Author: Katharina Stock

Dr Kaveri Mayra is a global health researcher with qualifications in midwifery, nursing, and public health. Her work focuses on understanding determinants of positive and negative perinatal care experiences. At the University of British Columbia, she leads the Continuum for Respectful Care (CORE) initiative and plays a key role in bringing out the qualitative narratives from the RESPCCT initiative through innovative arts-based research methods. In 2020, Kaveri was recognized as one of the 100 outstanding global midwife and nurse leaders by Women in Global Health (WGH) and the World Health Organization (WHO).

Kaveri and I discuss her experience as a young nurse-midwife, the problems facing obstetric and maternity care, as well as some unexpected potential solutions.

Currently, Kaveri is leading a Research Topic titled: Prioritizing Pleasure in Reproductive and Maternal Health to Address Obstetric Violence in Frontiers in Global Women’s Health.

In a lot of women’s lives, pregnancy is an exceptionally emotional and meaningful time. It’s a transformative experience which brings with it both excitement and a unique set of challenges. Beyond morning sickness, unusual food cravings, and planning for the arrival of the newest member of your family, the relationship with your care provider may not even make the list of things to think about. Will my care provider treat me with empathy? Will they respect my wishes for the birth of my baby? Will my body be treated with the respect it deserves? If you have never given birth, you may not think to ask yourself these questions and we rarely get to hear the answers to them from the people who have. There seems to be an eerie silence around bad birthing experiences.

Through research and advocacy, Dr Kaveri Mayra wants to bring this conversation out into the open. “In many cases, women don't reflect on their pregnancy and birth experience until years later because welcoming a child is such a happy occasion. There is an immediate atmosphere of celebration shared with the family. Even if they had a hard time, many women do not want to draw attention and make it about themselves,” Kaveri explains.

“I am an Indian midwife,” is what Kaveri leads with when asked to introduce herself. For ten years she worked in research, implementation, and advocacy in midwifery, nursing, and maternal health care before moving to the UK to pursue a PhD in Global Health at the University of Southampton. Today, Kaveri leads the CORE initiative at the University of British Columbia. Her work focuses on the experiences of women and other birthing people during the care process.

A passionate advocate for women’s sexual, reproductive, and maternal rights, Kaveri’s career in healthcare was borne from rather practical considerations. “My plan was to get just educated enough to find a good husband who would let me do what I liked,” she recalls, laughing. “I pestered my parents endlessly to let me get married. I saw marriage as my ticket to freedom.” After finishing school, her career options were limited to say the least – an experience she shared with many girls her age in India. The advertisement in a local employment newspaper for positions in a government nursing program came at the right time. With only twenty five spots available, Kaveri was selected as number thirteen out of thousands of applicants. “It was like striking gold,” she tells me, “even though it was more what my family was hoping for as opposed to my own choice.”

But the reality of being a nurse was different from what she had been taught in her curriculum. “One moment I was studying, having fun with friends, being a teenager, and then all of a sudden I found myself in the biggest government hospital, assisting in operation theaters, helping suture bodies, watching women give birth, and in some cases providing death care.” Overwhelmed by the seemingly endless suffering she observed, she began to reflect on the system she was now inevitably a part of. “What I witnessed in midwifery left a particularly deep impression on me. The violence around it all shocked me, especially as I saw it coming from obstetric care providers. It was so normalized.”

‘Obstetric violence’ is typically defined as a form of violence against women and other people who give birth at the hands of obstetric care providers. It is characterized by physical and verbal forms of abuse, such as nonconsensual or unnecessary medical procedures, neglect, gaslighting, surrogate decision-making, shaming, and discrimination. Initial research investigating the consequences of such experiences indicates that violence during pregnancy and childbirth may have negative effects on women’s ability to breastfeed, bond with their child, as well as physical and mental health outcomes that may affect them for years after giving birth.

Watching doctors, nurse-midwives, and non-health care staff ridicule, bully, and physically abuse the care seekers she was responsible for, Kaveri was confronted with the boundaries of her role as a midwife. “In college, I was taught that, as a midwife, I am an advocate for the women I care for, but when I spoke out against the doctors and nurses who perpetrated this kind of abuse, I was reprimanded. I felt powerless” she explains, “I was watching obstetricians and doctors conduct studies, teach students, and influence policies. Meanwhile, I studied the same textbooks, but I was nowhere close to having that kind of impact.” This is when she realized that she would need to publish her own research to shed light on the problems she saw.

