1. Obstetric violence and autonomy loss

Obstetric violence refers to pregnant and birthing people’sFootnote ¹ perceived experiences of loss of autonomy, consent, and abuse perpetrated by health providers and institutions in the context of pregnancy, birth, and postpartum. This phenomenon can produce physical, psychological, or symbolic harm. It has been classified as a type of gender, medical, sexual, epistemic, and reproductive violence, a violation of human rights, and a clear case of reproductive injustice. Obstetric violence results from structural health inequalities (Sadler et al. Reference Sadler, Santos, Ruiz-Berdún, Skoko, Gillen and Clausen2016; Abadía Barrero Reference Barrero and Ernesto2022), the unequal knowledge/power relations between patients and providers in clinical settings (Foucault Reference Foucault1976), and the hegemony of biomedical discourses in modern obstetrics that reduce pregnant and birthing people to passive subjects during their care (Gopal Reference Gopal2017; O’Brien Reference O’Brien2023). Sometimes studied along gynecological violence, which “encompasses a range of [violent] practices carried out by healthcare providers within the framework of gynecological care” (Cárdenas-Castro and Salinero-Rates Reference Cárdenas-Castro and Salinero-Rates2023, para. 2), obstetric violence scholarship and activism have vastly grown in the past two decades (Kitzinger Reference Kitzinger2006; Díaz-Tello Reference Diaz-Tello2016; Cohen Shabot Reference Cohen Shabot2016, Reference Cohen Shabot2020, Reference Cohen Shabot2021a–Reference Cohen Shabotb; Quattrocchi Reference Quattrocchi2019; Castro and Savage Reference Castro and Savage2019; Nalepa Reference Nalepa2020; Paula et al. 2020; Williamson Reference Williamson2021; Campbell Reference Campbell2021; Berzon and Cohen Shabot Reference Berzon and Cohen Shabot2023; Cantor Reference Cantor2023; Davis-Floyd and Premkumar Reference Davis-Floyd and Premkumar2023; Sargent and Davis-Floyd Reference Sargent and Davis-Floyd2023).

Obstetric violence encompasses multiple forms of dehumanizing treatment and medical abuse.Footnote ² Some of these practices include unnecessary interventions, movement restrictions, prolonged fasting, routine episiotomies, frequent unjustified vaginal examinations, verbal threatening, shaming, scolding, and other actions experienced as violent by the pregnant/birthing person during their care (Castañeda et al. Reference Castañeda, Hill and Johnson Searcy2022; Cohen Shabot and Sadler Reference Cohen Shabot and Sadler2023). In 2014, the World Health Organization recognized that abuse, disrespect, and mistreatment during childbirth were present in health facilities, affecting women’s dignity and rights (WHO 2014). Their statement responded to extensive efforts of scholars, activists, and policymakers denouncing longstanding abusive practices experienced by obstetric patients worldwide (Davis Reference Davis2018; Mejía Merino et al. Reference Merino, María and David Arango Urrea2018; Jojoa-Tobar et al. Reference Jojoa-Tobar, Darío Cuchumbe-Sánchez, Briyith Ledesma-Rengifo, Cristina Muñoz-Mosquera, María Paja Campo and Pablo Suarez-Bravo2019; Vallana-Sala Reference Vallana-Sala2019). Importantly, Indigenous, Black, Latinx, impoverished, queer, undocumented, young, and disabled people disproportionally experience this type of violence (Levine Reference Levine2008; Berry Reference Berry2010; Davis Reference Davis, Rivkin-Fish, Brodwin and Shaw2019; Rogerson Reference Rogerson2019; Strong Reference Strong2020; Grotti and Brightman Reference Grotti and Brightman2021; Gleason et al. Reference Gleason, Patricia Molina Berrío, Marcela Lopez Ríos and María Mejìa Merino2021).

Like other forms of medical and gender violence, obstetric violence is a multi-layered phenomenon connected to broader sociopolitical and economic inequalities, a manifestation of structural violence (Farmer Reference Farmer2004). It is another link in “the continuum of violence” (Kelly Reference Kelly1987; Cockburn Reference Cockburn2004) and “the violence of everyday life” (Das Reference Das2007) that entrap feminized bodies worldwide. Latin American countries have led the initiative to define and criminalize obstetric violence in the legal sphere (Quattrocchi and Magnone Reference Quattrocchi and Magnone2020). In 2007 Venezuela was the first country to describe obstetric violence in the “Organic Law on Women’s Right to a Life Free from Violence.”Footnote ³ México, Chile, Argentina, and Colombia also addressed the problem and have provided recommendations for a humanized and respectful childbirth experience. Unfortunately, there is no updated information in these countries about the reported number of cases of obstetric violence or the people persecuted for it. This suggests an important gap between legislative provisions and their effective application. For instance, in the last report from 2010, only seven cases of obstetric violence had entered the Venezuelan specialized courts, and none had been resolved (CEM-UCV et al. 2011).

