Episode 02

The Fight for Reproductive Justice

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Too often, treating women with respect is seen as a luxury. It is not. Violations of human rights during childbirth are all too common in labor wards, hurting women’s chances of surviving pregnancy and childbirth. This episode of White Ribbon Alliance’s Brave Voices, Bold Actions podcast explores Article 2 of the Respectful Maternity Care Charter, and the human right to information, informed consent, & respect for choices & preferences, including companion of choice during maternity care & refusal of medical procedures.

We hear from Monique Lacombe, who bravely shares her birth story and the damage caused by the disrespectful treatment she received at the hands of her healthcare providers, and reproductive rights advocate Isabel Fulda, who is working with GIRE Mexico to end obstetric violence in Mexico and beyond. Together, we have the power to destroy the structures that harm women during pregnancy and childbirth!

Topics

  • NWhat is obstetric violence?
  • NHow does framing mistreatment in childbirth through the reproductive justice lens help save women’s lives?
  • NWhat can governments and individuals do to ensure all women and newborns receive the respectful, dignified care they need during childbirth?

Resources

What Women Want Advocacy Agenda | What Women Want webpage | Respectful Maternity Care Charter endorsement | Monique Lacombe: in her own words | GIRE Mexico’s The Missing Piece: Reproductive Justice (English)

Alternative Naissance: Monique Lacombe volunteers with Alternative Naissance, a community based not-for-profit organization which has been working with women and families throughout Montreal, Canada since 1982. Its mission is to offer women and future parents a chance to experience a human approach to childbirth. Alternative Naissance offers services and activities which promote awareness about your rights and choices as a pregnant person. Find out more.

Diana Copeland (00:05): Too often, treating women with respect is seen as a luxury. It is not. Respectful care and a life free from abuse is due to every woman and every health system around the world, no matter what. Not only is respectful care a right, it is also vitally important to improving women's chances of surviving pregnancy and childbirth. On White Ribbon Alliance's Brave Voices, Bold Actions podcast, we're taking a close look, episode by episode, at the 10 basic rights women and newborns are due in childbirth. We'll use the respectful maternity care charter as our guide. Every episode, we'll dive into each one of the 10 articles, exploring what respectful care really looks like. My name is Diana Copeland and I work with White Ribbon Alliance, a locally led, globally connected grassroots movement, advocating for the health and rights of women and newborns.

Diana Copeland (00:59): In each episode of the Brave Voices, Bold Actions podcast, I'll be joined by White Ribbon Alliance colleagues from around the world, global human rights advocates, and community leaders creating real change. Together, we'll show you how to advocate successfully for yourself and for others wherever you are. Today, we are examining the right to information and informed consent with reproductive health advocate, Isabel Fulda, and chatting with human rights lawyer and our resident expert on respectful care, Elena Ateva, on the importance of choice during childbirth.

Diana Copeland (01:31): First, what happens when those rights are ignored? Monique Lacombe lives in Montreal, Canada. During her first pregnancy, Monique tried to prevent anxiety by not over researching. She assumed that the professionals would know what to do and that she could get answers to her questions as they came up.

Monique Lacombe (01:49): So my very last appointment with my OB/GYN, I think I was at 42 weeks and three days, if I'm not mistaken. And as my doctor was doing the internal exam, she said, "Well, maybe we should sweep your membrane." And I said, "Well, what is that? What does that mean? And what does that imply?" And before I'd know it, she'd done it. And I felt something. And then she took her hand down, and she's like, "Okay, that should move you along." And I was like, "Well, what did you just do?" And so she explained to me, and I said, "Well, I didn't even know what you were doing. I didn't say that was okay." And she was like, "Oh, don't worry. It's going to be fine. This will be the best way for you to..." And so, I just remember feeling, for the first time, a little bit like something wrong had happened.

Diana Copeland (02:42): Partway through labor, Monique said new orderlies and doctors just kept streaming in and out of her room.

Monique Lacombe (02:48): Each new person that came into the room, without asking, just sticks their hand right in you and starts checking around to see how you are. And it's just like, "Who are you? And what are you doing here?" "Oh, don't worry. We're just checking to see how far along you are." And I just thought, "Don't you have to ask?" And so, I remember at about mid day, I started saying to them, "Look. I can cooperate. We can work on this together. But you need to tell me what you're doing, or you need to ask me to do what you want to do. You cannot just impose yourself on my physical being without even introducing yourself or telling me what you're doing here."

