Rights & Consent

Vedam and colleagues at UBC ran the largest survey of US maternity-care mistreatment to date. The 2019 paper covered 2,138 women who had given birth in the previous three years. Across the full sample, 17.3 percent reported being mistreated by a provider, which works out to roughly one in six. The hospital-versus-home gap was striking.

Women who gave birth in hospitals reported a 28.1 percent mistreatment rate. Women who gave birth at home reported 5.1 percent.

The 5.5x gap is not explained by who chooses home birth, because the study controlled for demographics and risk factors. The specific behaviors reported included being shouted at (8.5 percent), being threatened with withheld treatment (4.5 percent), being ignored when asking for help, and having procedures performed without consent. The paper is one of the most-cited US sources on maternal mistreatment.

The Vedam team broke their mistreatment data down by race. The headline result: 32 percent of Indigenous women and 25 percent of Hispanic women in the sample reported mistreatment, compared with 14 percent of white women.

Black women in the sample reported being coerced into procedures without consent at roughly twice the white rate. The disparities held after controlling for income, education, and clinical risk factors.

This means the gaps are not explained by which kinds of women are more likely to have complicated pregnancies. They reflect differential treatment by the system. The pattern aligns with what shows up in maternal mortality data, where affluent and college-educated Black women still face worse outcomes than poor white women.

The Logan team analyzed mistreatment specifically in terms of coerced procedures, meaning procedures performed despite the mother saying no, or performed without her being given a real choice. Black women in the sample were twice as likely to report coerced procedures as white women.

The procedures most commonly described included episiotomies, internal exams, AROM (artificial rupture of membranes), and certain pharmacological inductions. The paper appeared in Birth, one of the standard journals for maternity-care research. The methodology was self-report survey, which has known limits but also captures the patient experience directly, which clinical chart review typically does not.

Hakimi and colleagues published a meta-analysis pooling data from studies of obstetric violence across multiple countries. The headline finding is that 55 percent of women worldwide report some form of obstetric violence during birth. The category includes verbal abuse, physical abuse, discrimination, and non-consented care.

Non-consented care alone showed up in 33 percent of the pooled sample. This is the first global-scale estimate that has pulled the regional studies together, and it is consistent with the smaller national surveys including the US Giving Voice work. The meta-analysis included countries with high and low income, public and private health systems, and varying maternity care models, which means the pattern is not specific to one kind of health system.

Episiotomy is a surgical cut to the perineum during the second stage of labor. It is one of the more common procedures performed without explicit consent. The Jacques team studied this directly in France and found that 60.2 percent of women who received an episiotomy reported that the clinician did not ask for consent before making the cut.

US data from ICEA, the International Childbirth Education Association, puts the equivalent number at 75 percent. Episiotomy has been associated with longer healing time, higher rates of severe tearing, increased postpartum pain, and sexual dysfunction lasting months to years. ACOG and WHO both recommend against routine use, advising the procedure only for specific indications.

Listening to Mothers III, the same 2013 survey of 2,400 US mothers cited in the interventions section, also collected detailed data on informed consent. Fewer than one in five women reported receiving complete informed consent for every procedure performed during labor. Across specific interventions, 15 percent of women reported being pressured into induction, epidural, or cesarean.

The pattern was not concentrated in particular hospitals or regions. It was distributed across the sample, which suggests the consent problem is structural rather than localized to a few bad facilities. The data has not been refreshed by a comparable national survey since, so the 2013 numbers remain the working baseline.

In 2014, the World Health Organization issued a formal statement declaring respectful care during childbirth a fundamental human right. The statement followed a decade of research documenting that mistreatment during birth was widespread enough across health systems to be considered a public health issue. The WHO defines respectful care to include freedom from physical abuse, freedom from non-consented care, freedom from discrimination, and the right to be treated with dignity.

More than seven Latin American countries have since enacted specific legislation criminalizing obstetric violence. The United States has none. There is no federal protection, no enforceable standard, and no formal definition of what constitutes mistreatment in a US labor and delivery setting.

Williams and colleagues published a review in BJOG covering the global landscape of obstetric violence legislation. Venezuela became the first country in 2007 to legally define and criminalize obstetric violence. Argentina followed in 2009.

Mexico, Bolivia, Panama, Brazil, Uruguay, and Costa Rica have similar laws on the books.

The laws vary in enforcement and reach, but they share a common structure: they define obstetric violence as a specific form of gender-based violence, list categories of behavior that qualify (forced interventions, denial of pain relief, verbal abuse), and provide a legal pathway for women to file complaints. No US state has comparable legislation. Federal law remains silent on the issue.

The Petrie-Flom Center is Harvard's bioethics and health law institute. Their 2025 analysis of forced obstetric interventions in the US starts from a sharp observation: pregnant patients are the only mentally competent adults whose right to refuse treatment is routinely overridden by physicians and the courts. Documented cases include court-ordered cesareans, court-ordered hospitalization of pregnant women who decline care, and court-ordered medical procedures on women in labor.

Florida had a high-profile case where a hospital obtained a court order for a cesarean on a competent adult who had refused it. The Supreme Court declined to take up the constitutional question in 1994, leaving the lower-court divide intact. The piece argues that this is a category of patient whose autonomy is being treated differently than any other adult in the health system.

The Kristeller Maneuver is fundal pressure: a clinician pushing down on the upper part of the uterus during the second stage of labour to speed delivery. The procedure has been associated with uterine rupture, third- and fourth-degree perineal tears, shoulder dystocia, and major pelvic floor injury. The UK banned the practice. WHO does not recommend it.

Youssef and colleagues published a 2019 case-control study in Ultrasound in Obstetrics & Gynecology that used four-dimensional transperineal ultrasound to compare women who had received the Kristeller maneuver against matched controls. Women in the Kristeller group had a 28.4 percent incidence of levator ani muscle avulsion (a tear of one of the main pelvic floor muscles, often missed clinically), compared with 14.1 percent in the control group.

After multivariate analysis, Kristeller emerged as an independent risk factor with an odds ratio of 2.5. The procedure is often performed without explicit consent. Many women describe being startled when it happens because they were not told it was coming.