In addition to the physical and emotional harm—the main focus of most studies—obstetric violence produces a loss of autonomy and decision-making capacity (Cohen Shabot Reference Cohen Shabot2020). According to Rössler (Reference Rössler2002, 144), “The normatively guiding idea forming the basis of the concept of autonomy is that we, each of us independently, are free and able both to choose and to live the life that will be good for us.” Autonomy loss is clearly stated in the 2007 Venezuelan legislation when defining obstetric violence:

Pregnant people’s loss of autonomy over their bodies hinders their capacity to consent to or deny medical interventions. It contributes to traumatic birth experiences, feelings of disempowerment,Footnote ⁴ loneliness, lack of recognition, and detachment from those attending their labor (Urrea-Mora Reference Urrea-Mora2014; Cohen Shabot Reference Cohen Shabot2016; Cohen Shabot and Sadler Reference Cohen Shabot and Sadler2023). Additionally, it fuels an extremely paternalistic model of care, characterized by accepting Western biomedicine as the authoritative knowledge during childbirth (Jordan Reference Jordan1983). Authoritative knowledge “helps to explain how the disempowerment and objectification of pregnant people creates a culture of silence, which ultimately dissuades individuals and their partners from engaging in active decision-making during childbirth” (Cantor Reference Cantor2023, 164). Medical authoritative knowledge directly targets the informed consent process and patients’ autonomy about their care.

In response to the structural conditions of a health system that re/produces unequal power relationships and coercive decision-making, Western bioethicists proposed a patient-centered model of care emphasizing individual autonomy as the primary—sometimes even exclusive—ethical principle to guide medical decisions (Rybak Reference Rybak2009; Mapes et al. Reference Mapes, DePergola and McGee2020). Beauchamp and Childress (Reference Beauchamp and Childress1994) initially proposed individual autonomy as one of four principles of common morality in biomedical ethics, along with beneficence, nonmaleficence, and justice. For these authors, individual autonomy in healthcare is a universal, reflexive “autonomous choice” process that allows people to make informed, intentional, and rational decisions. Beauchamp and Childress (Reference Beauchamp and Childress1994) defined autonomy as a capacity and liberty that health providers should consider along with the other three principles in their praxis and research (Cudney Reference Cudney2014; Flanigan Reference Flanigan2016). Despite the relevance of individual autonomy in healthcare, the traditional bioethical approach has been highly criticized for its pretended universality. This model often ignores structural hierarchies, sociocultural differences, and relationships mediating decision-making (Turner Reference Turner2009; Banerjee Reference Banerjee2022).

In this article, I critique the liberal bioethical framework of individual autonomy applied to obstetric settings because it ignores the relational nature of childbirth—and healthcare in general. I argue that individual autonomy is necessary but not sufficient for legitimately consenting to obstetric care and preventing violence. This does not mean that relationality should just be introduced into the concept of autonomy as an inherent aspect of it. Instead, I stress that autonomy, even during relational contexts, is reached only when someone “is able to decide about the relational context of action itself—to decide with whom and in what relationships she wants to live, which obligations she is willing to accept, and which personal projects she wishes to pursue” (Rössler Reference Rössler2002, 148). Childbirth is one of those relational contexts. It is a biosocial event that includes interactions between the pregnant person, their baby, and a group of health professionals, birth attendants, partners, and family members (Osamor and Grady Reference Osamor and Grady2016). I argue that, in addition to individual autonomy, we must address autonomy in relation to the cultural context and its multiple actors during obstetric decision-making and care.

Unfortunately, the exercise of both individual and relational autonomy have multiple structural barriers in common. Some of these problems include racism, sexism, poverty, incarceration, lower education, and power differentials that constrain obstetric patients and their families from providing free, informed consent about their care. To tackle these barriers, I highlight the role of birth advocates like midwives and doulas, who often serve as bridges between biomedical-oriented health professionals and pregnant/birthing people needing care. In addition to other structural changes required for a “deeply humanistic” model of birth (Davis-Floyd Reference Davis-Floyd1992, Reference Davis-Floyd2008), doulas and midwives can help nurture autonomy and caregiving skills (Bhandary Reference Bhandary2020) in obstetric patients and health providers. This strategy protects the informed consent process, prevents obstetric violence, and can be an effective way to recenter childbirth experiences in pregnant people and their families.

To develop my argument, I analyze the definition of informed consent proposed by the American College of Obstetricians and Gynecologists (ACOG) and review some causes of mistrust felt by pregnant and birthing people. I explain how testimonial injustice (Fricker Reference Fricker2007) leads to an extremely paternalistic model of care and reinforces medical authoritative knowledge. Then, I expand on the definition of individual autonomy proposed by medical bioethics, highlight its limitations, and criticize the expected archetype of the “Reasonable Mother” resulting from it. I call for advancing upon a definition and inclusion of relational autonomy in obstetric settings following the work of philosophers, anthropologists, and bioethicists applying relational autonomy to similar health contexts. Aligned with an intersectional feminist approach (Crenshaw Reference Crenshaw1991), I expose some structural conditions affecting the informed consent process. These barriers manipulate individual and relational autonomy and open the door for obstetric violence (i.e., obstetric racism, socioeconomic disparities, and legal coercion). Finally, I address the need for a structural reform of the model of birth and the inclusion of doulas and midwives in the healthcare team. I propose that these birth workers can help nurture the autonomy and caregiving skills presented by Bhandary (Reference Bhandary2016, Reference Bhandary2020) in her Theory of Liberal Dependency Care. Autonomy and caregiving skills are fundamental to ensuring just obstetric care and protecting the informed consent process of pregnant/birthing people and their families.

