On August 6, 2016, the number $16,000,000 echoed through the world of maternity care. It was a sum linked to a horrifying image: a woman in labor, held down, screaming in pain and terror while a nurse pressed her baby’s head into her vagina, preventing him from being born. It was the day that Alabama mother Caroline Malatesta won an astonishingly rare legal battle against Brookwood Women’s Health, the Birmingham hospital where she gave birth in 2012.

In the final minutes of Malatesta’s labor, she says this struggle became a violent physical assault. She describes how her nurse forcibly wrestled her onto her back while another nurse pressed her infant’s crowning head into her vagina for six minutes. Malatesta says her screams of “Stop!” were ignored as she struggled in what she calls “torture.” Her son Jack was born healthy and unharmed, but Malatesta suffered severe nerve damage as a result of the assault. She was later diagnosed with PTSD and pudendal neuralgia, an extremely painful and incurable condition, which prevents her from having sex and from ever giving birth again.

Malatesta chose Brookwood because she wanted “autonomy,” enticed by a seductive marketing campaign that advertised personalized birth plans and “natural” choices, according to Yahoo Parenting, which first reported her story in 2015. Her actual experience was far from that empowering picture. Malatesta had planned an un-medicated birth and wanted to move freely during labor, but her labor and delivery nurse ordered her to get in bed on her back and remain immobile, although her baby was showing no signs of distress. The obstetrician who had promised Malatesta a wireless monitor and a water-birthing tub was not on call. When she protested, the nurse ignored her questions and demanded that Malatesta obey. As Malatesta wrote later , “It became very clear that this wasn’t about health or safety. It was a power struggle.”

After the decision, media coverage of Malatesta’s case focused on her traumatic experience and the “bait and switch” maternity care she had received. Hundreds of commenters expressed shock, sympathy, and also skepticism that such an appalling violation could have occurred in a hospital. But for one group of people, Malatesta’s story was not shocking, isolated, or even highly unusual — birth doulas. Professionals trained to provide physical and emotional support but not medical care for birthing people, doulas saw the case as simply another incident of obstetric violence: abusive maternity care, which many doulas say they witness on a regular basis.

In 2016, after more than two years of litigation, Malatesta’s lawsuit did not prove that she had been criminally attacked by a person she trusted to care for her—there’s actually no US law against what was done to Malatesta. But a civil jury agreed that Brookwood had fraudulently advertised its childbirth options, and that her nurse had violated the standard of care.

While obstetric violence can cause both physical and emotional damage, legal observers have found that very few women ever make public complaints against doctors, midwives, nurses, or hospitals. If infant and mother are both reasonably healthy, most women prefer to put a traumatic birth experience behind them as they focus on parenthood. What was shocking for doulas that we spoke to was not the disrespectful way Malatesta had been treated or even her physical assault, but the fact that she had fought back publicly and legally against her abuse. And that she had won.

The term “ obstetric violence ” appears nowhere in US law, but other countries like Venezuela and Argentina are beginning to define it as a crime against people giving birth. It is an umbrella term that includes disrespectful attitudes, coercion, bullying, and discrimination from care providers, lack of consent for examinations or treatment, forced procedures like C-section by court order , and also physical abuse. In 2016, the American College of Gynecologists and Obstetricians (ACOG) issued a comprehensive committee opinion affirming that a "decisionally capable" pregnant woman has the right to refuse treatment, and discouraging "in the strongest possible terms" the use of "duress, manipulation, coercion, physical force, or threats... to motivate women toward a specific clinical decision." However, their opinions and resolutions are not binding.

Varnam recalls witnessing one particularly disturbing incident with a client where an obstetrician entered a labor and delivery room wearing street clothes: Without introducing himself to the client or requesting permission, the doctor inserted his fingers into her vagina and attempted to manually widen her nearly dilated cervix. Varnam says her client screamed in pain and protest, but it took Varnam’s insistence for the doctor to stop. “That happens to me all the time,” Varnam says. “The amount of times I have to say, ‘She’s saying no, and you have your hand in her vagina. You need to take it out’ is unreal. There can not be that kind of disregard for consent.”

Like many doulas, Varnam originally saw her role as supporting pregnant people. But she soon realized that her job could be better described as a “bodyguard.” Rather than offering comfort measures or encouragement at births, she felt she was really there to keep her clients safe, to protect their physical autonomy, to shield them from being victimized, and failing that, to stand as a witness to their abuse. It is job that Varnam believes should not need to exist.

“The amount of times I have to say, ‘She’s saying no, and you have your hand in her vagina. You need to take it out’ is unreal."

Emily Varnam, a doula and reproductive health educator in Detroit who previously worked in New York City, describes the experience of repeatedly witnessing obstetric violence as exhausting, infuriating, and deeply traumatic. “You pretty much one percent of the time see women getting the care that is appropriate for them,” says Varnam, who adds that she saw abuse regularly while attending births at nearly every New York City hospital. “Whether that’s from lack of evidence-based care or lack of compassion, or lack of respect for the human race, you pretty much just never see care that feels appropriate. Either it’s how they’re spoken to, or nonconsensual vaginal exams. It’s nonconsensual episiotomy or coercion, or bullying, or scare tactics.”

