Hello and welcome to FAB Gab. This is the podcast for the International Journal of feminist approaches to bioethics brought to you by fab Network. My name is Kathryn MacKay, and today I'm joined by Corinne Berzon, and Sara Cohen Shabot to discuss their paper entitled 'obstetric violence and vulnerability: a bioethical approach,' which is out in the recent issue of IJFAB. Hello, Corinne. Hello, Sara. Hi.
Thanks for being here.
Thank you so much.
My pleasure.
Let's get right into it. I wonder if one of you would like to give a kind of elevator pitch for the listeners about what this paper is about.
So essentially, Sara and I were working on a project around obstetric violence, which is really her area of very special expertise, and kind of thinking about it through the lens of vulnerability, which is a category imposed in research ethics that seems to have kind of bled into the treatment of women in general. And we kind of thought around whether certain understandings of vulnerability have impacted the prevalence of obstetric violence and kind of follow through different theoretical approaches to vulnerability, and how these may have impacted how frequently women are ignored and mistreated in the delivery room.
Yeah, I mean, if I can add something. Yeah, I mean, I would say I mean, I this article is part of a very broad research, a philosophical research on obstetric environments, which I am also very important parts of it. And I mean, I started by my research on obstetric relevance some years ago, because of personal, because of a personal experience, because my second birth, which was I consider it violent birth. And then I started to research with the tools that I have, which are philosophical, and then I really got into a territory, which was very unexplored. I mean, also, the, the recession of violence was only like being born more or less, but it's more of call, of course, in health sciences, sociology, etc. And this was my philosophical, like, take on this and super, I used a lot of I mean, maybe we could say more about it later, but I mainly use phenomenological tools. Also epistemic speak about epistemic injustice, and the epistemic tools. And I, what was, for me, amazing and enriching, very enriching about this meeting with Corinne is a bioethical analysis, and Corinne is, she's she works on ethics on feminist ethics, medical ethics. And this for me was very, very fresh approach, which is, of course, very important in this in the sub ject. But I mean, I didn't dare to do it myself. And I think this, this was a really, really good collaboration that we made together.
I agree. It was like a very natural kind of synergy between our two areas of study.
That's really cool. And I might come back to that and ask you some questions about that later, because that sounds really interesting. I think, first, I wanted to ask you some questions about the paper. I wonder for the listener. If you could just sort of explain first of all, what obstetric violence is.
Yeah. Well, yes. I mean, of course, in short, is this violent treatment that women received in medical scenarios, medical childbirth scenarios, and this concept of obstetric violence was born in Latin America, Latin America, activists with feminist activists were the ones who coined this term and also the last loss against violence have been made in places in Venezuela was the first place to bring a law. After that, Argentina Mexico also joined that, I mean, there's a lot to say in obstetric violence. The concept has been contested. It has been used as mistreatment. It has been also known as mistreatment and abuse. For example, the UN and the World Health Organization who had have recognized this panel I'm going on. Lately, they don't want to use so much the concept of obstetric violence. This is a concept which sometimes medical staff, it is hard for them. I believe this is a better concept than mistreatment and abuse in the sense that it it puts less responsibility, personal responsibility in doctors and medical staff and puts much more responsibility in a system in a structure, which allows violence. So this is one also one important thing.
The only the other important thing that I would like to say is that it takes many different forms. And of course, with very poor or marginal populations have suffered violence is more blatant, it's more brutal, it's more more easy, paradoxical is more easy for us to understand it to see it, to point it out. On like, what happens in our countries and in our populations? I say our because I mean, that's where Corinne and I, maybe you, come from, it, the system is much more subtle, in the form in which violence is performed. On these women, it's more a question of doing things, practices and interventions, which are unnecessary, and many times done without consent. And also the question of consent there. It's problematic because we know that if we don't recognize even these practices as violent, because they are very normalized, it's very difficult to resist them. So the question of violence in these wealthy populations, while these scenarios, it's more complicated for us to spot, it's more complicated philosophically to deal with.