2. Informed consent and “unreliable” obstetric patients

According to ACOG (2021), “the goal of the informed consent process is to provide patients with information that is necessary and relevant to their decision making … and to assist patients in identifying the best course of action for their medical care” (e34). Usually, informed consent takes the form of a physical document signed before the patient undergoes any treatment. However, a signed document “does not guarantee that the patient’s values and priorities have been taken into consideration in a meaningful way and that the ethical requirements of informed consent have been met” (ACOG 2021, e34). Informed consent requires a conversation between health providers and patients to develop trust and respect, which ultimately aims to provide good care (Flanigan Reference Flanigan2016). Obtaining the patient’s signature on a document, often difficult to understand due to medical and legal terminology, should not be considered proper informed consent (Martín-Badia et al. Reference Martín-Badia, Obregón-Gutiérrez and Goberna-Tricas2021). These documents might work as legal evidence to protect the institution during lawsuits. However, they rarely demonstrate that health providers followed the ethical procedures required for obtaining patients’ informed consent about their care.

Informed consent is supposed to be a patient-centered, individualized, and continued processFootnote ⁵ that includes all risks and benefits of the available treatment options and respects the patient’s values and priorities (ACOG 2021). Ultimately, the consent process should look at patients’ self-determination, ideally reaching a consensus between the patient and provider about the most reasonable treatment plan. In other words, it is a “mutual sharing of information between the clinician and patient to facilitate the patient’s active engagement in their treatment” (Campbell Reference Campbell2021, 66). If a health provider fails to obtain informed consent before a medical procedure, the patient may have a valid malpractice claim for any harm related to the procedure (Mann Reference Mann2004). Malpractice—failing to provide a proper standard of care resulting in patient harm—is one of the most common legal claims confronting the medical field. Notably, the doula community has popularized the BRAIN acronym for making informed decisions during childbirth. BRAIN stands for benefits, risks, alternatives, intuition, + nothing (Doula to Others 2018). With this tool, doulas teach patients and their families to explore the benefits, risks, and alternatives of each procedure with their providers. It encourages people to listen to their intuition and ultimately make the best choice for their situation, which can be doing nothing, waiting, or moving forward (Doula to Others 2018).

The doctrine of informed consent, as presented above, shifted throughout the twentieth century (Campbell Reference Campbell2021). First, it relied on a physician-based standard, which focused on the decision-making process from the perspective of the “reasonable medical practitioner” and their scientific standards. Under this model, patients presumed physicians knew what was best for them. Doctors were assumed to be unbiased and objective, with the expertise to make healthcare decisions for their patients. Later, bioethicists criticized this approach for its “excessive paternalism,” the lack of patient agency, and the immunity it granted to physicians during legal trials despite their malpractice. Eventually, lawmakers in the United States changed their perspective on consent by demanding health professionals provide their patients with all the information needed to make informed choices. Instead of passive receptors of care, patients were now considered “reasonable subjects” with the capacity to decide for themselves (Campbell Reference Campbell2021). In specific life-altering procedures, such as sterilization and end-of-life treatment, the informed consent process became more rigorous, in some cases requiring a mandatory waiting period before the consent is valid.Footnote ⁶

For legal purposes, most adult patients are presumed to have autonomous decision-making, which gives them the right to accept or refuse medical treatment (ACOG 2021). The exception to this rule is when a health professional determines “mental incompetence” in their patient, a strongly ableist category that scholars on neurodivergence and disability have criticized. Under “mental incompetence”—sometimes referred to in the past as feeblemindedness—people have been confined, devaluated, and excluded from moral and political theories, denying their capacity for individual autonomy, a chief marker of moral personhood (Davy Reference Davy2015; Lira Reference Lira2022; Di Giulio Reference Di Giulio2024). Despite these critiques, the doctrine of informed consent in healthcare still relies on the assessment of “mentally competent reasonable patients,” a category that does not apply to children, unconscious or intoxicated patients, or people with some mental disabilities, all assumed incapable of providing meaningful consent (Flanigan Reference Flanigan2016).

Surprisingly, health personnel often count birthing people as another group incapable of providing rational consent, and there are historical explanations for this mistrust. Villarmea (Reference Villarmea2021) says that physicians have fallaciously assumed that women are irrational, extremely sensitive, and emotional since the notion of the migratory uterus appeared in texts of ancient Egyptians. The misconception of a “wandering womb” that moves freely through the body, generating disease and unpredictable behavior, connects to the idea of wombs as animals present in Plato’s Timaeus: “The womb is an animal which longs to generate children” (cited in Villarmea Reference Villarmea2021, 38). The myth of the migratory uterus persisted for centuries in European academic medicine, serving as an etiology (the cause of a disease) for emotional volubility and imagined disorders like “hysteria.” We may think that modern medicine is far from such bizarre myths. However, “the pervasive construction of the uterus as an element that renders women wild, uncontrollable, and irrational continues to influence contemporary obstetrics” (Villarmea Reference Villarmea2021, 22).Footnote ⁷

The persistent notion that wombs govern people’s behavior has led healthcare workers to assume that women, and especially pregnant/birthing people, are not responsible for their actions, have no discernment capacities, and their emotional fluctuations make them incapable of making rational decisions. There is a persistent erroneous perception that people with a uterus cannot fulfill the requirements of “reasonable patients” and, therefore, cannot provide informed consent about their care. Living proof of this misconception is when health personnel infantilize obstetric patients and treat them as victims of pathological conditions requiring intervention (Vallana-Sala Reference Vallana-Sala2019). Instead of physiological processes, pregnancy and childbirth are seen as moments in patients’ lives where the uterus “takes control of the entire body,” and people’s actions become irrational (Villarmea Reference Villarmea2021). This sustained mental deficiency fallacy has not only produced medical violence but has also been used to deny women access to citizenship, their right to vote, and their autonomy for deciding about their bodies (Villarmea Reference Villarmea2021).

