One in four women has experienced informal coercion during childbirth.
Stephanie Meyer and Stephan Oelhafen / 20th October 2020
Survey on childbirth experience
In a nationwide online survey, Bern University of Applied Sciences and researchers from partnering institutions assessed the childbirth experience of over 6’000 women who gave birth in Switzerland between 2018 and 2019. The participants answered questions about various aspects of their pregnancy and birth, the care they received and any medical treatments they may have had. The main focus was to assess how often women are subjected to treatments against their will or how often they are pressured into agreeing to treatments. This report presents the most important findings in a simplified form. You can find detailed as well as comprehensive results in the preprint of the scientific publication.
Preparation for childbirth
Most women (81%) actively prepared for birth.
Asked about how they had prepared for childbirth, more than half of the women indicated that they had considered various options before deciding where to give birth. Regarding the amount of preparation, there were differences between first-time mothers and women who already had children: Only 11% of the women did not prepare for birth at all when it was their first one, whereas this number was higher for subsequent births (27%).
Type of delivery
90% of the women wanted a vaginal birth.
Preparing for birth usually includes thinking about one’s preferred type of delivery. During pregnancy, most women wanted a vaginal birth. All other women were undecided or wanted a Caesarean section. About 2% of all births were elective Caesarean sections, that is, the women chose to have a Caesarean section without any medical indication. The women who chose to have a Caesarean section typically reported having various fears as their reason for doing so: fear for their baby’s safety (50%), fear of pain or complications (38%) or fear of vaginal or perineal injuries (36%)
Decision-making during childbirth
Most women (87%) favoured a shared decision-making process.
Most women believed that women and health care professionals (HCPs) should make important decisions during childbirth together. Roughly half of the women were in favour of women making decisions independently after receiving sufficient information. In comparison, only a fifth of the women agreed that HCPs should decide on their own. Overall, the women experienced the care they were given during birth as generally positive. They reported that decision-making was usually shared and that the HCPs were open to individual wishes and needs.
Coercion during childbirth
Coercion during childbirth is common in Switzerland.
The present study was the first to assess the prevalence of informal coercion during childbirth in Switzerland (see infobox). More than a quarter of the women (27%) experienced informal coercion during their childbirth. That is, they felt ill-informed, pressured, intimidated or they disagreed with a treatment decision. Apart from informal coercion, a number of women also experienced other unpleasant situations during birth: 10% of the women reported that HCPs had insulted them or made other derogatory comments. Two in five women (39%) indicated that their freedom of movement was restricted during birth. One in six women (17%) felt disturbed by the CTG (monitoring of foetal heartbeat).
Infobox: informal coercion
According to the Swiss Academy of Medical Sciences’ (SAMS) definition, coercion in the medical sense constitutes every measure that is taken against a patient’s will or despite their resistance. Contrary to formal coercion, there is no legal base for restricting patients’ autonomy in the case of informal coercion.
Most women rated the HCPs’ behaviour during vaginal examinations as overall positive. They reported that the HCPs did everything in their power to make the exams as bearable as possible and that they respected their privacy. Nevertheless, more than one in ten women would have preferred fewer vaginal examinations.
Satisfaction with childbirth
Unplanned interventions affect women’s satisfaction with childbirth.
Participants were also asked to rate their overall childbirth experience. More than two thirds of the women (71%) reported a predominantly positive experience. This number was even higher among women who had a non-instrumental vaginal birth (no vacuum or forceps) or a planned Caesarean section: four in five of these women rated their childbirth experience as predominantly positive. Women whose baby had to be delivered by emergency Caesarean section, however, were much less likely to report a positive experience (36%), as were women who experienced informal coercion (48%).
A follow-up discussion of childbirth can help process the experience.
Distressing experiences during childbirth can affect women’s wellbeing for a long time after birth or even traumatize them. Women who had an emergency Caesarean section or who experienced informal coercion were at higher risk of post-partum depression or other mental illnesses. However, the present study does not allow any causal interpretations. In general, a follow-up discussion of the birth seems to be important: Roughly half of the women (48%) had the opportunity to discuss their childbirth with a HCP. Four in five of these women reported that they found the discussion helpful – irrespective of whether their overall birth experience was positive or negative.
The present study sheds light on the childbirth experience of more than 6’000 women in Switzerland and on various factors that influence it. Three in four women reported a predominantly positive birth experience. On the other hand, one in four women experienced informal coercion during childbirth. Women who experienced informal coercion were less satisfied with their birth and are likely to be more at risk of post-partum depression.
Most women favoured a shared decision-making process, that is, they believed women and HCPs should make important decisions during childbirth together. A shared decision-making process ensures the inclusion of both the HCPs’ medical expertise and women’s individual attitudes and needs. It is therefore crucial that women think about their wishes and ideas regarding birth and communicate these openly to the HCPs. This includes researching whether particularly important wishes for childbirth can be met at the planned place of birth.
Every woman has the right to refuse treatment suggestions. Women should only consent to a treatment if they fully understand the procedure and the reasons for it. Any form of informal coercion violates fundamental personal rights. Women who are subjected to informal coercion during childbirth should report it to the HCPs.
HCPs need to be aware of the fact that even actions believed to have no significance can trouble women. In order to prevent negative effects of informal coercion, sensitive aftercare is essential. Furthermore, HCPs should bear in mind that women often cannot process their birth experience until months later and should therefore not be misled if they do not express any immediate need. On a societal level, a debate on childbirth is called for to clarify the medical necessity as well as the advantages and disadvantages of interventions during childbirth.
More than 7'000 women took part in our online survey between August and December 2019. We were able to consider a total of 6’054 data sets for the present study. The participants were recruited online through Facebook advertising and offline by means of various channels such as leaflets in paediatric and gynaecological practices as well as advertisements in parenting magazines and the Swiss Federation of Midwives’ newsletter. The questionnaire was available in four languages (German, French, Italian and English) and the questions were carefully phrased to be both medically precise and comprehensible for people with no medical knowledge.
Swiss nationals who did not give birth in a hospital and who had a non-instrumental vaginal delivery were overrepresented in the sample. We therefore used a weighted sample for all analyses in order to obtain results that were representative of all new mothers in Switzerland according to the Federal Statistical Office. Accordingly, all the results presented above must be understood as estimates for the whole of Switzerland. You can find details regarding the methods in the preprint of the scientific publication.
Information about the women in our study
Further information about the births in our study
The project «coercion during childbirth» is led by
- Dr. Stephan Oelhafen, Bern University of Applied Sciences, Health Professions
- Dr. Settimio Monteverde, Bern University of Applied Sciences, Health Professions
- PD Dr. Dr. Manuel Trachsel, Institute of Biomedical Ethics, University of Zurich
- Prof. Dr. Luigi Raio, University Hospital for Gynaecology, Bern University Hospital
- Prof. Dr. Eva Cignacco Müller, Bern University of Applied Sciences, Health Professions
The project is financially supported by
- The Swiss Academy of Medical Sciences’ Käthe Zingg-Schwichtenberg Fund
- Lindenhof Bern’s Fund for Teaching and Research