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Consent and the problem of epistemic injustice in obstetric care
  1. J Y Lee
  1. University of Copenhagen, Kobenhavn 1017, Denmark
  1. Correspondence to Dr J Y Lee, University of Copenhagen, Kobenhavn 1017, Denmark; ji.young.lee{at}

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An episiotomy is ‘an intrapartum procedure that involves an incision to enlarge the vaginal orifice,’1 and is primarily justified as a way to prevent higher degrees of perineal trauma or to facilitate a faster birth in cases of suspected fetal distress. Yet the effectiveness of episiotomies is controversial, and many professional bodies recommend against the routine use of episiotomies. In any case, unconsented episiotomies are alarmingly common, and some care providers in obstetric settings often fail to see consent as necessary in context. In their article, ‘The ethics of consent during labour and birth: episiotomies,’ van der Pijl et al reiterate that consent is necessary for episiotomies. They specify, further, that the antenatal period is crucial for exchanging information, establishing trust between the birthing subject and provider, and exploring the birthing subject’s—rather than the care provider’s—values and preferences regarding episiotomies. They recommend an individualised approach, which would enable birthing subjects to choose how and when they want to give consent.

I applaud van der Pijl et al on their practicable recommendations regarding consent for episiotomies. This is certainly a step in the right direction where respect for birthing subjects’ bodily autonomy and integrity is concerned. Still, we must be reminded that consent alone is not coextensive with autonomy. The conditions for securing informed consent in healthcare does not guarantee that one’s decision is truly reflective of their values. After all, even valid consent does not rule out ‘normatively significant external influence’.2 Consent acquisition for obstetric procedures present no exception; the healthcare setting may fall short of securing a sufficient degree of ‘autonomy’ for birthing subjects due to various factors.

Further to this point about the disconnect between consent and autonomy, I draw attention to the following autonomy-undermining element for the remainder of my commentary: the problem of epistemic injustice as a mechanism of obstetric violence. The issue of unconsented episiotomies, as the authors already note, is symptomatic of the deeper issue of ‘obstetric violence,’ which describes not only physical harms but an ‘array of issues regarding the disempowerment of women’ during pregnancy, birth and the postpartum period.3 I take it that obstetric violence is therefore negatively correlated with any plausible account of birthing autonomy. In my view, cases of obstetric violence can also result from practices in which the epistemic authority accredited to healthcare providers is unjustly reified at the expense of birthing subjects, due to a ‘systematic consideration of women, and non-white women in particular, as flawed epistemic agents’4—that is, because of epistemic injustice. Chadwick adds that obstetric violations manifest through relational and affective dynamics in which ‘birthing/gestating persons are nullified, invisibilised, unheard and diminished’.5 These violations can occur even through seemingly benign counsel in which institutionally approved norms about what a birth should be like are recommended and reinforced by the healthcare provider despite potential harms to the birthing subject.

While van der Pijl et al assert that ‘labouring women ought to be considered capable of making decisions, even when in pain or highly medicated,’1 the reality is that healthcare providers’ knowledge and power in obstetric contexts ‘can trump, discredit and invalidate the legitimacy of women’s sensory, embodied experiences and the testimonies women provide based on those experiences’.6 In obstetric contexts especially, Cohen Shabot claims that labouring women tend to be perceived as less rational and more emotional, and are mistakenly considered ‘riskily vulnerable, out of control and incapable of accountability or good decision-making, to an even greater degree than when ill (and clearly more so than women who are neither birthing nor ill)’.4 Moreover, first-person accounts tend to get discredited because subjective knowledge of one’s condition does not qualify as reliable ‘evidence’ under a biomedical framework.7

Thus, while medical practitioners retain an unjust excess of credibility, birthing women face a deficit of credibility not only due to the fact that they are women, but also because of ‘the devaluation of the specific type of knowledge (women) bring to labour.’4 Not only does this disparity make birthing women vulnerable to instances of epistemic injustice, it also props up a broader underlying pattern of medical paternalism in obstetric settings, wherein the healthcare provider is presumed to have all the expertise about what is best for the patient. This places healthcare professionals in the self-legitimised position to shape patient values or (as we’ve seen with the case of unconsented episiotomies) make decisions on the birthing subject’s behalf.

These undertones are certainly reflected in the logics van der Pijl et al have observed in the way some care providers have approached episiotomies, for example, because ‘they believe they only perform episiotomies when actually necessary, or because they know the woman would agree anyway.’1 Here, a lack of consent is of course not the only issue: presumptive and prejudiced beliefs about what is good for birthing women, or what they would prefer, can be medically (and all too casually) enacted in the guise of supposedly ‘routine’ procedures done to women. The so-called ‘husband stitch’—an illicit practice in which doctors perform an unnecessary extra stitch after an episiotomy in the belief that this would result in greater sexual satisfaction for the birthing woman’s male partner8—is a worst-case scenario.

Another striking observation made by van der Pijl et al is the fact that even in an ideal scenario—in which, say, the patient has a lot of self-trust, and the care provider makes every effort to take into account the birthing subject’s values—most women ‘will agree with the care provider’s judgement.’1 This is not surprising given the existing inequality in epistemic authority between the birthing subject and care provider to which I have referred in previous paragraphs. It is not difficult to imagine that even the most well-meaning healthcare professionals could unwittingly wield influence over birthing women’s values and preferences through the way they present rationales for obstetric interventions like episiotomies. While van der Pijl et al have already identified systemic obstacles like lack of resources and time as disrupting the antenatal trust-building process between patient and care provider, it seems to me that the aforementioned epistemic challenges add another layer of complexity for birthing subjects navigating the obstetric context. As Dahan and Cohen Shabot have argued elsewhere, epistemic injustices committed against women during their medicalised childbirth experiences can be one of the most ‘insidious forms of obstetric violence, because of their subtle and manipulative character…’.9

The authors of the feature article have rightly pointed out that establishing trust between the birthing subject and healthcare provider is ‘essential to the ability to give informed consent.’1 But given the less than favourable conditions in healthcare settings for the uptake of birthing persons’ testimonies, preferences and values, one might put to question whether placing trust would in fact be warranted. So long as the unjust disparity in epistemic authority between the healthcare professional and birthing subject continues to be intentionally or inadvertently exploited to harm and undermine birthing women, improved practices for consent acquisition may not be sufficient to secure the autonomy that might be hoped for birthing subjects. Trust-building endeavours in the antenatal period makes sense for parties whose epistemic authority is roughly equal; but for this to happen, those responsible for carrying out obstetric care must establish themselves as trustworthy in the first place.

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  • Contributors JYL is the sole author of this commentary.

  • Funding This study was funded by Velux Fonden (00026589).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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