Additionally, some health providers working in maternity care erroneously believe that their patients are incompetent to provide informed consent because of the physiological and psychological changes occurring during pregnancy. “For decades, the concept of ‘mommy brain’ (also referred to as baby brain, mom brain, momnesia, and pregnancy brain) has permeated what it is to be a mother” (McCormack et al. Reference McCormack, Callaghan and Pawluski2023, 335). “Mommy brain” refers to a supposed memory deficit and impaired mental capacity that manifests during pregnancy and postpartum. This idea is not only scientifically inaccurate but hides the positive adaptations that emerge in parental brains, including caregiving expertise and better emotional regulation (McCormack et al. Reference McCormack, Callaghan and Pawluski2023, 335). Parents experience a neurologic developmental period known as “matrescence,” which is similar to the morphological brain modifications that occur in adolescence. While “mommy brain” denotes brain dysfunction, “matrescence” speaks of neuroplasticity and adaptation to new life demands. “The term matrescence, the process of becoming a mother, was first coined by the anthropologist Dana Raphael [1973], and later expanded by Aurélie Athan [2016] to include ‘a developmental passage where a woman transitions, through pre-conception, pregnancy and birth, surrogacy, or adoption to the postnatal period and beyond’” (Orchard et al. Reference Orchard, Rutherford, Holmes and Jamadar2023, 303). Davis-Floyd (Reference Davis-Floyd1992) attributes the term to the midwife and professor Denis Walsh (Reference Walsh2006). Importantly, “matrescence” (later known as “external gestation”) is not only a hormonal change but a social and cultural adaptation to parenting.

Some health providers have also used the pain and emotional distress experienced during childbirth as excuses for ignoring informed consent. “Health workers may interpret suffering as a barrier to voluntarism if a patient is seen as making her decision out of desperation rather than her previously held values” (Roberts 2003, cited in Flanigan Reference Flanigan2016, 229). However, empirical research into the effect of pain on deliberative competence shows that, while pain may change a person’s decisions during childbirth, it does not undermine their potential to give informed consent or to know what is better for their overall well-being (Flanigan Reference Flanigan2016). Moreover, ACOG (2016, 2021) has repeatedly stated that neither pregnancy nor childbirth pain are exceptions to consider obstetric patients as rational, capable subjects with the right to accept or refuse treatment for themselves and their fetuses.

Other scholars situate the medical professionals’ belief that birthing people are incapable of giving consent in the high-risk or emergency situation they face during labor, a time when making decisions can be challenging (Hawkins et al. Reference Hawkins, Redley and Holland2011; Flanigan Reference Flanigan2016). The language of risk in obstetric contexts is highly relevant. Obstetricians classify all pregnancies on a risk scale according to their expected outcome, where the safest pregnancy can be is “low risk,” meaning only one baby in cephalic presentationFootnote ⁸ without additional factors requiring medical intervention. It is true that childbirth always implies some risk and that the active phase of labor (when the cervix dilates from 6 to 10 cm and contractions become stronger and more regular) is not the most optimal scenario for decision-making.Footnote ⁹ However, the potential or actual risks during any stage of childbirth should not be a reason for health personnel to forcibly perform or deny any procedures on their patients. According to ACOG (2016), obstetricians should follow the informed consent process even during emergencies; otherwise, the pregnant person can experience those procedures as violent or intrusive.

According to Cohen Shabot (Reference Cohen Shabot2016), “childbirth also has a deeply sexual dimension that the medicalized model has almost completely erased: childbirth is a product of pregnancy, itself a product (almost always) of sexual intercourse. Moreover, childbirth (except in Caesarean sections) involves our genitals” (241). The sexual dimension of pregnancy and childbirth is often permeated by health professionals’ patriarchal constructs of feminine sexuality. While female bodies (and those assumed to be female) are interpreted as submissive, passive, non-assertive, and at the service of others, pregnant bodies will continue to be portrayed as available objects open to manipulation and control (Kingma Reference Kingma2021). It is not coincidental that some birthing people describe events of obstetric violence as rape, equating medical abuse to various forms of physical and verbal sexual assault (Kitzinger Reference Kitzinger2006; Cohen Shabot Reference Cohen Shabot2016; Mardorossian Reference Mardorossian2019; Restrepo-Sánchez Reference Restrepo-Sánchez2024). Sexist stereotypes of birthing people may explain, in part, why “the appropriation of women’s bodies” is a crucial part of the definition of obstetric violence (in the Venezuela law of Reference Venezuela2007).

