measures may furthermore impose risks to women’s access to high quality maternal healthcare and thereby affect women’s right to life and health. Early models estimate significant increases in mortality due to reduced availability of maternal healthcare services resulting from COVID-19.
As noted above, institutionalization of childbirth led to an increase in medical interventions. Reports received by HRiC of practices in Europe during COVID-19 signal that in a number of medical institutions, these interventions, undertaken without medical indication, are becoming the norm, thereby directly infringing upon women’s agency and integrity in childbirth. Croatian obstetricians, for example, called for compulsory cesarean sections in all (suspected) cases of COVID-19, and in Spain, women are subjected to inductions, instrumental births, and caesareans regardless of their infection status in order to minimize the risk of potential COVID-19 infection. Similarly, women in Poland that had travelled abroad and were therefore in self-isolation, reported that they were required to give birth by cesarean without any medical indication.
Finally, there has been widespread coverage of COVID-19 being used in as rationale for removing birth companions from delivery rooms. HRiC received reports on this practice from Lithuania, Portugal, Poland, and Germany. The WHO, recognizing that disrespectful and undignified care is prevalent in many facility settings globally, particularly for underprivileged populations, and that the prevailing model of maternity care in many parts of the world enables the healthcare provider to control the birthing process, recommends a companion of choice for all women throughout labor and childbirth. A Cochrane review of interventions by Bohren and colleagues, concluded that having a labor companion of choice improves outcomes for women and babies and is regarded as an important aspect of improving quality of care during labor and childbirth. WHO recommendations and research shows that having a birth companion can drastically decrease the chances that members of marginalized groups will develop severe complications or even die during childbirth.
The notion that these newly restrictive measures in maternal healthcare are necessary in light of the pandemic offers a false understanding that they are isolated responses to COVID-19, which will only last for the duration of the pandemic. This narrative overlooks the context in which women’s rights in childbirth have – gradually – been undermined in the past decades and also brings with it a serious risk that this precarious status of women’s rights in childbirth will become the new normal post-pandemic.
COVID-19 is a watershed moment for birth rights. It will either magnify the existing harmful policies around maternity care and create an important impetus for a radical rethinking of the way maternity care is delivered or result in a further degradation of women’s rights in childbirth. We must strive for the former.
Daniela Drandić is a Croatian maternal and newborn health advocate and a board member of the international NGO Human Rights in Childbirth. She is one of the authors of the Report on Rights Violations in Maternity Care during COVID-19. Ms. Drandić is currently working on the second edition of this report.
Fleur van Leeuwen, LL.M., Ph.D. is a lecturer in law at Bogaziçi University, Istanbul, Turkey and a senior affiliated researcher at Atria – Institute on Gender Equality and Women’s History in Amsterdam, the Netherlands. She is the managing editor of Tijdschrift voor Genderstudies (Journal of Gender Studies).