The Experience of Birth Professionals Who Witness Obstetric Violence During Childbirth

Abstract

Research:

The experience of obstetric violence is well documented. However, the impact on and experience of doulas and midwives who witness OV deserves more attention. The research questions that guided this study were: What types of harm are doulas and midwives witnessing, what factors influence their decision to intervene, and what impact does this experience have on their professional career and well-being?

Methods:

This exploratory study used semi-structured qualitative interviews to understand how doulas and midwives navigate the experience of witnessing OV. The data analysis included reflexive thematic analysis. Feminist standpoint theory was employed to center the lived experiences of women and other individuals from marginalized groups in the research and in the knowledge acquisition process.

Key contributions:

This study found that independent birth professionals like doulas and midwives are struggling with how to navigate their roles in the obstetric system. They find creative ways to advocate yet are often met with mistreatment themselves. This work is a call to action to the field of social work to engage in issues related to perinatal health and reproductive justice.

The experience of obstetric violence (OV) during maternity care is well documented (Logan et al., 2022; Mohamoud, 2023; Vedam et al., 2019). The rising rate of maternal mortality (MM) in the United States has also received a great deal of attention (Wang et al., 2023). While there are many underlying root causes of the maternal mortality crisis (Klawetter, 2014), discrimination and violence committed by healthcare professionals are central issues (D’Oliveira et al., 2002). In this paper, I refer to these independent doulas and midwives as birth professionals. Both midwives and doulas are trained birth professionals who provide services to birthing and postpartum people. Midwives are trained medical professionals who provide medical support both within and outside the hospital setting. Doulas do not provide clinical services but focus on emotional support. This study centered the lived experience of independent doulas and midwives who are not employed by hospitals. Independent doulas and midwives are hired by birthing people for their support and owe no loyalty to the hospital systems where the birth happens. The midwives in this study were practicing homebirth midwives and most of what they shared related to patients who were transferred to hospitals after a planned home birth required transfer.

As social workers have been called upon to address issues of social justice, so too have midwives and doulas. Advocacy, education, and empowerment are deeply embedded in all three professions which can lead to a natural alliance among birth professionals and social workers. Social workers need to actively engage with perinatal health (Deichen Hansen, 2022) and reproductive justice (Hyatt et al., 2022; Ketteringham et al., 2016) and recognize how they may be able to partner with doulas and midwives to support birthing people and to reduce obstetric violence.

This exploratory study used semi-structured qualitative interviews to understand how midwives and doulas navigate the experience of witnessing OV. The study explored the factors that influenced their decision to intervene or to remain silent. The research questions that guided this study were: What types of harm are independent birth professionals witnessing, what factors influence their decision to intervene (or not), and what impact does this experience have on their professional career and well-being? While there is evidence that doula and midwifery care improve outcomes (Gruber et al., 2013), the impact on and experience of doulas and midwives who witness OV deserves more attention.

Literature Review

The “problem of violence as embedded within the obstetric institution” (van der Waal et al., 2023, p. 91) has received limited attention in the US. Inherent in this lack of attention is indecision around how we speak about and define obstetric violence (Pickles, 2023; Sen et al., 2018). Coming to a shared understanding of obstetric violence is critical because naming the problem helps make sense of what is occurring and provides the language for raising awareness, improves reporting and research, and directs focus for addressing the structural factors to bring about social change (Boyle, 2019; Salter et al., 2021). Harm and violence directed at birthing persons occurs on a spectrum, whether referred to as mistreatment (Lappeman & Swartz, 2021), disrespect and abuse (Pickles, 2023), or obstetric violence (Sadler et al., 2016; Salter et al., 2021). Notably, the lived experiences of pregnant and birthing individuals who are harmed tell similar stories.

Obstetric violence occurs during the childbearing year and can include physical, sexual, and/or emotional abuse perpetrated by a medical professional involving bullying, manipulation, coercion, non-consensual procedures, and leveraging power differentials (van der Waal et al., 2023). OV is structural in nature (Sadler et al., 2016); it is a form of racialized gender-based violence (Diaz-Tello, 2016; van der Waal et al., 2023) that is normalized and institutionalized (Perrotte et al., 2020; van der Waal et al., 2023) and situates birthing people in a position with less privilege and less power than the healthcare professionals (Diaz-Tello, 2016; D'Oliveira et al., 2002). Hospital medical staff who assert power over the birthing person's decision-making process and disrespect their wishes about how they labor and birth commit a form of OV. Obstetric violence is also present when medical staff become part of policing pregnant people's behavior (Ketteringham et al., 2016), a form of OV where social workers may be complicit. Understanding these forms of OV can enable hospital staff, including social workers, to resist engaging in OV.