Diana Copeland (03:24): Things started to go downhill as Monique was rushed into a C-section.

Monique Lacombe (03:28): And the room fills up with people. There was like 12 to 15 people, all of a sudden come into the room, and they put paperwork on my chest, and they're like, "We need you to sign this." And it's four or five pages of print about this big. And I said, "What is all this?" And they're like, "This is a waiver for the surgery and blah blah." And my husband's with me. He's in shock, he doesn't know what's going on, but he's trying to be... And I was just like, "How do I sign this? I'm exhausted. And now the epidurals running out, I'm in horrible pain." My husband basically explains to me the broad strokes of the paperwork. And it was basically like, "You have to sign this or your baby's going to die. We've got to get you into surgery."

Monique Lacombe (04:08): So I signed the paperwork, and I gave it back to the orderly, and then they said to my husband, "You have to come with us. We have to get you ready for the surgery." And then they took me away, and I just... It all happened so quickly. And the next thing I know, I'm in the elevator, and I'm surrounded by, there must've been, eight to 10 people that are coming into the surgery room. And they're all talking to each other about their weekend, and about what they'd eaten that day. And I'm in tears lying there, and I'm looking around and nobody's talking to me, nobody's... And I am, for the first time in my life, feeling so weak and vulnerable. I've never felt that weak and vulnerable in my entire life. I would describe myself as a very strong person. And I've always been somebody who justice is really important to me. And all of a sudden, I just felt so powerless. And I just thought, "What's going to happen?"

Diana Copeland (05:14): Article II of the Respectful Maternity Care Charter says that you have the right to the information you need to make the best decision possible for you and your baby. You deserve to have your choices upheld, no matter what. It is important that you know that no one is allowed to force you or do things to you or your baby without your knowledge or consent. You have the right to a companion of your choice during maternity care, and you can also refuse medical procedures.

Diana Copeland (05:51): Joining us on our discussion on the right to respectful care is Isabel Fulda, a reproductive rights advocate based in Mexico City who holds a degree in Political Science and International Relations from the Center for Economic Research and Teaching, as well as a Master's Degree in Legal and Political Theory from University College London. Isabel joined GIRE, the Grupo de informaci�n en reproducci�n elegida, a Mexican reproductive health organization, in 2012 and, as of March 2020, is their Deputy Director. Welcome, Isabel!

Isabel Fulda (06:23): Thank you very much. Thank you for the invitation. I'm glad to be here.

Diana Copeland (06:27): That's wonderful. I know you've done incredibly important work, especially around the idea of obstetric violence. This term might be new for some listeners. Can you let us know what obstetric violence looks like?

Isabel Fulda (06:37): From a women's rights perspective, we've been speaking about mistreatment during pregnancy and childbirth for many, many years. And obstetric violence comes like a new concept, I guess, in this conversation. It's a form of institutional violence that happens during pregnancy, childbirth, and puerperium. And the idea of speaking about obstetric violence as opposed to individual mistreatment or maternal mortality, for example, that is a very used term as well, tries to shed light on the structural nature of these types of violence. There are different examples of obstetric violence. It can be where women are not allowed to have quality services or services at all of different types of procedures that are not consented by women. So we have different examples of practices that can be obstetric violence, but in general, it's a form of violence against women, and it's a violation of their human rights, and it happens in the space of health services.

Diana Copeland (07:44): I'm curious now how doctors and health providers react when they find out that something they've always done or how they were taught is actually completely inappropriate and harming women. How do they respond to that?

Isabel Fulda (07:58): This resonates very much with most women, if not with all women. We all know, if we haven't experienced individually a situation like this, we know someone who has. But that doesn't happen the same with doctors. We have found a lot of resistance, specifically because doctors, they can maybe recognize that some of their partners or they've seen this type of situation, they very rarely recognize that they've done it themselves. And they tend to be very defensive around it. We do not believe that in situations of such a structural nature, it is appropriate to punish individual people.

Isabel Fulda (08:40): There are some extreme situations in which this could be appropriate, but in general, we do not think this. But we have found a lot of resistance from health care personnel, which are suspicious of the way that we work, because they do believe that they can be criminalized. So it is challenging to not find this resistance. We have found a better reception of these ideas with young doctors or with young nurses, people that are still in education, as opposed to people that have been working in this aspect for many years. But of course, we have some allies. But it is difficult.

Diana Copeland (09:20): What causes obstetric violence?

