Obstetric Violence as Ontological Boundary Work in Second Trimester Pregnancy Loss

An interrupted pregnancy, which ends before its expected time without a living baby, has the potential to offer insight to social science about experiences of pregnancy loss, and also about normative pregnancies which do not end in this way. My ethnographic work with women in England who experienced miscarriage, foetal death, premature labour, or termination for foetal anomaly describes pre-viability second trimester pregnancy and loss as a distinct phenomenon which exists in relation to ‘normal’ pregnancies which end at term. My book based on this research describes a teleological ontology of pregnancy as it becomes visible through the site of second trimester pregnancy loss. This ontology underpins biomedical and legal discourses in which a ‘real’ baby is one which is born alive, or after UK legal viability at 24 weeks’ gestation. In this model, foetal beings born dead or which die before viability are not understood to be ontologically ‘real’ persons, and the pregnant women in whose bodies they gestated are consequently not understood to be ‘real’ mothers undergoing ‘real’ labours and deliveries. At the same time, second trimester pregnancy losses are usually managed in the English National Health Service by vaginal delivery, often induced through the use of Mifepristone and Misoprostol, and the process of labour and birth is similar to full term birth.

Experiences of obstetric violence in second trimester birth

For the women whose experiences of obstetric violence are described in my book, there was a tension between their embodied and social experiences of a developed pregnancy and a labour and birth, and the way their loss was managed in clinical contexts. Their stories resonated with understandings of obstetric violence as violations of integrity targeting women’s pregnant and birthing bodies.

Women’s exclusion from institutional NHS care started when they had difficulty accessing medical attention for concerns during the second trimester, a time when very little can be done to maintain a pregnancy which is ending, or to ‘save’ a pre-viable foetal being which cannot survive outside the pregnancy. Pregnant women’s own needs at anxious times were downplayed. The use of space and bureaucracy in clinical encounters labelled their experience as deviating from the norm, but also repeatedly placed them alongside women whose pregnancies were proceeding normally. Women experiencing pregnancy loss were shuffled out of back doors, or asked to justify their presence in spaces, expected to sit digesting bad news alongside those who were celebrating their pregnancies, or to labour and deliver their dead babies within earshot of the cries of living babies. Their difficulties in accessing the spaces of care cast doubt on their integrity as pregnant women.

In advance of labour and delivery, women were underprepared by clinical staff for the experience of labour and birth, its duration, the levels of pain they might experience, and the risks to them of this mode of delivery. This form of loss management frequently did not involve fully informed consent:

I thought it was gonna be like what the lady said, be a couple of hours, a few period pains. God knows I didn’t know what to expect. […] Why not tell me the truth?  […] It was a shock when I went into what I classed as full on labour.

                                                                                              ‘Amber’

The ‘full on labour’ many of my participants went through was not managed with the pain relief available to full term labouring women. Many labours were managed with just paracetamol for long periods or throughout, even though research and guidelines say this is ineffective. Epidurals were usually not an option. Women were not offered medical support during labour and were routinely left to labour and birth the foetal being alone:

I had no midwife, I had no-one. I had [husband] and my mum. And I had no idea what I was doing. I’d never had a baby before. I just had, I was just completely clueless. […] And the nurse basically just said ‘when it’s happened, come and get me and I’ll sort it out.

                                                                                               ‘Bethany’

For some women, management of the event of loss was in specialist pregnancy bereavement suites, but for many others the labour and birth happened on gynaecological wards or even general wards, where there was less access to support, pain relief such as gas and air, or experienced staff. Sometimes this led to judgemental or unsupportive attitudes from staff which reinforced the sense that what had happened was a deviance from the norm:

She said ‘he’s intact, you know, he’s all in one piece and he doesn’t look that scary.’ She said ‘if you want to see him you can. It’s better to do it now,’ she said, ‘because I’m more comfortable doing all the preparation to bring him, whereas some of the nurses aren’t 100% comfortable.’