Numerous studies exploring pregnant people's experience of their care have confirmed high rates of OV. The Giving Voice to Mothers project found that 17% of birthing people experienced one form of mistreatment, including verbal abuse, neglect, and privacy violations, and that respondents of color were 2–3 times more likely to experience harm and coercion (Logan et al., 2022; Vedam et al., 2019). The CDC analyzed data from a survey of 2,402 respondents and found that approximately one in five mothers reported mistreatment during maternity care (Mohamoud, 2023). In response to this OV epidemic, advocates, policymakers, and birthing people are calling for increased access to doulas and midwifery care (Nash, 2019), and the Federal Health Department released $4.5 million in new grants to train, certify, and employ community-based doulas (HHS, 2022). Nash believes this shows evidence of “a crisis mediation tactic” by the state (2019, p. 31). It certainly indicates that the federal government as well as others are charging doulas and midwives with the task of improving the maternal health system while giving them little additional power with which to advocate for changes.

Doulas and midwives bear witness to a host of harmful and violent practices. Researchers found that 65% of birth professionals reported witnessing a lack of informed consent, and 1/3 of doulas and nurses surveyed witnessed practitioners pressuring birthing people to accept procedures against their will (Morton et al., 2018). In a qualitative study conducted by researchers in 2020, birth professionals explained that they saw themselves as “witnesses to institutional mistreatment and violence” but also stressed that their presence often acted as a “deterrent to OV, disrespect, and abuse” (Searcy & Castañeda, 2021, p. 7). The decision to speak up and face retaliation or remain silent and bear witness represents only one of the many challenges doulas and midwives face. The experience of birth professionals navigating this liminal space (Horstman et al., 2017) has not been explored adequately.

While bystander intervention has been researched in many different settings (Jensen & Raver, 2021; McMahon & Banyard, 2012; Polanin et al., 2012), research on bystander intervention in the birthing room is limited (Runyon et al., 2023), yet that is exactly what many doulas and midwives are engaging in. In response to witnessing OV, birth professionals must choose to use their voice to speak up, remain silent, or exit the field altogether (Castañeda & Melchiors, 2022) a phenomenon that evokes a theory from bystander intervention that individuals who witness harm can resist through mechanisms of voice and exit (Farrell, 1983). Central to this decision making process is the issue of power.

Power differentials and hierarchy contribute to the conflict birth professionals experience in these settings (Horstman et al., 2017) where they often receive mixed messages about their role and scope of practice. While they are hired by patients as advocates for bodily autonomy and informed decision making, they are also told by medical professionals and certifying organizations to stay within their scope of practice, “not to speak on behalf of clients or directly to providers,” and, above all else, “not [to] interfere with the medical team” (Pascucci, n.d.). Research demonstrates the ways in which these unequal power dynamics impact the work. In one of the first studies to look at the relationship between doulas and doctors in the birth room, Adams and Curtin-Bowen (2021) found doulas needed to strategically navigate and manage their relationship with doctors, using deference and subordination. The interviews with doulas indicated that they felt they must remain quiet and non-confrontational to retain the ability to remain at the birth of their client or their right to work in the hospital (Adams & Curtin-Bowen, 2021).

This research speaks to a disconnect between what is expected of birth professionals in addressing MM and OV and whether they can meet these expectations given their need to maneuver this space within the medical-industrial complex that is fraught with power dynamics. The aim of this study was to explore the decision-making process of doulas and midwives in navigating their intention to intervene while remaining cognizant of the inherent power dynamics, burden of care, fear of retaliation, and experience of vicarious trauma and burnout. This work aims to better understand the process and impact on the lives of the individuals who have been tasked with addressing the maternal health crisis in this country.

Methods

Reflexivity Statement

I identify as a multi-racial, cis-gender, heterosexual woman who has extensive experience working as a doula, childbirth educator, and homebirth midwifery assistant. For almost a decade, I have worked in the field of gender-based violence with a particular interest in obstetric violence. My interest in this research stems from not only my experience witnessing forms of OV but also as an insider who has experienced manipulation and disrespect within my own reproductive and obstetric health. The sample of doulas and midwives in this study seemed to interact openly with me knowing that I am a doula and would understand many of the dilemma-filled circumstances they had to navigate. I am also a social work professional and educator who feels that social work has inadequately engaged with reproductive and birth justice. My analysis and perspectives of the data are thus shaped by my experiences as a pregnant woman, birth professional, and social worker. My identity and positionality have influenced not only my experiences as a birthing person and doula but as a social work researcher as well. These lived experiences taken together with peer and mentor debriefing meant that my analysis was enriched by varied viewpoints on the material.