Isabel Fulda (09:23): Obstetric violence is caused by multiple factors. It is related to structural inequalities and different forms of oppression against women. Of course, gender inequality plays a very important part. The fact that health providers normally do not work in good conditions, they work very long hours. It's a system in general that is prone to enable different types of abuses. And it is related in gender inequality, but also other forms of inequality. A very crude example of obstetric violence and very relevant historically is forced sterilization. And we know that this, in countries like Mexico and in Latin America, has been related, for example, to race. So historically, indigenous women have been sterilized, the same as women with disabilities. So we know that these types of practices are also related to racism, to homophobia, to ableism. So it's a form of violence that is result of different types of forms of oppression.

Diana Copeland (10:34): Because I am curious too, in an ideal world, what could a country or a funder or donor do to incorporate a reproductive justice lens into their work, and make sure that these sorts of structures are removed?

Isabel Fulda (10:47): There are many things that that can be done. I think a very important, very strong one is listening to women's testimonies. I think that a lot of these legislation, public policy, judicial solutions are done from a top-down perspective, in which they seem to be thought of as technical solutions. But very rarely do states or other groups listen to actually women's experiences. And women's experiences have many things in common, but they're also very diverse. And in listening to them, we can shed light to some things that maybe medical doctors cannot see. I think another very important thing is this intersectional lens. So not only looking at cold numbers, I would say, and not only looking at, for example, when we see the goals that were set up in the international arena, they are normally very simplified.

Isabel Fulda (11:52): The development goals tends to be a number for the whole country. And I understand why that is, but I think that if we look at specific context, we need to see who is being affected by these types of violence. Is it young women? Is it indigenous women? Is there a racist aspect of it? And what are the differences between the urban and the rural care that they get? Listening to midwives can also be very, very important. They have been silenced for many years by the health system, at least in Mexico and in Latin America. Maybe in other places, not so much. So we do need a more sophisticated lens to speaking about this, and one that is more based on people.

Diana Copeland (12:41): It's definitely not a one size fits all solution at all. It really does need to involve women, girls, community members to create this change. But I'm also curious about what an advocate listening at home could do right now to ensure that women's rights and women's voices are listened to and upheld in the community, not only during childbirth, but beyond.

Isabel Fulda (13:04): Something which is often overlooked, but is very, very strong for cultural change, is simply speaking about these situations. We try to do that and to promote these types of conversations, but this can obviously happen also within families and within communities, speaking of what we normally think of as normal and actually questioning that. And this does not have to be a conversation that only happens within women's rights groups or human rights organizations. This is a conversation that can happen, as I said, between parents and their children, that can happen between friends.

Isabel Fulda (13:33): We think that actually putting a name to this and having, for example, grandmothers speak about what their experience was like with childbirth, but also with marriage, with gender issues in general, can be very, very strong. Right now, I think, with the COVID pandemic around the world, we've had very important conversations about, for example, the domestic work that is done when we stay at home. And I think that these conversations, they can be done in very small groups or in a more large environment, but they can be very, very strong to actually understand what we have normalized and what types of relationship we have created, and to maybe start thinking of new ones or new ways to structure the world.

Diana Copeland (14:28): Do you feel that the COVID-19 crisis has put a mirror to so much of what has been pushed under the rug? We now can't look away. And I'm really curious about how GIRE in particular is working to overcome the challenges to human rights that we're seeing now every day in the news, because of COVID-19.

Isabel Fulda (14:50): Yes, definitely. I think that the COVID-19 pandemic has shed light on so many things that maybe we knew, but they weren't so evident until now, housing issues inequality in general, the problems with the health care system in general in the world, but also in specific countries, the specific situation with certain populations, such as sex workers, trans people, migrants. So I do think that, in a way, we can see the structures better in a situation such as this. One of the biggest challenges that we're facing now regarding the pandemic has to do also with what happens when things like the complaint mechanisms and the health system that exists now are shut down because of a crisis.

Isabel Fulda (15:48): So in the situation in which we are now, the judicial system in general is stopped, maybe for certain emergency aspect is still working. But in general, a lot of the institutions that we tended to work with in specific cases of mistreatment or of sexual emergencies are now, in a way, detained. So the idea is to document what actually happens during this time. But of course, we are limited by the situation that we're in, staying at home, no travel. As I said, these mechanisms are not working. So it is going to be very challenging times. In particular at GIRE, we are trying to get information from different groups that work with women's rights in order to do a platform where we can document different types of human rights solutions and the response that the state has been giving different groups related to women's rights.