Structural sexism, historical and cultural misconceptions of pregnancy, birth pain, or emergency situations are not valid reasons to invalidate a pregnant/birthing person’s consent. Most pregnant/birthing people meet the “reasonable patient” capacity to “understand information that is relevant to [their] choice, communicate a choice, appreciate the consequences of [their] choice, and compare [their] choice to alternatives” (Appelbaum 2007, cited in Flanigan Reference Flanigan2016, 227). When health providers do not acknowledge that pregnant and birthing people are “reasonable patients,” they are exercising epistemic violence in the form of preemptive testimonial injustice. “Testimonial injustice occurs when prejudice causes a hearer to give a deflated level of credibility to a speaker’s word” (Fricker Reference Fricker2007, 1). Testimonial injustice is a form of patient objectification and constitutes a common form of obstetric violence (De Barros Gabriel and Guimarães Santos Reference De Barros Gabriel and Guimarães Santos2020; Massó Guijarro Reference Guijarro2023), often led by identity prejudice—“a label for prejudices against people qua social type” (Fricker Reference Fricker2007, 4). Other forms of epistemic obstetric violence occur when medical authoritative knowledge excludes pregnant/birthing people from the production of knowledge in medicine, including their participation in clinical research (Bellón Sánchez Reference Bellón Sánchez2014).

3. Individual and relational autonomy during childbirth

Individual autonomy, understood as a person’s sense of self-determination and ability to act on their own values and interests, has been the crucial pillar of the informed consent process in healthcare. However, in addition to “mental incompetence” (explained in the previous section), this principle has other restrictions. Children, for example, have special protections from the moment they are born. Despite being considered incapable of consent, “Courts are generally authorized to make medical decisions in the interest of a child even when the child’s parents disagree” (Dare 2009, cited in Flanigan Reference Flanigan2016, 225). During public health emergencies, governments may impose obligatory quarantines and vaccinations to prevent a contagious person from threatening the lives of others. In both cases, the individual autonomy of some subjects is limited for the perceived benefit of others. In the case of maternal care, should this rationale of protecting someone’s well-being over another’s autonomy apply to unborn infants? According to the US Constitutional Court, fetuses are not covered under the definition of “constitutional personhood” protected by the Fourteenth Amendment (1868). Therefore, pregnant and birthing people in the US should have the right to make individual choices about their health, even if those decisions represent danger for themselves or their fetuses.Footnote ¹⁰

In line with this idea, Flanigan (Reference Flanigan2016) argues that obstetricians should only consider the mother’s and not the baby’s autonomy: “Though there are strong moral reasons for women in labor to mitigate the risks to unborn infants, they would not violate anyone’s rights by failing to do so, whereas forced interventions during childbirth would violate the mother’s medical rights” (226) and constitute a form of obstetric violence.Footnote ¹¹ Pregnant people are allowed to make medically inadvisable choices during childbirth, like refusing a C-section that may compromise the fetus’ well-being. Even when these decisions are “morally risky,” they should not justify medical coercion or forced treatments (Flanigan Reference Flanigan2016, 234). The ownership of medical rights by the pregnant/birthing person, and not by the unborn infant, protects patients’ autonomy and rests on the existential and relational constructs of personhood as a state of value (White Reference White2013).

Some paradigms in maternity care rely on the assumption that parents are willing to make sacrifices for their children, so not prioritizing the fetus represents a violation of pregnant people’s autonomy. About this argument, Kingma (Reference Kingma2021) explains that “these presumptions hold true only because, and only insofar as, women, as autonomous agents, take on the value of altruistic maternal sacrifice (to at least some extent), as well as the value of love and care to the degree that another’s pain is one’s own (again at least to some extent)” (461). Parental sacrifice is not a violation of individual autonomy but a reaffirmation of it. Not all parents are willing to risk their health for their unborn children’s well-being. However, for those who prioritize their fetus’s health over their own, their decision is grounded in and is ultimately an expression of individual autonomy.

Other authors have explored the role of individual autonomy in risky situations of reproductive care where morbidity and mortality are higher. Some examples include a patient’s request for vaginal birth in a second pregnancy after a cesarean (Rybak Reference Rybak2009) or the use of assisted reproductive technologies after a renal transplant (Lockwood Reference Lockwood1999). In these situations, it is important to ensure a more thoughtful informed consent process, emphasizing evidence-based recommendations and additional advice from medical academic committees. However, despite the increased risk, medical personnel should not violate patients’ individual autonomy over their bodies. This would result in malpractice and reproductive violence. “The experience of non-consensual medical intervention is often extremely traumatic for patients” (Flanigan Reference Flanigan2016, 233). Moreover, it has been widely documented that people who experience traumatic births and other forms of medical violence have a higher risk of post-traumatic stress disorder and postpartum depression symptoms (Olza Reference Olza2013; Junqueira et al. Reference Junqueira, Rattner and Bauermann2017; Martinez et al. Reference Martinez, Rodríguez, Hernández and Miguel Martínez2021).