Design

As this work aims to understand the experiences and narratives of individuals who witness OV, qualitative methods were utilized to allow a deeper understanding of the topic through the voices of those experiencing it (Swigonski, 1994). Data were collected using semi-structured interviews. The data analysis approaches included reflexive thematic analysis (Braun & Clarke, 2021) and feminist standpoint theory to center the lived experiences of women and other individuals from marginalized groups in the research and in the knowledge acquisition process (Brooks & Hesse-Biber, 2007; Swigonski, 1994). This study and all its procedures received approval from the University IRB.

Sampling

As the Principal Investigator (PI) for this study, I conducted all the interviews and used my existing birth professional networks in various areas of the U.S. to recruit. Recruitment materials included specific language targeting doulas and midwives who had witnessed disrespect and abuse/OV during labor and delivery. Purposeful snowball sampling was also used as a method of recruiting participants. Potential participants were identified through connections to the birth community and social media networks. To participate in the study, participants needed to be over the age of 18, live in the US, have attended more than five births, and practice as an independent doula and/or midwife. Incentives were not offered for participation.

Data Management and Process

As PI, I contacted all individuals who responded to the recruitment notice to conduct a brief screening process via phone to ensure that the participant met all the inclusion criteria. All interviews (n = 17) were conducted via Zoom between December 2023 and February 2024. All participants consented to the audio-recorded interviews. The interviews were semi-structured with open-ended questions and lasted from 60 to 90 min. The questions were rooted in the objectives of the study and allowed the exploration of topics raised by the participants. The interview guide was developed with peers, and I worked with a peer debriefing group (Braun & Clarke, 2006, 2021) to pilot it. The interview domains included questions about the participants’ education and practice, definitions of OV, exposure to OV in the birth room, how they responded to the mistreatment, what factored into their decision-making process, and the impact witnessing mistreatment had on them. Participants were diverse in age, geographic location, years of practice, race, and ethnicity. The interviews were recorded as digital sound files, transcribed, and cleaned. The data were uploaded and stored on a secure university server.

Data Analysis

The data analytic strategy included thematic analysis based on Braun and Clarke's updated reflexive method and involved an iterative process that included establishing a deep familiarity with the data, generating initial codes and themes, searching for and reviewing the themes, defining and naming the themes and producing the report (Braun & Clarke, 2006, 2021). The research was approached through a feminist standpoint lens because it allowed me to explore the social structures and institutions (particularly power) that shape and influence the lives of the participants through their narratives (Swigonski, 1994) and was key to understanding their experiences. Memoing was used to document my reactions and important observations to inform the analysis process. Peer and mentor debriefing were also used to enhance rigor.

Results

The reflexive thematic analysis indicated four themes that provide an overview of the study's findings. The first theme, bearing witness, tells the story of obstetric violence and how participants navigated language and communication with clients and colleagues. The second theme, “You always have to calculate the risk of speaking up,” included subthemes about finding one's voice, positionality, and power in the work. The third theme, “My greatest joy and my biggest heartache,” detailed how participants managed the effects of the work. The final theme, “How do you continue to dance the dance in a system that is traumatizing people?” included two subthemes focused on re-evaluating ways of doing the work and resignation as an unwanted option. To ensure confidentiality, the author assigned pseudonyms to the narratives.

Bearing Witness

While discussion about the language of obstetric violence is heavily debated in the literature, participants had their own way of understanding, interpreting, and communicating about their experiences in the birth room. Participants shared a wide range of harmful practices they observed happening during labor and delivery. All of the participants spoke about a continuum of violence. The spectrum ranged from subtle behaviors and comments that shift the energy in the room to more extreme behaviors that include verbal, sexual, and physical assault. Stevie, a long-time doula, described how subtle the energy shift could be and how power is maintained.

Oftentimes, medical professionals will enter the room and not introduce themselves and just come to the bedside and stand over the woman with this energy that exerts the idea that they are the doctor, they know what is best, and if you want to give birth in their hospital, on their watch, you will do what they say.

Participants spoke about medical professionals not respecting a patient's choice. Ines, a doula, emphasized a lack of “value placed in the physiological process of birth”; she and other participants viewed “overmedicalization of the process as a form of obstetric violence.” Participants spoke about birthing people being intentionally isolated, and the partner or doula being asked to leave the room. While describing one such experience, Missy, a relatively new doula, explained:

If I just stepped out of the room, even just to go to the bathroom, just to get a break, I didn’t feel safe even doing that, because that was when they would come in, and someone would do a cervical exam or something that my client didn’t want.

Participants shared stories of birthing people receiving little to no attention or having their concerns dismissed or denied; they were belittled or not believed or even, in some cases, blamed. There were many instances of medical professionals not explaining procedures or obtaining informed consent. Amaya, a doula of three years, described it as “obvious things like cutting without consent, providers just pulling out the scissors and cutting without warning, doing exams and [membrane] sweeps and being like, oops, your water broke.”

