Reproductive Justice is a term coined in 1994 by Black women activists as a way to address the ongoing struggles for reproductive rights and social justice through a human rights lens. (1) Two decades after its birth, the term is often mistakenly tossed around in connection solely with abortion rights, however it was created to bring together multiple social justice issues left out of the pro-choice movement and to centre the voices of those experiencing the most marginalization. It is a framework with which to examine a spectrum of issues including those related to pregnancy, parenting, abortion, and birthing options. (2)
“Reproductive Justice as the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.” (SisterSong)
The Birth Justice movement, led once again by Black and Indigenous women and activists of colour, exists under the umbrella of Reproductive Justice, and “is part of a wider movement against reproductive oppression” (3)
In their 2010 working paper “Birth Justice as Reproductive Justice”, The National Advocates for Pregnant Women discussed the inextricable links between Birth Justice and Reproductive Justice. The complete integration of these two, they explain, “occurs when the goals of reproductive justice fully address and incorporate not only women’s ability to make decisions about whether and when to have children, but also about how they are treated during the critical times of labor and childbirth.” They further note that “[Birth Justice] is, at minimum, having access to evidence-based maternity care, accurate information about pregnancy, the risks and benefits of medical procedures, and the agency to choose whether or not to undergo those medical procedures. It is having the power to make those choices and give birth free from fear of intimidation or interference from the state due to “noncompliance” with medical advice, or because of poverty, race or ethnicity, or immigrant status. It is also having access to competent and culturally respectful labor support.”(4)
Though interactions with the healthcare system are just one small sliver of the issues that Reproductive Justice is meant to address, it is one worth looking at to imagine a future in which the reproductive healthcare available in Canada is truly accessible, equitable, and focused on the unique needs of each patient.
The Obstetric Justice Project (formerly The Reproductive Justice Story Project) came about from the idea that issues of patient mistreatment and abuse in reproductive healthcare are part of this same family of social justice and human rights issues, and can therefore be framed as reproductive justice issues. As a website with white founders, the choice to borrow this bold term was not taken lightly but remained a consideration to wrestle with, critique, and explore. Eventually, the decision was made to update the name to avoid causing further dilution to the powerful message of reproductive justice and to honour the communities and organizations who continue to do the most meaningful work on these issues.
The absence of access to respectful and inclusive reproductive healthcare disproportionately affects patients from marginalized communities and those with vulnerable life circumstances. Indigenous, Black, and people of colour, young people, 2 Spirit and LGBTQIA+ folks, incarcerated and criminalized folks, those living on low incomes, with different (dis)abilities, whose first language is not that of their care providers, folks with diverse gender expression or presentation, less conventional family structures, mental health or trauma histories, and many others feel the gaps much harder than those of more privileged identities and experiences.
One central goal of this project is to work towards bringing together many voices to highlight the work that must be done before justice can exist for all in the healthcare systems here in Canada. This is truly a work in-progress.
1. "Reproductive Justice” SisterSong Women of Color Reproductive Justice Collective -
2. “What is Reproductive Justice?” by Loretta Ross, Founder & National Coordinator of SisterSong
via The Pro-Choice Public Education Project - www.protectchoice.org/section.php?id=28
3. “What is Birth Justice?” Black Women Birthing Justice - http://www.blackwomenbirthingjustice.org/what-is-birth-justice
4. ”Birth Justice as Reproductive Justice” National Advocates for Pregnant Women -
”Reproductive Justice Briefing Book: A Primer On Reproductive Justice and Social Change” Berkeley Law - https://www.law.berkeley.edu/php-programs/courses/fileDL.php?fID=4051
”A Story of Indigenous Birth Justice” by Rebeka Tabobondung, Mice Magazine -
”Birth Justice is Social Justice” by Emma Krupp, FourteenEast Mag -
”Reproductive Justice and Childbearing Women” National Women’s Health Network -
Obstetric Violence and Gynaecological Violence
Parts of the following definition were first published in our survey report of Patient Experiences at St. Joseph’s Health Centre, Toronto in June 2018.
Obstetric Violence is defined as “the act of disregarding the authority and autonomy that [pregnant and birthing individuals] have over their own sexuality, their bodies, their babies, and in their birth experiences.”(5) Though it exists at the intersection of structural/institutional violence and gender-based violence (6), obstetric violence can be perpetrated by care providers regardless of title or gender and can have a disproportionate effect on marginalized populations.(7) Much like other forms of gender-based violence, obstetric violence can be subtle and underhanded, rooted in the stark imbalance of power between patient and care provider throughout the childbearing process.