Western cultures often equate individual autonomy with independence, self-sufficiency, and self-directedness, characteristics of the Cartesian ideal of a rational man (Osamor and Grady Reference Osamor and Grady2016). The current emphasis on individual autonomy in healthcare exalts self-determination and self-government, core principles of Western democracies, and “neoliberal philosophies and policies that emphasize individual responsibility and ‘choice’” (Rajtar Reference Rajtar2018, 185). Individual autonomy operates under the paradigm of patients being autonomous, reasonable individuals, detached from cultural factors that could potentially bias their decisions. Applied to maternal care, the “Reasonable Mother” emerges as the archetypical subject in the neoliberal obstetric establishment. The Reasonable Mother complies with the expectation of obstetric patients exercising their individual autonomy in isolation, making rational decisions about themselves and their babies without the influence of their context and culture. A Reasonable Mother accepts medical authoritative knowledge (Jordan Reference Jordan2023), engrains herself in the technocratic model of birth (Davis-Floyd Reference Davis-Floyd1992), and, consequently, becomes the perfect victim for symbolic, epistemic, and obstetric violence (Bourdieu and Wacquant Reference Bourdieu and Wacquant1992; Fricker Reference Fricker2007; Cohen Shabot Reference Cohen Shabot2021b; Castro and Frías Reference Castro and Frías2022).

The Reasonable Mother is only one phase of the “modern woman” expected from liberal societies (Van Hollen Reference Van Hollen2003). This relentless subject exculpates the institutions of patriarchal capitalism, blames other women for their disadvantaged positions, exercises intense surveillance over other bodies, and constantly calls for endless work on the self, centering the notions of empowerment and choice (Rottenberg et al. 2020, cited in Darling Reference Darling2022). For a Reasonable Mother, womanhood and motherhood are often inseparable; thus, she engages in “body projects” of intensive self-regulation, self-transformation, and the disavowal of any aspects of embodiment that are non-compliant with the values of containment and optimization (Darling Reference Darling2022). Sometimes, the structural demands for performing “good motherhood” translate into violence in the delivery room, with “gendered shame” playing a crucial role in reifying laboring women mainly as mothers-to-be (Cohen Shabot and Korem Reference Cohen Shabot and Korem2018).

Individual autonomy also plays a central role in the discourse of white liberal feminists fighting for reproductive rights, with the “pro-choice” movement as a remarkable example. Generally, people who identify as “pro-choice” believe in their right to control their own bodies, including their capacity to decide when and whether to have children. In contrast, people who want abortion to be illegal and inaccessible—often using conservative Christian rhetoric to support their views—self-identify as “pro-life.” In many scenarios, these are considered outdated terms: “‘Pro-choice’ and ‘pro-life’ labels don’t reflect the complexity of how most people actually think and feel about abortion. Some people and organizations, including Planned Parenthood, don’t use these terms anymore” (Planned Parenthood 2024, para. 5). The Reproductive Justice Movement, as described by Loretta Ross and Rickie Solinger, “refuses the logic of individual choice. It clarifies how one’s health, sovereignty, and capacity for family formation are intimately entwined with the broader social, political, and cultural landscape” (Murillo and Fixmer-Oraiz Reference Murillo and Fixmer-Oraiz2021, 762). The problem with individual autonomy, as reproductive justice scholars have constantly argued, is that it ignores that people make reproductive choices in contexts influenced by power dynamics and shaped by cultural values, beliefs, norms, and traditions.

Autonomy is instrumentally essential for decision-making about care seeking, utilization of services, and choosing or declining treatment options. However, while individual autonomy is crucial, more is needed to understand the consent process in obstetric settings. Giving birth is a communal experience that includes (at least) the pregnant person and their baby and (often) a group of health professionals, family members, and birth workers. The social dimension of childbirth influences decision-making, inviting us to problematize the autonomous, Reasonable Mother archetype. Critiques of the liberal individual autonomy model propose that autonomy is a multidimensional process connected to different aspects of social life. People rarely make their healthcare decisions in isolation. Cultural models of health and disease, community rules, and care providers’ advice influence our decisions (Shih et al. Reference Shih, Rapport, Hogden, Bierbaum, Hsu, Boyages and Braithwaite2018). Furthermore, relationships of interdependence, such as friendship, kinship, love, care, and obligation, play a preponderant role in health choices, including the ones taken during childbirth (Gammeltoft Reference Gammeltoft2008; Osamor and Grady Reference Osamor and Grady2016).

Under the framework of relational autonomy, people make decisions with and supported by others, and their goals are usually mixed up with the decisions of others (Cohen Shabot Reference Cohen Shabot2020). The relational here is not limited to intimate relationships among people but to interconnected relationships with institutional structures, law, civil society, and multiple religious and secular discursive traditions (Nedelsky Reference Nedelsky2011, Dokumacl Reference Dokumacl2020). The idea of relational autonomy has roots in early feminist accounts of womanhood, as we can read in the description of de Beauvoir’s carnal subject, a being never isolated nor purely mental: “De Beauvoir’s subject [in contrast to the Cartesian subject] is ambiguous in that it is always situated, particularly embodied, located in a concrete time and place, and thus singularly itself—but also always carnally open and reaching out, and thus more than (only) itself” (Cohen Shabot Reference Cohen Shabot2020, 7). Herring (Reference Herring2014) offers us a rich and compelling feminist study of the relational self—versus the individual self—and states that relational autonomy challenges the traditional conception of individual autonomy, which is built on a patriarchal liberal conception of the subject (Cohen Shabot Reference Cohen Shabot2020).