There were also examples of manipulation, coercion, gaslighting, and disrespect. Ines described the physician's comments, “’Oh, just have the c-section; you don’t want to ruin your vagina, do you?’ or ‘Don’t be a hero, get the epidural, you know you want it.’” Ines shared how they would amplify the manipulation, “Do you want to kill your baby? Oh no, then, do what I say,” or in Melissa's experience, “If you don’t do XYZ, we are going to call child protection.” Almost every participant brought up hearing threats like this.

Racism, homophobia, and multiple forms of discrimination were also common occurrences discussed in the interviews. “Fatphobia” came up in almost every conversation. Rainne, a doula and midwife, shared the following experience:

I can’t tell you how many times I have witnessed a healthcare provider blame everything on a client's body size; the Pitocin isn’t working; it is because you are fat, or I can't tell the position of the baby because you are fat. I have watched providers assume a client had hypertension or gestational diabetes because of their size.

Participants also described witnessing experiences that they classified as “outright assault.” Romy, a midwife for over two decades, shared an experience that she has not been able to forget: “He had his fingers lingering in her vagina and was asking leading questions about a potential induction like she was a puppet. There was no reason for his fingers to be in there that long.” Multiple participants spoke about doctors continuing to operate on someone whose epidural had worn off. Missy explained, “I had to argue with the anesthesiologist, and they finally gave her morphine, then they turned to me and said, well, if she were really in pain, she would have shouted out and not just laid there quietly.” Cheryl, a midwife, described the “literal silencing of my client” as she shared the following:

My client was laboring quickly, and you know how that can go when you get to transition too fast. They called the obstetrician. He came in, my client was really loud, she was vocal, and she was having this really big experience. The doctor turned to the table, took one of the blue towels, and just shoved it in her mouth. He basically told her to shut up and then walked out. I reported the event. Nothing happened.

Each of the participants carefully considered how and when to talk to their clients about the topic of obstetric violence. For many, it depended on the client, but for others, it was a conversation that started “on day one.” Some participants talked about using different language with clients than with colleagues. For example, Taylor shared, “Among other doulas, I will use language like violence and assault, but with my clients, as a practice, we don’t use language like that. We say things like disrespected, dismissed, etc.”

However, many participants were moving away from what Tamika described as “sugar-coating the experience of childbirth in this country.” She continued,

Violence is an action; this abuse is repetitive, it is all about power and control, we wouldn’t downplay domestic or sexual violence, so why should we downplay obstetric violence? I don’t use language like mistreatment or disrespect. I call it what it is. Words like mistreatment can sometimes seem like it was unintentional or an accident, but that is not what I am witnessing.

When asked about how and when she brought these issues up with clients, Morine shared:

Being a Black woman, I have always talked very candidly with my clients. Often, I am told they want someone who is not afraid to speak up. Right from the beginning, at the very first intake interview, we start this discussion about who their provider is and where they plan to give birth. In that conversation, before they hire me, we are talking. Is this person going to help you get your goal? Is this person or environment safe? So, the conversation has to happen from day one.

In most cases, doulas and midwives felt they could have open and honest conversations with colleagues about what they were witnessing in a supportive environment. They called it what it was, “assault and violence.” Missy, however, felt “shut down and discouraged” when telling colleagues and mentors about the harm she witnessed:

I felt like they were gaslighting me. They told me that what had happened probably needed to happen and that what the doctor told my client wasn’t a lie, that there were no risks to the baby. They had me questioning myself, that maybe I was wrong. I was encouraged to accept what I had witnessed and the trauma it created in the spirit of collaboration. I was not to challenge, question, or step out of line.

“You Always Have to Calculate the Risk of Speaking Up”: Decision Making About Advocacy

The decision of when and how to intervene on behalf of a client who was experiencing a form of obstetric violence was a complicated one for most participants. Sometimes, there was not enough time to speak up because it was happening so quickly. Or, according to Amaya, there was a “fear of retaliation,” or the sense of being “unsure what my client wanted me to do.” Most participants spoke about this decision-making point as challenging. When asked about this, doula Sara shared:

You always have to calculate the risk of speaking up. You are constantly gauging what to do, and sometimes, you have a matter of seconds to figure it out. You want to speak up when you see something that is not in alignment with what your client wants, but you always run the risk of retaliation, being removed from the room, or being ignored. It is hard to figure out what to do.

Sometimes, participants talked about having to get a read on what their client wanted in the moment, despite the prenatal agreements. Melissa shared that as a doula she has “had clients that wanted me to be in that space with them to advocate, but once we step foot in that hospital, and they see that white coat, they become uncomfortable with challenging that authority.” Open and honest prenatal conversations were emphasized by many of the participants but did not necessarily eliminate the need to calculate the risk of speaking up.