And so for me, what was really remarkable about encountering this concept, I mean, I come from bioethics. And my specialty was on organ donation policy and, and late term abortion policy. So I've really been focused on like public policy elements of bioethics. And this, this felt deeply personal to me in a way that none of the other subjects that I've focused on have, because I do have four kids. And I've had, I've had four births. And every woman that I speak to, in any crowd of women, it only takes a few minutes before people start speaking about birth experiences about, you know, pregnancy experiences. It's such a common, global, almost no matter which society you come from which culture you come from, women are so deeply impacted by not being heard and respected during birth. That I find this topic just really resonates. And I feel it deeply and personally. And I think that's fascinating. Like, I'm listening now to The Retrievals podcast, and I was discussing necessarily leading up to, to our talk today how it just feels so important now that these conversations are being had. And we're talking about data gaps. And we're we're talking more about how women are ignored how their pain is ignored. And that this is even more exacerbated in the delivery where, where there's a fetus. And there's all these other things that are that are coming into play, where it's not even just a woman's voice that's being ignored as being like sidelined by this, like hyper over concern with the fetuses well being. And if we think about, if we think about medical mistreatment, like you would never, you would never tell somebody, you know that they are being forced to have heart surgery. Like someone could die meeting a stent, no one is going to drag them kicking and screaming, knock them unconscious and force them to have a stent. But when it comes to birth, there is this tendency of of a saying, Wow, you're not equipped, you're not thinking clearly, you don't realize the risks to the fetus as if that should totally outweigh a woman's autonomy over her body in that moment. So I, I do I do think that this is a very good time to be talking about this. And I feel like I'm hearing it more and more, which, which is, I guess, a very positive road forward.
Yeah, absolutely. That actually makes me want to ask you about the the other kind of main pillar in the paper which is vulnerability, because you're giving a vulnerability analysis basically, of obstetric violence in this paper and thought vulnerability is a very contested term. But we can easily imagine being in labor as being at a vulnerable point for a variety of reasons. You know, you're in pain, you're in a process that's not within your or anyone else's control. There's elements of unexpected things happening around you, then of course, there's the whole obstetric apparatus around you. So what was the addition of vulnerability here? What was the analysis based on vulnerability that you wanted to give here?
So really the question of vulnerability when I started looking at this question, with Sara, what really stood out for me is the medicalization of, of natural processes in women's bodies. So that menstruation is pathological. And the pain associated with it needs to be treated rather than accommodated, that childbirth is viewed as something that requires medical intervention, instead of communal support at home that emphasizes independent decision making. So I, I'm, I kind of have an issue with categorizing any woman's bodily function as an inherent vulnerability, I think that that's, like, therein lies the problem. Where, where a woman regards herself as vulnerable in that moment. So it's, instead of it being an empowering place where she can state what she wants, and express what her needs are, and be heard, and have choices put in front of her in a way that is clear and explained well, and not rushed over. To say, to the paternalistic treatment of this is what you need. And this is what we're going to give you because you are vulnerable in this moment. And we're going to help you that kind of paternalism, that comes from the terminology, which I think it is misplaced, because these are natural functions of a woman's body, we we can approach it differently. And of course, there are vulnerabilities situational vulnerabilities. As Sara mentioned, in marginalized populations in the you know, these experiences are far more prevalent among women of color women and, you know, in in the Global South, this is this is something that we, that we understand there are very special vulnerabilities involved. But these vulnerabilities are not specific to childbirth, they're not just purely situational, this giving birth does not inherently make a person vulnerable in a way that requires paternalistic care. If anything regarding vulnerability is something that needs additional, we write about scaffolding of creating a system, a systematic support system that empowers women to make choices, rather than than being bullied in the name of care. I think that that take on vulnerability is problematic. And that's kind of what we were trying to to address here. Of course, understanding that vulnerability is something that we all possess insofar as we're human, and we are subject to the societies and the environments and the lives that we lead. But when the language of vulnerability comes about care and paternalism and intervention and less about mutual obligations, then then I think that we we've kind of gone astray.