Healthcare providers may be committing acts of obstetric violence, regardless of intent, when they reinforce this power imbalance, by prioritizing their own needs or plans, communicating disrespectfully, or removing opportunities for patients to exercise informed, autonomous decision-making and have agency over their own bodies. It is important to note that “labour and birth can be framed as sexual events, with obstetric violence being frequently experienced and interpreted as rape.”(8)
The harm of obstetric violence can even be difficult to pin down and put into words by those who experience it, as it can occur even when no physical violence is present, even if the birthing person and baby are physically healthy and safe.
”[O]bstetric violence portrays a violation of human rights and a serious public health problem and is revealed in the form of negligent, reckless, omissive, discriminatory and disrespectful acts practiced by health professionals and legitimized by the symbolic relations of power that naturalize and trivialize their occurrence.” (9)
On the flip-side of the same coin, you’ll find gynaecological violence: a similar set of issues against folks who are not pregnant, giving birth, or in the postpartum period.
It is important to note that in the context of reproductive healthcare, disrespect and discrimination are forms of violence.
Obstetric and gynaecological violence includes misogyny, sexism, medical paternalism, racism, xenophobia, queerphobia, transphobia, Islamophobia, anti-Semitism, cultural insensitivity, discrimination based on immigration status, insurance status, HIV+ or STI status, body-shaming, slut-shaming, health-shaming, fatphobia, ageism, ableism, classism, bias based on language, religion, occupation or income source, history of criminalization or incarceration, cultural background and much more. Whether the victim experiences subtle microaggressions or blatant bigotry; interpersonal tension or the harm of system-wide policies and norms, these all fall under this same umbrella.
5. Dr Amali Lokugamage’s address at the RCOG World Congress 2014 https://www.youtube.com/watch?v=Ziy5kSFm7U8
6. “Obstetric Violence” - International Day of Action for Women’s Health
8. “Moving beyond disrespect and abuse: addressing the structural dimensions of obstetric violence” by Michelle Sadler - https://doi.org/10.1016/j.rhm.2016.04.002
9. “Obstetric violence in the daily routine of care and its characteristics” by Danúbia Mariane Barbosa Jardim and Celina Maria Modena - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6280177/
"Obstetrical and gynaecological violence - 26 January 2018" - http://assembly.coe.int/nw/xml/XRef/Xref-XML2HTML-en.asp?fileid=24491&lang=en
“There Is a Hidden Epidemic of Doctors Abusing Women in Labor, Doulas Say” by Sarah Yahr Tucker - https://broadly.vice.com/en_us/article/evqew7/obstetric-violence-doulas-abuse-giving-birth
“Assault and battery” in the delivery room: The disturbing trend of obstetric violence” by Rebecca Grant - https://qz.com/1177627/assault-and-battery-in-the-delivery-room-the-disturbing-trend-of-obstetric-violence/
Birth Trauma or Postpartum PTSD
Parts of the following definition were first published in our survey report of Patient Experiences at St. Joseph’s Health Centre, Toronto in June 2018.
Birth Trauma refers to symptoms of post-traumatic stress disorder (PTSD) experienced by some individuals after giving birth. Although birth trauma can be caused in many ways (i.e. a frightening emergency situation during labour, unexpected complications, etc.) for some patients it can be a direct result of obstetric violence, for “it is not always the sensational or dramatic events that trigger childbirth trauma but other factors such as loss of control, loss of dignity, the hostile or difficult attitudes of the people around them, feelings of not being heard or the absence of informed consent to medical procedures.” (10) It is estimated that 33-45% of individuals who have given birth perceive their experiences to be traumatic, while as many as 9% experience postpartum post-traumatic stress disorder following the birth. (11)
Although Postpartum PTSD is not particularly uncommon, there are still few accessible supports, even in city centres with otherwise decent mental health infrastructure. There also seems to be a profound lack of awareness of Postpartum PTSD even amongst mental health professionals who are supposed to be the "experts".
For example, birth trauma is frequently omitted from conversations around perinatal mental health, the focus being narrowly highlighting only perinatal depression and anxiety - both incredibly important to address, of course, and these diagnoses often overlap with PTSD - but it means that folks struggling with other conditions like birth trauma that don’t quite fit into the “depression” or “anxiety” boxes often have trouble getting an accurate diagnosis, validation from care providers, and effective treatment for their symptoms. (12)
Here in Toronto, there are incredibly limited resources for individuals struggling with the aftermath of a traumatic birth experience. Even the well-respected perinatal mental health programs at major downtown hospitals do not comprehensively address Postpartum PTSD. If birth trauma is mentioned at all, it’s in connection with near-death complications and emergency interventions, not care provider abuse (obstetric violence.) It’s unclear why mental healthcare providers continue to ignore the evidence. Private therapists and counsellors who bill themselves as “birth trauma experts” fill in the gaps, but most operate on a fee-for-service structure which is out of reach for many families.