Many doulas have similar stories, and often they only feel comfortable sharing them anonymously. An unnamed Alabama doula , speaking on the “Birth Allowed” podcast in 2017, described seeing a doctor straddle a laboring patient from behind as she leaned over her hospital bed. The doula says her client had declined a vaginal exam, and that the doctor told her, “So, this is how we’re going to do this,” before pulling up her skirt and forcing his hand roughly into her vagina from behind. “If that had happened outside of the hospital, he would be in jail,” the doula said. “We had all these witnesses. It was a sexual assault, and it was very sexual, the position of his body.”

Balazs says she has also witnessed sexual assault during birth, and she makes a distinction between “unwanted medical touching” of the vagina, which some consider to be sexual assault, and incidents that were overtly “sexualized.” “I have actually had very sexually explicit things said to people while they’re in labor,” says Balazs. “I can’t even describe how incredibly strange it is when you watch what can only be described as a rape, and then someone has their baby handed to them, and then it’s the best moment of their life.”

"I can’t even describe how incredibly strange it is when you watch what can only be described as a rape, and then someone has their baby handed to them, and then it's the best moment of their life."

Los Angeles–based doula Mychal Balazs agrees with this assessment. In her two years of attending births, she tells Broadly, she has seen every type of obstetric violence. Balazs feels that lack of consent in particular is overlooked as a maternity care issue and is one of the primary reasons for birth-related trauma. Balazs is most disturbed by a practice called “manual tearing,” which she says she sees often in Los Angeles hospitals. Rather than episiotomy, which involves a surgical cut to enlarge the vaginal opening, Balazs says she frequently sees care providers stretch and tear a patient’s perineum with their hands, even when the patient has not received an epidural, causing intense pain.

There is data that supports Varnam’s experience. A 2014 survey of over 2,000 doulas, childbirth educators, and labor and delivery nurses in the US and Canada found that almost 90 percent had witnessed a care provider engage in procedures “without giving a woman a choice or time to consider,” and nearly 60 percent had observed providers perform procedures “explicitly against the wishes of the woman.” Many outside the childbirth field find these figures difficult to believe. Varnam has struggled to convince people that the things she has seen were not simply the occasional errors of a few “old school” obstetricians. She says she has seen the same behavior from young doctors, female doctors, midwives, and nurses: It’s happening everywhere.

Most doulas agree that the issue of obstetric violence is especially severe for women of color, and that discrimination based on race, ethnicity, age, socio-economic status, and marital status are widespread in maternity care. Ravae Sinclair, a birth doula and attorney in Washington, D.C., who has attended births for nearly 16 years, says she notices providers being even more authoritarian than usual in their behavior when attending to families of color, giving them orders, questioning their choices, and assuming that couples are unmarried or uneducated.

As a new doula starting out in a Milwaukee maternity hospital, Sinclair says that what horrified her most were the lies — when doctors justified nonconsensual acts by falsely claiming that infant or mother had been in danger. More recently, Sinclair has found assertive ways to combat this type of misinformation, and she says more and more Black women want this kind of protection. Her Black clients tell her: “I want one day — me bringing my innocent child into the world — to not be infused with racism, with me having the burden of being Black. I don't want to have to manage anybody else's baggage, because what I am managing is labor, which is big.”

According to the CDC, Black women in the US are three to four times as likely to die from pregnancy or childbirth-related causes than white women. A 2014 report by SisterSong and other reproductive justice organizations found that “in some areas of Mississippi, the rate of maternal death for women of color exceeds that of Sub-Saharan Africa, while the number of white women who die in childbirth is too insignificant to report.” But across the country, the maternal mortality rate is steadily rising. The most recent ratio from the CDC is 17.3 maternal deaths per 100,000 live births — the highest in the developed world.

"Obstetric violence has been visited upon pregnant women by the people that they look to for help and guidance.”

“Why are women dying?” demands Dr. Katharine Morrison, an OB-GYN in Buffalo, New York. Morrison believes the answer lies in maternity care that is male dominated, unscientific, and often dangerous. She points to the C-section rate in the US, which is currently over 30 percent, more than double the figure recommended by the World Health Organization. C-section carries risks of complications and death that can be three times higher than vaginal birth. “It has to do with this combination of fee-for-service medicine and misogyny,” Morrison says.

In standard OB-GYN care, Morrison says, women are barred from making choices in ways that would be unthinkable in other medical situations. She believes the root of this approach, and of obstetric violence, is the idea that a mother and baby are separate entities, that the baby has “rights” that supersede his mother’s. “So all agency has been taken from women,” Morrison says. “And the people who have done that are obstetrician-gynecologists. Obstetric violence has been visited upon pregnant women by the people that they look to for help and guidance.”

Without help or guidance from the medical field to confront obstetric violence, women are turning to activism. Many in maternity care feel that only a consumer movement demanding respect and autonomy will curb the abuse; internal regulation is unlikely, they say, and state-by-state changes to criminal code would occur far too slowly. The national organization Improving Birth offers an “accountability toolkit” to help women file complaints about their treatment. And advocates like Cristen Pascucci of Birth Monopoly are working to publicize the stories of obstetric violence survivors. Pascucci is currently collaborating with Caroline Malatesta on a documentary film, Mother May I? focused on bringing this hidden epidemic into the light.

But the greatest weapon for pregnant people may be information, and birth doulas are often the most knowledgeable about local providers and hospitals. Many doulas say they refuse to work at certain hospitals and with certain doctors because of the abuse they have witnessed, and they endeavor to keep their clients fully informed without terrifying them. Others feel compelled to keep quiet, fearing their warnings could cause professional backlash. This cautionary role is not part of a doula’s job description, but it is becoming a critical one.