“I Had to Find My Own Voice and Figure Out How to Use It”: Positionality and Motivations for the Work

Positionality is a term used to refer to where an individual is located in relation to their various social identities. Several participants identified as a member of a marginalized group, i.e., as a woman of color, a member of the LGBTQ + community, an immigrant, and/or as a survivor. Their identities were often part of their motivation to do the work, and these participants were more likely to articulate an inability to remain silent when they witnessed harm occurring. Ines explained:

I came to this country as an immigrant. I know what it is like to be silenced. I came to a point in my birth work where I just had no choice. If I saw something that was not right, I said something. It was worth the risk; I am not beholden to anyone but myself and my client.

Morine, a doula and self-identified survivor, shared, “When I saw this resident go to cut my client against her will, I physically put my hand on his to stop him from performing the episiotomy. I caught hell for it, but I prevented it.” Taylor, who also identified as a survivor and as a member of the LGBTQ + community, explained:

I have been advocating for the rights of survivors and LGBTQ + folks for decades, and I can tell you, I am not concerned about getting kicked out of the hospital. What is the point in being in the room if not to speak up, if I don’t stop the violence from happening, what am I even doing there?

Some participants discussed how “drawing on the strength” of their identity empowered themselves and their clients. Neve explained, “I had to step into my power as a Chicana doula, as a doula of color, because DONA (Doulas of North America) doesn’t teach that. I had to find my own voice and figure out how to use it.” Additionally, Tamika, a doula of color and survivor of medical violence, described how she intentionally shares her experience with clients because when they learn about how she “fired her doctor right there in the room,” it empowers her clients and “reminds them of their rights.”

“I Definitely Felt a Difference as a Licensed Provider”: Power Differentials Affecting Advocacy

Power could be a source of strength for doulas and midwives in the birth room, a way to advocate and show up, or it could be a barrier to advocacy. The more experience and the more education a participant had, the more confidence they had to speak up when they saw harm occurring. Most participants felt the need to seek out advanced training on topics related to trauma-informed practice, supporting survivors, advocacy, obstetric racism, and violence because they felt that their early training was inadequate. The more knowledge they obtained, the more power they felt they had to navigate those difficult decisions to intervene. In some cases, clinical practice and licensing gave participants more authority in the birth room. Rainne, who started out as a doula and eventually became a midwife, spoke about her experience. “I definitely felt a difference as a licensed midwife. So, from being a doula to a student midwife to being a licensed midwife, there was a shift. I was able to speak with providers on different levels.”

The more seasoned and experienced the participants became, and subsequently, the more harm they witnessed, the more likely they were to confront the behavior. Ines remembered:

In the beginning, when I first started, I think back, and I wasn’t really great. I was so scared, and I always wanted to please the doctor and nurses, which breaks my soul now. As I started seeing more and more things, I got more confident. I will say something like, can we have a second? I don’t think this is part of her plan.

Often, power was disproportionately in the hands of the medical staff and not with the doula, midwife, or birthing person. Meredith, a doula, articulated this well.

You do not have a voice, as a doula, as a birthing person. The system is set up to strip you of your voice so that they can do what they need to do. I had no idea before going in just what I would be up against.

Cheryl learned early on that “advocacy can only go so far. They have the power to kick me out of the hospital at any time and for any reason. I have no rights as the doula.” Neve shared an experience wherein the hospital was “making doulas sign documents,” saying they “would not advocate or speak on behalf of their client.” Micaela, a doula, reported that some hospitals were implementing “pre-approved lists of accepted doulas, and if you weren’t on that list, you weren’t getting in.” Power is also inherent in whose knowledge and experience are valued. For example, Amaya shared:

It is a question of whose knowledge is valued and centered, with no respect for other forms of knowledge. They think they have the degree, so they have all the power, never mind the hundreds of births I have attended or the experience of the person in labor.

Another common occurrence was hostility and anger directed towards the doula or midwife. Taylor was “physically moved out of the way” and told, “This is my OR. You need to get out of my way.” Participants shared similar stories to that of Melissa's, where medical professionals intentionally “went behind my back to get my client to consent to a procedure they didn’t want.” Stevie shared an experience of not being allowed back in:

I left the room to use the bathroom, but I was told I couldn’t go back in. When I texted my client's partner, he told me the staff told him I left. I had never experienced anything like this before. I finally got back in, but the damage had been done. They talked her into all kinds of things and manipulated her into believing that I had abandoned her. She didn’t want to have her water broken so early, that is all we asked for, and we weren’t even disrespectful about it. We just asked questions, we used B.R.A.I.N. (benefits, risks, alternatives, intuition, nothing), just like DONA (Doulas of North America) teaches us. The moment I stepped out of the room, they swarmed on her, and by the time I had been allowed back in, her water was broken, she was on Pitocin, and they had an internal fetal monitor on the baby's head.

