Tied2Beds: Spatial Hauntings in Obstetric Care

We contend that naming obstetric violence is vitally important because it helps us to identify the institutional obstetric processes and practices that constitute violence. In this post, we expose those unseen but obvious material arrangements that make violence possible in the first place. Pointing to a focus on beds in birthing facilities, we show that accepted norms in obstetric practice contribute to and perpetuate obstetric violence. We bring beds into the discussion to identify their power and implication in producing the tensions and contradictions that emerge in obstetrics and constrain ethical and professional caring practices. Beds have a materialising force that play a pivotal role in what happens during maternity care. Can we imagine birthing units without beds and what are the implications of their removal?

The current, past and future ways obstetrics is professionally practiced and individually experienced within institutions is in itself problematic. We propose a relational approach that contributes to arguments supporting the naming of obstetric violence by identifying the material relations embedded in institutionalised processes. These dynamic relations contribute to violating birthing individual’s dignity, but are seen as medically necessary. Through a critical examination of the function and agency of beds in the labour ward, we illustrate the messy entanglements of un/professional “caring” practices that constrain birthing autonomy, restrict physical movement, enforce docility and contribute to various other forms of obstetric violence.

In the literature, institutional obstetric caring practices are seen as drivers of the many violences imposed on women’s bodies. We put forward an argument that spatial haunting materialises with the arrangements of beds in labour wards, which we simplify as ‘Tied2Beds’. Spatial hauntings linger into the future impacting on birthing individuals, as well as all those connected to that event. In implicating beds as a component of the materiality of violence, what emerges is that violence is manifested through material relations on the ward floor. In the literature and legislation, it is acknowledged that forcing women to give birth in a supine position and restraining women to the bed enacts physical violence on birthing bodies.

There is little work that looks specifically at spatiality, materiality and temporality. Karen Barad  claims that “space, time and matter are mutually constituted through the dynamics of iterative intra-actions”. These entangled intra-actions provide an important consideration for obstetrics and a radical shift from traditional Cartesian models of separation and binary thinking. In contrast to conventional human-centred perspectives, we suggest a transdisciplinary approach that engages with human and more-than-human relations that emerge with/in the tensions of facility-based birthing practices. By drawing on Barad’s relational ontology, it is apparent that timespacematter are co-constituted with each birthing enactment.

In terms of our positionality, we are two passionately interested researchers, educators, and mothers living in South Africa. South Africa has a long history of colonial oppression and racial conflict that is rooted in medical training and the current structure of the healthcare system. Our doctoral research projects investigated the ways in which medical training is complicit in obstetric violence and continuous with structural health systems violence. By foregrounding the role of beds, we put forward the concept of Tied2Beds as an enactment of obstetric violence. Veronica’s research emerged from her student workshops titled ‘Me and My Dilemmas’, in which she engages with undergraduate medical students’ often traumatic experiences in labour wards. Nicole’s research included clinician obstetricians, and the pregnant and birthing people who consulted them.

Below we describe two poignant narratives associated with the healthcare professional-bed-labouring woman relationships that stand out for us. Firstly, a senior obstetric consultant’s use of the metaphor bed-juggling to explain ways of coping within an under-resourced setting where beds are in high demand. Bed-juggling requires that medical professionals make decisions about patient entitlement that disregard the need for care in labouring persons. The bed operates here as a visualising mechanism, making women’s needs visible only when and if they are positioned on a bed. The bed legitimates their status as a patient of the facility who can then be monitored, measured and given a place within the system. This helps us perceive neglect as a form of mistreatment that invisibilises bodies without beds.

So my role
I was in charge of labour ward
I did a lot
a lot of bed juggling

people on chairs
trying to sort out the sickest person to get the bed
who needs to go first
who can wait
who’s been waiting all week
who?

So that was one of the reasons
I left
I just couldn’t handle it.
there’s no time to get involved in individual care
I mean
you’re just so, so busy.

Secondly, Veronica recalls how frequently the bed became the central focus of discussion around many interviewees’ drawings, as indicated by the image heading this post. Furthermore, undergraduate medical students observe the power of the bed that constrains movement, despite being taught to promote freedom of movement. Students are educated in terms of promoting human rights but in practice they find themselves limited in their capacity to act against any injustices they may observe. They narrated experiencing empathy for the emotional violence they witnessed in the normalised practices of the ward floor.

Our socio-material approach foregrounds the material relations with/in the labour ward that occur as part of the structural violences enacted on women’s bodies. While beds in birthing facilities are a necessity for certain procedures, they contribute to the multiple tensions within the institutional arrangements. Global communities can learn from revised practices in Peru that adapted to the needs of women to facilitate mobile and upright positions. These required that practitioners care for and attend to women in different ways during birth, catalysing a shift in the orientation of medical training, learning and caring practices. Imagining new and different forms of labouring and birthing within facilities reconceptualises birthing timespacematters. Obstetric violence framing needs to acknowledge that Tied2Beds is a crucial contributor to the abuse of birthing individuals.

Dr Nicole Daniels, Postdoctoral Fellow, DSI-NRF Centre of Excellence in Human Development, University of the Witwatersrand

Dr Veronica Mitchell, Research Associate, Women's & Gender Studies Department, Faculty of Arts, University of the Western Cape