                                                                                                ‘Phoebe’

Obstetric violence as ontological boundary work

These forms of treatment illustrate how mistreatment, disrespect, and obstetric violence overlap in the management of pregnancy loss. They also provide insight into underlying cultural ideas about what is happening in second trimester loss, and in pregnancy more broadly, which I argue reveals how obstetric violence can perform a specific type of work in clinical settings.

Obstetric violence has been described as prompted by the prioritisation of foetal wellbeing over the pregnant woman’s autonomy. However, in second trimester pregnancy loss, before foetal viability, the motivation to perform obstetric violence cannot be the wellbeing of the foetus over that of the pregnant woman, since the foetal being will die in most circumstances anyway. I argue that what is happening here is that decisions have already been made about the ontological status of second trimester loss in relation to it not involving a ‘real’ baby, because the foetus will not survive. What follows from this diagnosis and classification is that this is not a ‘real’ labour which would deliver a ‘real’ baby. Therefore the pregnant woman cannot be experiencing a ‘real’ labour and birth - because the performance of one reality on one object entails the performance of that same reality on other objects – and therefore she does not require the level of care she might expect in a full term birth. The consequent minimisation of pain and duration of labour, lack of support in labour and birth, and the lack of attention to informed consent around induction of labour as the NHS’ usual form of loss management is classificatory boundary work performed through differential trajectories of healthcare. The way second trimester loss resembles normative, full-term labour and birth but cannot produce the same outcome means it must be ontologically separated from ‘real’ third trimester births through the performance of obstetric violence to maintain pre-existing classificatory boundaries.

This understanding of obstetric violence as performing ontological work which is political in its recognition of some realities and not others adds to understandings of the concept as a gendered form of violence. It focuses on the function, use, and performance of obstetric violence as a function of power, in this case linked to fundamental ideas of what a pregnancy is. Second trimester loss allows us to see that the pregnancy in the English NHS is the possibility of the production of a new living person. Pregnancy, labour and birth as the experience of the pregnant woman is not the central reality here. This focus on boundary work also adds to understandings of the mechanisms which produce obstetric violence, besides intersectional inequalities and institutional structures. The potential transgression of deeply held cultural beliefs about reality can also be a driver for obstetric violence, played out on the individual bodies of women.

In recognition of the women who participated in this research:

Abbie Chanter, Alex Smith, Becki Phinbow, Carly Lobb, Caroline Kearsley, Cassie Young, Catherine Lee, Charlene Yates, Emily Caines, Emma Allison, Emma De-Riso, Fran Osborne, Hannah Mazouni, Helen Dilling, Helen Woolley, Jessica Nordstrom, Katie, Karen Morgan, Kirstie Collins, Laura, Lauren Wilcox, LeahAnne Wright, Lisa Congdon, Mo, Pip Ali, Sam Cudmore, Sarah Glennie, Sharron Whyte, and those who chose to remain anonymous.

And in memory of their babies:

Adelaide Caines, Aishlynne Lewis, Alice Phinbow, Beau Adi Cawse, Belle Osborne, Ben Hayman, Bobby Allison, Daisy, Dylan, Emma Osborne, Grace Collins, Harry, Hope Mazouni, Hope Turner, Isabella, Isabelle Caines, James Hamer, Liam, Luke, Max, Michael Smith, Owen Hamer, Rain Yates, River Yates, Robin Wilcox, Rose Whyte, Rowan Glennie, Saoirse, Seth Nordstrom, Sophie Dilling, Stanley Lee, Stevie George Baker, and those who were mourned but not named.

Dr Aimee Middlemiss, Research Fellow, School of Nursing and Midwifery, University of Plymouth

Invisible Labours: The reproductive politics of second trimester pregnancy loss in England (2024) can be downloaded Open Access here: https://www.berghahnbooks.com/title/MiddlemissInvisible