Mackenzie and Stoljar (Reference Mackenzie and Stoljar2000) developed a rich anthology of contemporary feminist theories of agency. These authors critique the notions of individualism and retheorize autonomy as compatible with social interdependency. To explain their theoretical move, Mackenzie and Stoljar (Reference Mackenzie and Stoljar2000) distinguish between procedural and substantive accounts of autonomy. The procedural accounts relate to individual autonomy, which relies upon rational reflection and the agent’s independence of their beliefs, attitudes, desires, and values. Procedural autonomy is “content-neutral,” disconnected from interdependent relations and cultural contexts. In contrast, substantive accounts of autonomy are connected to our desires, beliefs, and values, which cannot be separated from internalized oppressive structures and societal norms (Mackenzie and Stoljar Reference Mackenzie and Stoljar2000). Therefore, substantive—and not merely procedural—accounts of autonomy matter for understanding how people’s autonomy works under oppression.

Oshana (Reference Oshana2006) provides another essential contribution to theorizing social-relational autonomy. According to this author, we must consider the overall autonomy of a subject instead of their episodically autonomous actions; autonomy requires power and authority, making it impossible for subalternized subjects to be truly autonomous. Being autonomous is to be free from oppressive structures (Oshana Reference Oshana2006). In contrast, Mackenzie and Stoljar (Reference Mackenzie and Stoljar2000) and Bhandary (Reference Bhandary2016) defend the possibility of achieving autonomy, at least to a certain degree, even under oppressive structures. Their perspective highlights agency and the pursuit of freedom as essential aspects of the subaltern’s independence mission. According to MacDonald (Reference MacDonald2010), relational autonomy should conceive external forces to the agent not simply as threats or barricades; it must address dependence as constitutive of autonomy and transform it to allow for interdependent relationships to be balanced with power and agency. When people negotiate between different social features, including their desires, values, available options, and oppressive structures, they exercise “an account of socially embedded agency that is fundamentally and essentially social” (Webster Reference Webster2021, 117). This type of agency is different from shared agency—“which explores what it takes for two or more individuals to act together” (Webster Reference Webster2021, 118)—and it can exist even under circumstances of oppression.

From the ethics of care, Held (Reference Held and Olsaretti2018) states that “human beings [are] vulnerable, dependent, above all interconnected, rather than [resembling] the rational, self-sufficient, autonomous individuals of the liberal traditions on which our reigning models of law and politics, and the moralities that expand them, are built” (231). A relational conception of the self closely connects care ethics with relational autonomy (Keller Reference Keller1997). Interestingly, Bhandary (Reference Bhandary2016), a liberal care ethicist, rejects the concept of “bare autonomy” present in the liberal theory of Hume and Rawls, pointing out that “people’s current choices arise from a cultural context with forms of prescriptive socialization that make choices within these cultures autonomous in only a very minimal sense” (54). For Bhandary (Reference Bhandary2016), “choices are made in specific contexts that are personal, familial, social, political, cultural, and temporal, and they are shaped by the availability of options and by our conceptualizations of those options” (55), which aligns with the principles of relational autonomy.

Researchers have analyzed relational autonomy and its limitations in the decision-making process of multiple health situations. Some of the cases include refusing blood transfusions by Jehovah’s Witnesses (Rajtar Reference Rajtar2018), chemotherapy options for breast cancer patients (Shih et al. Reference Shih, Rapport, Hogden, Bierbaum, Hsu, Boyages and Braithwaite2018), and palliative care guidelines in critically ill patients in the intensive care unit (Mapes et al. Reference Mapes, DePergola and McGee2020). One of the studies that examined relational autonomy in gynecological and obstetric settings was developed by Kaplan et al. (Reference Kaplan, Kandodo, Sclafani, Raine, Norris, Chemey, Khan and Chunda2017). The authors associated the limited autonomy of rural Malawi women with their increased risk of developing obstetric fistula after birth. During interviews, Kaplan et al. found that the “last word” on labor and delivery resided in the husband’s authority. Men often sought the advice of the elderly women in the village and prioritized their opinions over those of their wives and the doctors providing antenatal care. This study illustrates the multiple actors involved in reproductive decision-making and how relational autonomy could harm individual autonomy and birth outcomes. However, Kaplan et al. (Reference Kaplan, Kandodo, Sclafani, Raine, Norris, Chemey, Khan and Chunda2017) also found that young women in Malawi were not passive victims; they had subversive ways of expressing their reproductive autonomy, for example, secretly using contraception without informing their husbands.

Relational autonomy is particularly relevant during obstetric care, and its violation can be considered a form of obstetric violence. According to Cohen Shabot (Reference Cohen Shabot2020), “cutting the original links to our bodies and the world that constitute our phenomenological condition” (1) is a form of obstetric violence. Women and birthing people not only suffer in their physical bodies. In addition, health personnel often exclude partners, birth advocates, and support networks from the birthing rooms (Cohen Shabot Reference Cohen Shabot2020). This practice damages “the social, communal character of childbirth … [increasing] vulnerability, banning support and demolishing relationships and interdependence between laboring women and their significant others during childbirth” (Cohen Shabot Reference Cohen Shabot2020, 2). Feelings of isolation and abandonment are common among birthing people in institutionalized environments with strict protocols for patient visits. Unsurprisingly, the protocols and restrictions established during the COVID-19 pandemic, some of which are still in place, have dramatically increased the number of situations involving giving birth in isolation (Hussein Reference Hussein2020; Sadler et al. Reference Sadler, Leiva and Olza2020).