But that's great. And I mean, I think I will just just add that I, that I think that what also mainly Corinne did in this in this paper is to show how this vulnerability constructed as as something which infantilizes women has made, its has created like a snowball win, which women are recognized more and more as vulnerable, and those less and less like capable of you know, you cannot give them any medicines you cannot get you cannot taste on them anything because they are vulnerable. But then because of that, you start recognizing them as more as more vulnerable. And I think that what we try to make to make in the paper, it's also the this putting we're putting vulnerability into the context of feminist, the feminist philosophical research on vulnerability, which mainly sees vulnerability as a common as a common part of existence, of of human existence. And then tries, tries also to say, Okay, this has not to be part of also of the only of women's, women's existence. And at the moment that we recognize our shared vulnerability, we can offer really, as Corinne said, two different tools, which are not the paternalistic common tools for this, but more tools of solidarity of really common, common protection, respect. Yes, because, of course, the argument is not to say women in labor are not to be, strong enough not to be cared for, for example, so the pain is not vulnerability. Or, or yes, no, there there. I don't know, maybe even an essentialist, kind of saying on women, all they are like, these great goddesses, giving birth, they don't need anything, no, but their bodies? No, of course not, of course, women need help, and complications might come. And this is a vulnerable moment, that has to be encountered. By, again, respect here. Being with. Yes, I think this is a concept of vulnerability and protection and respect that we wanted to, to enhance in this paper.
So one of the movements that that kind of worked through was what vulnerability would apply to pregnant women. So what makes a vulnerable subject, what makes a patient of vulnerable, you know, a member of a vulnerable population, to be like for lack of medical knowledge, susceptibility to coercion, these types of things, and when you work it through, none of them really apply. This is it's a very unique situational vulnerability that can be generalized from like research ethics or from other types of fields within within medicine. And so a special consideration needs to be given here where, where we are acknowledging that it is a time where women require support. But, but that they are not, you know, they're not a permanent member of a vulnerable population by virtue of just being a birthing subject. So, so that kind of like objectification that comes from treating a woman as if she's incapable of going through this on her own without medical intervention, I think has, has kind of shaped the way we see obstetric violence occurring. You can think like that the response to the thalidomide scandal was not how do we include pregnant women in research safely? It was let's exclude pregnant women from research. So you know, that that kind of like heavy handed approach to women's health, I think has has perpetuated a lot of harm. And in that sense, kind of fits into which I found a very, very important contribution from Sara's research, it fits into this overarching kind of systemic violence against women. Which, which often goes unrecognized. And and as she mentioned, it's very, very subtle for for many of us. And that's why I found a lot of this. So eye opening, because I was like, Oh, wait, you know, you have to give consent to get an episiotomy. Like, you need to give consent to be given drugs that will hasten your contractions like, wow, you know, who would have thought that we had so, you know, so much autonomy to make choices about our bodies, even as we're acting as vessels for these new lives. So, so I found that really remarkable, huh?
Yeah, that's really interesting. Something that I was thinking about while I was reading your paper is that there's, through all the talk about vulnerability, there's, and I've read some of the other literature that you've referenced as well, there's sometimes not a reference about what a person is vulnerable to. And I'm always curious about what it is that we're vulnerable to. So it's interesting in this paper that you're pointing out, like women are vulnerable to the disrespectful actions of other people, but that's not the same thing as being vulnerable to pain. As you said, Sarah, like, yes, of course in labor, you will have pain and you need help with that. But that's a completely different notion of vulnerability here like I don't know I just see those things as maybe you needed to come apart or something.