Despite these unequal power dynamics, participants found ways to, directly and indirectly, challenge power using intentional tactics. Participants developed signals or facial expressions to communicate with the client's partner. As Melissa described it, “It was like I was the baseball coach, and the partner was on second base, looking for what to do next; we created our own signals.” Using deferential, non-confrontational tactics and subtle challenges to authority were common strategies. Micaela said, “If I see something about to happen, I get close to my client's ear and ask, ‘Do you want this to continue?’” Similarly, Ember described,

I say out loud what I see is happening. I will say, “ok, the doctor is grabbing the scissors, they are preparing to give you an episiotomy, they are giving you magnesium, they are increasing your Pitocin.” Then mom can say no, or the partner can ask a question.

Another common tactic was presenting a question or asking permission in a way that, while confrontational, comes from what Jemma described as “pretend curiosity.” Sara used similar language:

If I am going to say something, I present it as a question. Do you think…? I put myself in a position where I am not going to tell you what to do; I am asking if you could possibly consider this option as if I am trying to learn from it, as if I don’t already know.

Due to the nature of the work, intervening in the moment is rarely an option. That did not stop the participants from taking action, where appropriate, after the event. This advocacy can come in the form of talking about and processing the experience with the birthing person, speaking to a head nurse or hospital administrator, writing letters to the hospital, encouraging the birthing person or partner to write a letter, reporting the doctor, filing a report with the state, or taking to social media.

Whether or not a doula or midwife is empowered to intervene directly or indirectly, in the moment or after the fact, at the very least, they know that their presence in that space can make a difference in that birthing person's experience. Jemma explained, “What matters at that moment is that my client feels like someone heard them and that someone has their back or created a space where they could speak up for themselves and that they don’t feel alone.”

The role of the doula is a heavily contested topic, both in scholarly literature and in the lives of the participants. Almost every participant addressed what Taylor called “the doula debate.” Sara shared her perception, “There really are these two types of doulas; those who are very, very vocal. And it's not that I am against that because if that is what their client wants, that is fine; that is just not me.” Stevie approached her work in a different way,

I think there are some doulas who want to be accepted by the system; they want to become a part of the system, so they let things go. I have never been that person, but there are some people who think doulas should not advocate. They should just sit there and do their hip squeezes and breathing exercises and keep their mouths shut.

“My Greatest Joy and my Biggest Heartache”: Doing the Work and Managing the Effects

It is evident that engaging in birth work is both rewarding and incredibly difficult. While discussions ensued about the most rewarding aspects of the work, further explication of that is beyond the scope of this paper. The impact on the doulas and midwives is wide-ranging. Almost all participants used language like, “exhausting and tragic to witness” at some point to describe their experiences. Participants often spoke of burnout and vicarious trauma; Micaela felt she was “not functional,” and Taylor shared that she felt the need to seek out therapy as a direct result of her experience witnessing harm in the birth room. Participants expressed a range of emotions and feelings, including anger, unhappiness, pressure, hopelessness, and helplessness. Missy felt “paralyzed,” and Morine felt an “unbearable sense of failure, to the point where I felt like I was shutting down.” Tamika talked about how rare it was for her to meet someone who had been “doing this work in the double digits because of how difficult it can be to survive in this field.” Many participants shared a sense of inner conflict. While they felt passionate about the work, they also experienced pain and heartache. Raine shared:

It is difficult to stay motivated and I think what keeps me in the work is my passion for it. My passion for the birthing folks and their families, the hope that it can get better. There was a point in time where I just felt like I had witnessed so much obstetric violence and felt so much pain that I was considering leaving and just doing abortion work, but there is just something about it, something that draws me in and keeps me here.

Meredith expressed a similar conflict. Her “heart could not take it anymore. Doing this work is my greatest joy and my biggest heartache.” She further explained:

I kept telling myself, I can do this, I can do this, but I just felt like every time I was walking into that hospital, I was walking into a war zone like, willingly and knowingly. I just know about all the horrific things that are happening in that building at any given point in time, and there wasn’t anything I could do to stop it.

Many participants felt frustrated by the pressure they were under to what Romy described as having to “be the answer to the maternal health crisis.” Stevie shared her feelings on the subject, “You can’t put this all on us; we didn’t cause the problem; stop using doulas as damage control – too much pressure on the individual level and no emphasis on changing the actual system that is causing the harm.” Tamika expressed her disappointment in a similar way, “You give, and you give. We are overworked, underpaid, and unsupported and now they are like ok; can you all go fix this problem, this other big issue but we don’t really want to hear about, just go fix it.”