Diana Copeland (16:58): I don't want to take up too much more of your time, Isabel, but I did have one more question.

Isabel Fulda (17:03): Yeah, of course.

Diana Copeland (17:06): Great. With things so hard and difficult right now due to COVID, but also because of the work that you do, I'm curious about how do you stay positive as a positive force for good in the world. You're doing so much for the women of Mexico. It must be difficult.

Isabel Fulda (17:22): Thank you. Thank you very much. Well, it is challenging. It is difficult to remain focused on the work that we're doing during these times. Of course, we're all worried about individual situations and context. And at the same time, we have find difficulties in our work right now, because a lot of the important things that we tend to use in our work are stopped. But I think a very important thing to stay positive is to try to be focused on why we're doing what we're doing and remembering how it has an effect on women's lives, a very direct effect. Some of the strategies that we do, maybe we don't feel it as direct because we only see the results 10 years later. And some things can be maybe more immediately satisfying because we can see that we changed the family's life in a more immediate sense. But trying to stay focused on the reason why we're doing this, I think is very useful in this sense.

Diana Copeland (18:30): I agree. And I just want to say thank you so much for coming on the podcast and sharing so much about GIRE's work and the work that you do, because I find it so inspiring that there are women like you out there doing so much to help other women and girls, and just making communities that are open, and respectful, and based on human rights. So, thank you so much, Isabel.

Isabel Fulda (18:54): Great. Thank you.

Diana Copeland (19:04): And now I'm happy to welcome Elena Ateva, my friend and colleague, a human rights lawyer, and the convener of the Respectful Maternity Care Council. Welcome Elena.

Elena Ateva (19:13): Hello, Diana.

Diana Copeland (19:15): It's great to have you on. And it's also great to have you share your advice on Article II, which is everyone has the right to information, informed consent, and respect for their choices and preferences, including companion of choice during maternity care and refusal of medical procedures. Let's talk about this. I think it's a very important article, and there's a lot in it. So can you break it down for us a bit?

Elena Ateva (19:37): Sure. Of course. Yes. In my opinion, this is probably one of the most important articles because so many of the other articles depend on this one. Whether you receive enough information to make your decisions, and then once you make a decision, whether that decision is respected, as well as whether you can have somebody close by, whether it's your partner, your husband, your sister, your mother, with you in the delivery room. Because it's such a critical time to have support, and to have support from somebody you know well.

Diana Copeland (20:13): We know that respectful dignified care was the number one ask from the What Women Want campaign, but how exactly does having informed consent contribute to a respectful, dignified experience?

Elena Ateva (20:26): It is such an uncertain time. You need information on what's happening with your body, because you don't know, especially the first time, you don't know what will happen. And they rely on medical professionals to supply that advice. So it's really critical for providers to take the time and explain what's happening, what should be expected, even well before birth starts. Informed consent is really building that trust between you and your provider. So that's a really critical part of understanding informed consent, is that this relationship building this trust needs to happen well before childbirth. Informed consent for the individual is also about in the moment, when procedures are proposed, or somebody is asking you to do something, that you have an option to continue asking those questions. And some examples of what those questions could look like to give you enough information to make a decision could look like that.

Elena Ateva (21:34): You can, for example, ask what is being proposed. Is it a procedure or treatment? And what is that procedure or treatment addressing? Now, what would be the benefit to you or your newborn? That might be a next question. And what happens if this procedure or this treatment is not successful, what are the next steps? You also need information about the risks or the side effects. Every intervention might potentially have side effects. So you need to understand those before you can make a decision. And then you can ask about any alternatives. Again, that might not be the only intervention or the only procedure or treatment suggested. Maybe there's something else that can be done, including waiting or doing nothing. How would that affect the outcome?

Diana Copeland (22:24): You also have the right to change your mind.

Elena Ateva (22:26): Absolutely. Maybe you agreed to a procedure, but you don't like it, doesn't work for you. You have the right to change your mind and to say, "No, I changed my mind, and I don't want to proceed with this course of action." You have a right to refuse procedures, treatments, interventions. It is your body. It is really critical to have somebody with you during the moments of childbirth, and even postpartum, to have that support. If you're pushing at the moment, for example, and you can't do that, somebody that knows your preferences and knows your decisions, but can articulate them on your behalf if needed, or just somebody who can help you and support you emotionally while you're going through a life changing experience. And sometimes, unfortunately, this is what happens when there is a partner in the room, he might be asked, "Talk to your wife," or, "Talk to your girlfriend. You need to convince her she needs a C-section."