Kaveri’s goal is to change the way violence during pregnancy is reported and transform the way these experiences are studied and measured. Her work across India and Canada shows that experiences of obstetric violence are a global problem. “Of course, there are differences,” Kaveri elaborates. “If you give birth in Canada, you are less likely to experience extreme forms of violence. But many women still report abuse that is not very different from what I have seen in the Global South”. Examples of types of disrespect and abuse that have been reported include being coerced into agreeing to medical interventions, being denied the presence of a chosen supporter, or being denied pain relief. Not surprisingly, women from marginalized communities, such as racial or cultural minorities as well as birthing people with diverse sexual and gender identities, are especially vulnerable to this kind of treatment.

In an effort to better understand drivers behind positive and negative perinatal care experiences, Kaveri has developed the Continuum of Respectful Experiences (CORE) model. “The idea is to develop a tool that visualizes a person’s entire perinatal experience, including every pregnancy and birth they had. It will show how many times someone has been physically abused, discriminated against, how many times they felt well cared for or respected and at which stage of care this happened”. In the future, she hopes that the CORE model can be used as a tool to change patterns in care provision, teach care providers ways to reduce abuse, enable person-centered decision making, and understand the needs of people with different identities to uphold every birthing person’s right to a respectful care experience.

“My health, my rights” is the theme of this year’s World Health Day. The World Health Organization (WHO) defines sexual and reproductive health as a state of “physical, emotional, mental and social well-being” that is not simply characterized by the absence of disease, but requires a “positive and respectful approach” to sexuality and reproduction. However, few healthcare systems are delivering on this ideal. According to the US Centers for Disease Control and Prevention, 1 in 5 women report mistreatment during pregnancy and delivery care. In recognition of the health concern posed by mistreatment during maternity care, the WHO released a set of recommendations for positive birth experiences in 2018. A year later, the UN Human Rights Council published a report on violence against women in reproductive health services. 

Despite this universal acknowledgement of the problems facing obstetric and reproductive care services and in spite of the fact that “obstetric violence” is a legal construct recognized in a number of countries in Latin America as of 2007, the term “obstetric violence” remains controversial. Medical professionals globally have spoken out against the use of the word, citing concerns regarding the emotionally charged nature of the terminology, the harm it does to healthcare providers, and the fear of criminalizing normal medical interventions. 

With many cases of medical mistreatment being a result of inexperience, misunderstanding, or systemic problems, Kaveri concedes that often obstetric violence may not be intentional. “Care providers are just as much victims of an abusive system as care seekers are,” she tells me. “They are massively overburdened; expected to be like machines, switching from one sensitive experience to another. It’s not possible to be fully present for every patient every hour of the day. You can’t protect yourself from the inevitable erosion of compassion.”

But Kaveri is not convinced that this is a strong enough argument against “obstetric violence” as a concept. She points out that similar reservations don’t seem to hold much weight when discussing other forms of gender-based violence, such as intimate partner violence or sexual violence, both widely recognized terms. “It's easy to talk about gender-based violence when the perpetrator is the family or the husband. It’s easy to say that that kind of violence is intentional. When it comes to healthcare providers, suddenly it becomes an institutional issue. We shy away from acknowledging the systemic nature of the problem and openly discussing the oppressive and discriminatory structures it is embedded in. There is a significant power imbalance between patients and care providers.”

Throughout our conversation, Kaveri recalls a number of cases she had witnessed herself and heard of from affected women and fellow obstetric professionals. In one example, a doctor teaching vaginal exams instructed a whole group of students to take turns examining the same young woman and compare their findings without obtaining her consent. In another, the attending doctor laughed out loud and joked about the appearance of a pregnant person’s pubic area while performing a pelvic exam. In yet another, a woman was unnecessarily given multiple episiotomy cuts (incisions made in the tissue of the vaginal opening during childbirth to prevent tearing) to allow students to practice suturing.

“Academics don't like using the term ‘obstetric violence’. They call it activist language. But consider the kind of verbal, physical, and sexual abuse I witnessed; those acts weren’t misbehavior or mistreatment. It is violence! I believe calling it that is important to ensure it is treated with the necessary urgency,” Kaveri explains firmly.