“How do You Continue to Dance the Dance in a System That is Traumatizing People”: Fighting the System

Many participants voiced how difficult it was to “fight the system” and how that has impacted their work and their well-being. Stevie asked, “How do you continue to dance the dance in a system that is traumatizing people?” Micaela reflected many participants’ sentiments, talking about how difficult it was to “buck the system and be a part of it.” They questioned how long they had to keep on fighting. Amaya recognized their clients’ reality that if they are “choosing to birth in that system, they need to be prepared to navigate and fight that system,” but also acknowledged that the “choice” wasn’t always a choice, that many of her clients are “systemically forced into this paradigm.” She continued:

The reality is that you can get into the work with the best intentions, but when you are trained under and within this system, when you are working within this system – well, the issue is the system. It is not always the individual; it is not always the people; it is the system they have to follow. They follow policy, not nature.

Many participants continue their work as an act of resistance, both within and outside the system. Rainne believed, “Birthwork radicalizes you. You don’t necessarily come into this work as an activist or wanting to create change, but you start doing the work, and you soon realize you have no choice.” Cheryl became a midwife because she wanted people to “have an alternative option outside of the system. She shared her motivation:

Knowing what is possible is what keeps me going; that is what gets me up in the morning. Witnessing birth, supporting a mama, or watching a family grow. There is nothing like it and I want that beautiful, gentle, uninterrupted experience for everyone. I know what is possible, and it doesn’t have to be negative or traumatic. That is what radicalizes me, knowing another world is possible.

“I Need a Change”: Re-Evaluating Ways of Doing the Work

Some participants had to re-evaluate their relationship to the work. Some have stopped attending births altogether and others have tried to change the scope of their practice. Amaya was trying to “focus on attending births outside of the hospital, like in the birth center or homebirths because I need a change.” Meredith was not attending as many hospital births as she had previously, but she “still want[s] to keep my toe in the water, so for me, that is childbirth education, not being in the birth room.” Romy intentionally made the move “into more macro, systemic work” because she recognized that “there is a limit to what you can accomplish in your role by the bedside.” Amaya struggled with the need to re-evaluate her practice:

It has been pushing me away from the hospital system, but that is where the people I want to serve have to give birth. They don’t have the same access to homebirth or birth center births. The people that look like me are giving birth in the hospital. How can I not be there for them?

Other participants felt the need to take time off or take a step back. Taylor took a break because she began to recognize, “I don’t have as much patience with my clients. I am so burned out that I can’t give them what they deserve right now. I love my work; I need to figure out another way to do it.” Missy was already struggling with her future, “I am really grappling with what my role is and how I am showing up. I have considered leaving so many times. I am still here, trying to figure that out.”

“I Left the Field…I Miss Catching Babies”: Resignation as an Unwanted Option

Interestingly, not many participants “gave up.” While a few did, most spoke about knowing other birth professionals who either resigned themselves to try and fit in and work within the system or left the profession altogether. Romy reluctantly shared, “I left the field, I miss the moment, I miss catching babies and welcoming and supporting a new family. But I don’t miss all the crap you have to go through to get there.” Tamika took a deep breath and exclaimed, “Sometimes you have to just walk the fuck away and realize that there is nothing else we can do here.”

Discussion

The purpose of this study was to explore the experience of doulas and midwives who witness obstetric violence in the birth room. Using the lens of reflexive thematic analysis (Braun & Clarke, 2021) and feminist standpoint theory, a tenet of which is that research should begin with the lives of marginalized individuals (Brooks & Hesse-Biber, 2007; Swigonski, 1994), findings indicated that birth professionals witness a wide spectrum of harmful behaviors, and the factors that influence their ability to intervene are not the same for all participants. Many recognized that their “power” in the birthing room was limited by their social location, positionality, and marginalized identity.

Within the reproductive justice movement where people's bodily autonomy is prized, the birth justice movement focuses on how birthing people have the power and right to make decisions about how their obstetric care will be carried out. The independent birth professionals in this study kept that tenet of birth justice first and foremost in each of their narratives. The doulas and midwives interviewed had to navigate and weigh the risk of intervening and were influenced by issues like power, positionality, experience, and level of training. Navigating these issues in the context of bearing witness to obstetric violence has had a severe impact on participants. Responses ranged from experiencing burnout and vicarious trauma to reevaluating their scope of practice or leaving the field altogether (Castañeda & Melchiors, 2022).

Doulas are tasked with addressing harmful systemic practices (Nash, 2019) but are not given the power or position to be able to do so. The need to navigate this liminal role (Horstman et al., 2017) is often referred to as “the doula debate.” Addressing power dynamics and the low status of doulas and midwives in the birth room is critical to addressing the conflict that participants spoke of.