Elena Ateva (26:20): And I think sometimes, providers are genuinely concerned, and sometimes providers really lack skills that can help a woman in a situation. There's so much that midwifery brings to the table, where simply turning a woman on her side might actually improve the vitals for the baby, simple things like that. But if you don't have those skills, you don't know to do that, so maybe you're genuinely concerned and you want... But sometimes, I think it's really abusing your position of knowledge and power. Because the woman doesn't know what the readings on the machine mean. She doesn't know what's really happening. And if you tell a mother, "Your baby might die," she'll say, "Cut me open. I don't care. Just help the baby." Of course she'll do that. But that shouldn't be what we ask of women, right? A woman should not be asked to sacrifice herself for her newborn, yet that's very often what we expect mothers to do. And that's the very first moment of realizing your motherhood, when you're giving birth. So it's sad that that's the... There's so many subtle ways to pressure women.

Diana Copeland (25:05): What would you recommend to the people at home, so that they can uphold their right to information, informed consent, and choices, including their right to a birth companion?

Elena Ateva (25:16): Yes, absolutely. I think you do have to become your own advocate. Make sure you use every opportunity during prenatal appointments to talk with your healthcare provider and to establish that relationship of trust. If you don't feel comfortable, you need to maybe look for other care. And that is the time to look for other care, while you're still pregnant. You don't need urgent assistance and you have your choice. It is hard. I want to recognize that it's hard to advocate for yourself. So there are other ways you can join forces with other women to access women's support groups, access childbirth preparation classes, create that community that can also help you both to identify good care providers, care providers that you can trust, and also to help you as you're navigating pregnancy and childbirth, especially the first time around.

Diana Copeland (26:20): All right, Elena. Thanks so much for joining us.

Elena Ateva (26:23): Thank you, Diana.

Diana Copeland (26:26): This episode of Brave Voices, Bold Actions was produced by Diana Copeland, Elena Ateva, Stephanie Bowen, Nina Garcia Wright, Kendra Hanna, with support from the entire White Ribbon Alliance team. Our theme song is called Mama by Eric Wainaina, and can be found on White Ribbon Alliance's "Advocacy in Audio." Learn more about the Respectful Maternity Care Charter and find links to more resources at whiteribbonalliance.org/bravevoicespodcast.

Episode Team

This episode produced by Diana Copeland, Elena Ateva, Stephanie Bowen, Nina Garcia Wright, Kendra Hanna, with support from the entire WRA team. Special thanks to Lorraine Fontaine from Regroupement Naissance-Renaissance, Canada.

HOST

Diana Copeland

Senior Communications Officer

Diana Copeland joined White Ribbon Alliance in 2016 as the Communication Coordinator, working to strengthen and disseminate the organization’s message on its website and social media platforms, and was promoted in 2018 to Senior Communications Officer in order to oversee and grow White Ribbon Alliance’s digital and offline presence.

GUEST

Isabel Fulda

Deputy Director, GIRE

Isabel Fulda holds a degree in Political Science and International Relations from the Center for Economic Research and Teaching (CIDE) and a Master’s Degree in Legal and Political Theory from University College London (UCL). She joined GIRE in 2012 and, as of March 2020, holds the position of Deputy Director. Previously she has worked as a research assistant, as well as in consultancies related to gender issues and human rights. Follow Isabel and GIRE on Twitter at @GIRE_mx.

CONTRIBUTOR

Elena Ateva

Advocacy Manager

Elena Ateva is the Advocacy Manager at White Ribbon Alliance and the Maternal Health lead for the USAID/Health Policy Plus Project. She is responsible for facilitating the work of the Global Respectful Maternity Care Council, leading global advocacy efforts to strengthen the midwifery workforce and providing assistance to WRA National Alliances that campaign to improve reproductive, maternal and newborn health and rights. Elena is an attorney and a human rights advocate who has been involved in the movement for respectful care in her home country, Bulgaria, and throughout Eastern Europe. Prior to joining WRA, Ateva was the Eastern Europe Legal Advocacy Coordinator for the international non-profit Human Rights in Childbirth and later served on the board of the organization. Her work has also focused on prevention of other forms of violence against women, including domestic violence and trafficking in Bulgaria and the United States.

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