Yeah. So yeah, I mean, the generalized vulnerability like, we are vul- like we can be mugged. So in that sense, we're vulnerable, as you know, you know, creatures walking in the world. But this kind of special category of vulnerability, where we're doing things that are totally normal, natural. And that can be, you know, as Sara mentioned, complications can arise there, you know, not to diss the whole medical establishment of childbirth, you know, we know that outcomes are significantly better now than they were 100 years ago. That's, that's like not even, not even a question. It's more about how ascribing vulnerability diminishes autonomy in that moment. And whether vulnerability, as conceived is not having the opposite effect that instead of augmenting agency in moments of vulnerability, it's diminishing agency in moments of vulnerability.
I am aware of how this is not very simple, mainly in the ethic, value ethic context and medical context. Who makes the decision? Of course, there is also there are questions of knowledge, I think the question of knowledge here is very important and very relevant, because I think sometimes when I speak with my students about these structural barriers, and I say, for example, when you get into the hospital, yes, and you come for, for example, heart surgery, and so you don't come and and tell the doctor, you know what, I will prefer you to do the surgery, like vertical and not horizontal in my chest, because I think that's better for me, there is a there is one of the authority who you trust, you trust their knowledge, to a certain point. But women come to birth in hospitals without a tautology. And they come, at least with a certain knowledge, if not with a very good knowledge of what is happening in their bodies. And this, they should be considered being in a totally different position, that somebody who comes from heart surgery, right. And in that sense, they shouldn't be vulnerable in the sense of you don't know anything, or you don't have the knowledge and epistemic authority here. It's a very important point.
I wanted to ask you a question just about sort of about this paper, kind of about how you came together? Which I also wonder is, if maybe it's connected to a question about whether or not there were any challenges for you in writing the paper? Like, was there any challenge that you faced in blending your two different approaches and methodologies together?
I don't, I don't have like the depth of knowledge of like phenomenology in the philosophy behind behind obstetric violence, which there has been like fleshing out for years and years. And so it's like, I don't even necessarily have the language to fully understand this approach. But, but I spent a lot of time reading through the works to see the citations or, you know, there's like a whole body of work on this that Sara's authored. And and, and even though I haven't mastered that language, that that philosophical language, I think it contributed so much, to understanding how we got where we are, why we are where we are, and kind of giving like a lens to this perspective, because if we're trying to solve for a problem, it's not super helpful to have to have a very limited surface understanding of the problem. And so I really appreciate the depth that went into this kind of philosophical consideration of what's happening to women.
No, of course, it's easier to respond to this question, because of course, I mean, I mainly brought my already done work on obstetric violence, these informed coordinates coincide. Yes. And yes, she was the one to bring, as I said, In the beginning, this ethical, medical ethical, theoretical approach, informed by feminist also concepts, of course, and so it was very super enriching for me. i i It's very, it's very bad to say that I love this paper, sorry. I'm sorry to say this, justifying for myself, I think. Yeah, I think it's, it's an important one. And of course, if it gets also into the ethics realm it's which is more really more practical, more, more, more practical directive, and it's I think it's very important to have this kind of work ah, outside there. Yes. Yeah. That's cool.