Policymakers who call for increased access to doulas and midwives (Nash, 2019) and are tasked with designing initiatives to address phenomena like maternal mortality, medical racism, and obstetric violence need to incorporate intentional efforts to strengthen support systems for birth professionals. These include but are not limited to mentorship programs, community-building efforts, and labor rights. Hospital and medical system policies should include independent birth professionals in such a way that allows them to have more input and power within the hospital setting to alleviate the need for them to find ways to exert their power through deferential or countervailing tactics (Adams & Curtin-Bowen, 2021). Hospital social workers and birth professionals should be encouraged to establish collaborative working relationships to support birthing people and their families before and after they arrive at the hospital. Additionally, systematized methods for reporting obstetric violence should be developed, including professional accountability measures. Further, postpartum mental health support services should be offered to those who experience OV.

Abolition medicine “is the idea that our health care system has a moral, ethical, and professional obligation to use its social powers to interrogate and disrupt systems with a history of harming people” (Hayes & Gomez, 2022, p. 190), including the medical industrial complex and family policing system. This concept is relevant as several participants spoke about hospital staff members’ threats to call child welfare as a form of obstetric violence. Paltrow and Flavin (2013) analyzed 413 cases involving the criminalization of pregnant people and found that at least 60% of the reports that lead to arrest and prosecution came from hospital staff whose primary motivation was to ensure compliance with medical directives, especially when patients were not adhering to recommended treatments or protocols. This reliance on reporting to law enforcement or the family policing system reflects a broader effort to control and regulate pregnant bodies through criminal and legal frameworks. Understanding these experiences through abolition medicine is warranted. Key to abolition medicine is centering individual's stories (Collins, 2022) through narrative medicine (Charon, 2017). Engaging with the stories and experiences of individuals who have been harmed by OV centers those who have been marginalized (Swigonski, 1994) and allows for multiple allies (doulas, midwives, social workers, nurses) to create critical mass to bring improvements to maternity care.

A salient implication of this study is advocating for improved training opportunities about bystander intervention (McMahon & Banyard, 2012) and advanced advocacy skills. Participants shared their creative tactics for intervening in direct and indirect ways in the birth room. However, many of these skills formed over years of experience. Incorporating early bystander advocacy training could help empower birth professionals in navigating their roles in the birth room. Continuing to build upon and explore how birth professionals who witness obstetric violence resist through mechanisms of voice and exit (Farrell, 1983) is indicated to better understand what works and to increase sustainability. Social workers who recognize the importance of speaking up and resisting coercion of birthing people could be useful in developing this area of training.

As a field, social work has been called upon to engage in more intentional ways with issues of reproductive justice, bodily autonomy, and institutional violence (Beck et al., 2024; Hyatt et al., 2022). This paper amplifies the call to social workers to engage with birth justice which is a part of the larger reproductive justice movement. Birth justice aims to dismantle inequalities that lead to negative birth and postpartum experiences for everyone, but in particular, for marginalized communities. Birth justice aligns with the core mission and values of social work, and in particular, social work's ethical call to support self-determination. Social workers, especially those working at the intersections of perinatal social work and gender-based violence are in a powerful position to engage in this work. As social workers who are trained to work across systems, to engage in root cause analysis, and to center the experiences of marginalized communities, we need to better explore social justice in maternal and perinatal health.

Limitations

Although the sample was diverse, a limitation of the current study is the sample size (n = 17). As the PI, I had to turn away interested parties due to the short time frame of the project. Similarly, time constraints meant member checking was not included in the study design. Additionally, I acknowledge that participants’ accounts were retrospective and are thus subject to issues related to recall and memory. While the field of midwifery and doula work primarily consists of women-identified individuals, there was an underrepresentation of male participants. Recruitment was limited in that it specifically sought out birth workers who have witnessed obstetric violence and who work independently of hospitals or obstetric practices. Further research could include recruitment of all birth workers, regardless of gender, personal experience, and scope of practice.

Conclusion

In conclusion, the goal of the current study was to explore the experience of independent birth professionals who have witnessed obstetric violence. The aim was to understand not only the impact this experience has on them, but how they are able to or unable to intervene on behalf of their clients. Clearly, they generally work to intervene and advocate for birthing people, but at high cost to themselves due to the resistance of the hospital-based obstetrical complex. As doulas and midwives are continually being called upon to address systemic issues related to maternal health, their voices and experiences should be centered. While many social workers are already beginning to engage in this work, this is a call to the field to become more familiar with the phenomenon of obstetric violence and to explore ways to collaborate with doulas and midwives in preventing and responding to harm.