Despite all she has seen and witnessed, Kaveri remains an optimist. Her solution to the problem of obstetric violence includes something unexpected: pleasure. Part of her current work focuses on experiences of pleasure during pregnancy and delivery. Anyone who has read the likes of Glamour magazine, Marie Claire, or even the Daily Mail in recent years, will have heard of orgasmic births - yes, it is exactly what you think it is. Anecdotally, orgasm and sexual stimulation during childbirth is said to reduce stress, provide natural pain relief, and even prevent perineal tears. But despite the buzzwords and media attention, clinical research on the subject is scarce. Kaveri isn’t surprised. “When I started researching obstetric violence, I didn’t think to consider pleasure either. Like many others, I just accepted that pregnancy and childbirth is supposed to be difficult and painful as a fact of life,” she recalls. “But then, how was I supposed to know any different?” Kaveri elaborates on the noticeable absence of female pleasure and sexuality from public discourse. As examples, she points to masturbation as an accepted and normalized behavior in teenage boys, while heavily stigmatized in girls, as well as the lack of priority given to women’s pleasure during sex. She sees a link between the omission of women’s pleasure from traditional narratives around femininity and the disheartening tolerance women seem to show towards the mistreatment and abuse of their bodies. She asks me, “how am I supposed to know that my body is something to be valued? That my pleasure is important? That I am not supposed to endure violence? If I was taught to value my body and my pleasure, perhaps I would be more likely to speak up when I am being hurt or disrespected.”

The idea of prioritizing pleasure in the birth process may be a rebellious one but while sex and sexuality play an important role, pleasure can also take other forms. It can mean prioritizing rest, feeling comfortable and relaxed, using atmospheric lighting and music or non-sexual touch and affection. Kaveri believes that midwives and doulas could play an important part in facilitating such experiences. The philosophy of midwifery prioritizes working in partnership with the person giving birth and fundamentally recognizes pregnancy and labor as natural and healthy processes. The unnecessary medicalization of childbirth is a continuous problem with rising rates of cesarean sections (c-sections) in particular causing concern globally. “The accepted rate of c-sections is around 10%. In some hospitals it is 40% or more. I have seen rates of up to 75%.” Kaveri explains, “I consider this a form of obstetric violence in and of itself.

Over the past century, obstetrics and modern medicine have been crucial for managing complications during pregnancy and delivery, undoubtedly saving many lives. But Kaveri emphasizes that pregnancy and childbirth remain natural processes which should not require medical intervention in most cases. She believes empowering midwives to be able to advocate for women effectively could prevent many births from becoming medicalized experiences, enabling pleasure and reducing abuse. “Ideally, we would work together with the care seekers, their family members, and doulas, to help facilitate a truly individualized birth process. It’s about continuity of care. Midwives should be there throughout the whole process, get to know the birthing person and their support network, know their needs, likes and dislikes, and be aware of past birth experiences and traumas.”

Kaveri’s approach to obstetric care is one that unapologetically prioritizes the experience of the person set to give birth. It’s a radical perspective though it shouldn’t be. Throughout our conversation, again and again, we touch upon the same fundamental issue; more often than not, women seem to self-impose a need to endure. Having watched women shy away from speaking up against disrespect and abuse, hiding pain and suffering, what makes the philosophy Kaveri shares with many other midwives and doulas so revolutionary, is the audacity to inspire women to demand pleasure and deny pain.

Towards the end of our conversation, Kaveri shares a final anecdote: 

“I was born in a military hospital. My father was serving in the military in India. When I was writing my PhD thesis, I asked my mother about her birth experience. She told me ‘I never experienced any violence. The doctor was very good.’ She said she had heard stories from other women though. Many women, she said, mentioned that [the doctor] shouted at them for screaming in pain. She told me, ‘I prepared myself and I was such a textbook patient.  Whenever I was in pain I clenched my teeth. I didn't make a single sound. So why would he abuse me? I didn't give him a reason.’ I was speechless. In her mind, she truly did not experience any abuse. She didn’t give the doctor the chance because she disciplined herself,” she pauses, “she didn't have to.” 

Frontiers is a signatory of the United Nations Publishers COMPACT. This interview has been published in support of the nine planetary boundaries.