While the trauma of giving birth is rarely given the spotlight it deserves, even rarer still are public conversations about the mental health impacts of other reproductive health matters like pregnancy & infant loss, abortion, complications, sterilization, and chronic reproductive health concerns, to name a few.
10. “What is Birth Trauma?” Birth Trauma Association UK - http://www.birthtraumaassociation.org.uk/help-support/what-is-birth-trauma
11. “Lessening the Risk of Birth Trauma” by Karin Beschen, AWHONN Connections - https://awhonnconnections.org/2017/03/16/lessening-the-risk-of-birth-trauma/
12. “The Mothers Who Can't Escape the Trauma of Childbirth” by Ilana E. Strauss, The Atlantic - https://www.theatlantic.com/health/archive/2015/10/the-mothers-who-cant-escape-the-trauma-of-childbirth/408589/
”For parents” Birth Trauma Ontario - http://birthtraumaontario.ca/for-parents/
”Post-traumatic (childbirth) stress disorder” by Jessica Leeder, Today’s Parent - https://www.todaysparent.com/family/womens-health/post-traumatic-childbirth-stress-disorder/
”Recovering from a traumatic birth” Centre of Perinatal Excellence, Australia - http://cope.org.au/birth/recovering-from-a-traumatic-birth/
The Heavy Flow Podcast, Episode 08 with Amanda Laird - http://amandalaird.ca/episode-08-birth-trauma-with-olivia-scobie/
”Resource Guide” Prevention and Treatment of Traumatic Childbirth - http://pattch.org/resource-guide/
When we say that Trauma Informed Care can be framed as a reproductive justice issue, it’s because interacting with big institutions (like hospitals, healthcare systems, and professionals in positions of power) can be traumatizing and sometimes dangerous. Fear and distrust of these individuals and institutions (who have demonstrated that they do not always have our best interests in mind) is a barrier to accessing care and having the full ability to make informed decisions about our bodies, families, health and lives.
”Trauma Informed Care is care that recognizes the far-reaching, pervasive impacts of trauma on people from all backgrounds and walks of life. Trauma Informed healthcare providers, institutions, and organizations respond to the widespread nature of trauma “by fully integrating knowledge about trauma into policies, procedures, practices and settings.” (13) The idea is that hospitals and medical staff incorporating trauma-informed practice treat all patients in a compassionate manner recognizing that the childbearing process, for example, can be harrowing even for individuals without previous trauma, and for those with trauma histories there are many opportunities to be retriggered by interventions and situations that may arise. Trauma Informed Care means that “an individual should not need to disclose previous trauma in order to access care that is sensitive to their needs.” (14)
There is a misconception that Trauma Informed Care is just for trauma survivors. That it is something that should only be provided to individuals who “inform” their care providers that they need “special” treatment. Trauma Informed Care needs to be a universal precaution applied to all patients in every situation at all times.
”You don't need to have a history of trauma to be traumatized by the treatment you receive. When patients are belittled, pressured, coerced, and assaulted by their care providers, that can be traumatic. When patients are in a vulnerable position, feeling ignored and dismissed by their healthcare providers who hold all the power, that can be traumatic. There seem to be more resources becoming available about providing sensitive trauma-informed care to survivors of childhood sexual abuse and sexual assault, and while this is so important and necessary (especially in the #MeToo era) we must remember to think about trauma in a much broader way. Sexual trauma is not the only trauma that can impact folks' interactions with the health system while accessing reproductive healthcare! Adverse childhood experiences are trauma. Poverty is trauma. Oppression is trauma. Racism is trauma. Neglect is trauma. Intimate partner violence is trauma. Historical & intergenerational violence, war, housing instability, incarceration, forced hospitalization, the child welfare system... all of these and so much more can be experienced as trauma! Not every person with a history of trauma uses the word "trauma" to describe their experience, but that doesn't make its impact any less valid.” (15)
If trauma education for healthcare professionals is focused on screening for trauma, and/or providing Trauma Informed Care only to those who self-identify as survivors of trauma, this completely misses the point. Trauma Informed Care is a universal precaution!
13. “Trauma-Informed Toolkit” - Second Edition, 2013 - http://trauma-informed.ca/wp-content/uploads/2013/10/Trauma-informed_Toolkit.pdf
14. “#Metoo shows we need trauma-informed maternity care” by Rebecca Schiller - http://www.birthrights.org.uk/2017/10/metoo-shows-we-need-trauma-informed-maternity-care/
15. “We Don’t Require a History of Trauma to be Traumatized by the Care We Receive“ - Instagram post January 18 2019 - https://www.instagram.com/p/BsyiH6IHoEq/?utm_source=ig_web_copy_link
Trauma Informed Care
The Obstetric Justice Project © 2017-2019