Then in terms of challenges, they were significant, because they said, there was like a global pandemic that started, I think I was supposed to start like January 1, and by March, the world was shut down. And we live three hours apart by train, like the Haifa University and where I live. So the, you know, with public transportation shut down during the pandemic, university shut down, no, in person classes, no one person conferences, or even have older children in the house in the house. My partner was in a different country for most of the pandemic, and I was home with four kids. And I, you know, was laid off from my day job, like, it was a whole package of, of stuff. And in Sara's, and she was dealing with her own, you know, workload and personal life, like it became difficult just because of the situation that we found ourselves in, along with the entire world. But also, that was kind of put a spotlight on how important this work is. And even even in a more general way, you know, in the wake of the pandemic, understanding how female academics struggled so much to publish and get their research done, that the publication rate for women decreased dramatically during the pandemic, whereas that event increased dramatically during the pandemic, as they just like, kind of, not to generalize, but that it was like more, I guess, easy to kind of close the door to your office and delve into work. When the the burden of home is not, you know, squarely on your shoulders. Again, I resist kind of making these generalizations, but I think the data backs that up. And so much has been said about it. And there's been so much data to kind of show it not to bash male academics, but to say that the situation's of our lives are so different. And the pandemic really shone a light on that, that where we felt, you know, maybe beforehand that we'd achieved the sort of equity and health and professional equity, and a shifting of, you know, household responsibilities that made it more possible for, you know, women to, to progress in their careers and, and the pandemic kind of said, like, not as much as you think, not as much as you think. So I think the challenges as much as they were, and I can like, really distinctly remember, like, typing away on my computer with like, kids screaming in the background, and like, you know, not being able to, like it was it was for sure, chaotic, but at the same in the same, you know, the other side of the coin is that it was even more important, and even more impactful. And it felt and it resonated even more deeply. So I think the outcome, the final version of the paper, is probably more more fine than it would have been without those challenges. And also, the reviews really helped us right, yeah, or the reviewers were were were exceptional, like, really allowed. I mean, I can't I can't speak for you, Sara. But for me, it allowed me to really, really clean up my understanding of this concept, and approach it from a much more critical place.
Well, that's great. It's always really good to hear that and I think, hopefully is encouraging to maybe less practice scholars to hear that reviews can be friendly and helpful. Not always scary.
I wouldn't go so far as to say friendly, but definitely helpful. Okay. No, it can be hard, it can be hard, it can be hard to go through a few rounds of review, but that's, you know, that's that's academic review is there to, you know, to make it better. And I really did feel that with us that the that the critique was there to lift it up and not to push it down.
Nice. Well, I wonder if there's anything that you really hope like, if there's just sort of like one idea that you really hope that readers will take away either from just listening to this podcast or from reading the paper? What's your sort of takeaway message,
As this I would say this, adopting a different idea of vulnerability regarding women and subjects in general and of course labouring women, and going more for, like an understanding, feminist understanding of, of how to treat vulnerability and what we're asserting childbirth. And yeah, and putting into context of course, this medicalization of childbirth, and the, the, the, the, the challenges that it presents and how to approach them.
So yes, I actually in preparation have been was was listening to another talk of Sara's on shame in the context of childbirth, and and, you know, reading other research now around data gaps around women's pain in medical situations. And that the kind of deeply embodied experience of women as patients. So I'm I kind of hope, I kind of hope that women read this paper, not that men are not also going to read it. But my takeaway I would like there to be as that a woman reading this paper is able to regard her own experience, through a different light that this shame that women associate with their own bodies, with their, with their births, with their, with their menstruation, with their pain, that that that feeling of shame that so many women carry and and make them less able to stand up and say, No, this hurts. No, I don't want this. No, this is my choice to have the kind of validation that we're allowed to do that, and that we have to do that. And that the expectation is that medical practitioners will listen to us. I hope that this contributes to a growing body of literature, supporting women and making those kinds of choices without feeling shame. And without looking at themselves as difficult as a difficult patient as an unwieldy, shrill person that needs to be managed. And I think our tendency to regard ourselves that way is very, very difficult to overcome. So if there's any takeaway, I want to come out of this, I hope I hope that it contributes to that kind of shift in perspective.
Yeah, amazing. Me too. Well, thank you so much for speaking with me, Sara and Corinne. This has been super interesting.
Thank you so much, Kathryn, for inviting us.
Yeah, my pleasure. And thank you for listening to this episode of FAB gab. You can find Sara and Corinne's paper linked in this episode's notes along with a transcript of our discussion. FAB Gab is hosted and produced by me Kathryn MacKay. You can find our other episodes on Spotify, Apple podcasts, or wherever you get your podcasts of quality. And you can subscribe to fab gab so that you'll never miss an episode. Thanks again for listening. Bye