With the normalization of authoritative knowledge and the medicalization of birth in Western societies (Davis-Floyd and Cheyney Reference Davis-Floyd and Cheyney2019; Sargent and Davis-Floyd Reference Sargent and Davis-Floyd2023), some health professionals may be afraid to cede ground to family members or other birth attendants because this could affect their autonomy. Decreased professional autonomy is defined as a lowered decision-making level, decreased job status, or inability to voice their professional opinion in the workplace. As de Jonge (1998) explains, “Job autonomy is of high importance as it protects healthcare professionals against somatic complaints, psychological distress in their work, and burnout” (cited in Perdok et al. Reference Perdok, Cronie, Schellevis and Verhoeven2017, 68). However, literature shows that good collaboration in maternity care between professionals, patients, and family members enhances the value of relational consent and improves the quality of care, job-related well-being, and satisfaction for health personnel (Perdok et al. Reference Perdok, Cronie, Schellevis and Verhoeven2017). A support network during childbirth enhances pregnant people’s capacity to be autonomous, evaluate options, and make better decisions while promoting better working conditions for health providers (Hunt and Ells Reference Hunt and Ells2011; Shih et al. Reference Shih, Rapport, Hogden, Bierbaum, Hsu, Boyages and Braithwaite2018).

Structural conditions can affect both individual and relational autonomy. Multiple situations distort the informed consent process, constraining a pregnant/birthing person’s autonomy and increasing adverse health outcomes. These circumstances constitute what Campbell (Reference Campbell2021) calls an “informed consent gap,” a disjuncture between patient-centered care, the law in practice, and the healthcare delivery system. Many structural barriers increase the informed consent gap and reproduce structural violence in the health system (Galtung Reference Galtung1969; Farmer Reference Farmer2004). Despite not being exclusive to gynecological and obstetric care, I review three of these barriers (i.e., racism, socioeconomic disparities, and legal coercion) to understand better the structural challenges that pregnant/birthing people and their families navigate in the health system. These barriers should be understood as “interlocking systems of oppression,” as proposed by the Combahee River Collective (in Moraga and Anzaldúa Reference Moraga and Anzaldúa2015), or as intersectional dynamics of inequality with multiplicative effects (Crenshaw Reference Crenshaw1991).

In Reproductive injustice, Davis (Reference Davis, Rivkin-Fish, Brodwin and Shaw2019) exposed the precarious situation of Black mothers in the US health system. She attributed this fact to “obstetric racism,” explaining that Black women had far worse outcomes in maternal mortality and morbidity than their white counterparts, even in similar socioeconomic statuses. For Davis (Reference Davis, Rivkin-Fish, Brodwin and Shaw2019), racism works when health personnel dehumanize Black bodies by denying their pain or believing they have a higher pain threshold, a misconception with roots in the American history of chattel slavery. The relationship between Black bodies and pain resistance is an arbitrary assessment that often justifies medical and pharmacological treatment delays (Davis Reference Davis2018). Health providers can influence patients’ decisions with their racial prejudices about what some bodies need (like a higher/lower dose of analgesics during childbirth), even without making explicit recommendations about it (Campbell Reference Campbell2021). Obstetric racism is part of a medical continuum of violence that historically has used the pseudoscience of eugenics and social Darwinism to exploit Black bodies for medical experimentation, unauthorized autopsies, and even grave robbing (Washington Reference Washington2008). Importantly, the experiences of pregnancy and birth of Black and other Women of Color “are shaped not simply by violence and coercion by patriarchal institutions but also by the multifaceted ways in which gender interacts with interlocking systems of race, class, age, ability, sexuality, and nation” (Chinyere Oparah and Bonaparte Reference Chinyere Oparah and Bonaparte2016).

Socioeconomic conditions also affect pregnant and birthing people’s autonomy and consent. In a literature review about women’s autonomy in “low-income countries,” Osamor and Grady (Reference Osamor and Grady2016, 191) found that “many such societies still have strong social structures that rigidly define the roles of men and women, usually encoded in religious, tribal, and social traditions.” It is crucial to acknowledge that “low income” indicates a country’s location in the global economy, often due to legacies of colonialism. Socioeconomic conditions are highly influenced by structures of oppression such as racism, ageism, colonialism, ableism, and cis-heterosexism, all of which are correlated and directly influence women’s autonomy (Kaplan et al. Reference Kaplan, Kandodo, Sclafani, Raine, Norris, Chemey, Khan and Chunda2017). Low income does not have a causal relationship with patriarchy or conservative cultural traditions. Still, one cannot freely opt for the “best maternal care” within a health system facing precarious economic conditions, including a lack of resources and personnel. More qualitative studies should be developed to improve the instruments that assess autonomy in precarious contexts, especially being careful not to reproduce the narrative of the “trapped/poor women without agency” in the Global South.Footnote ¹²

The surveillance of the legal system over healthcare creates additional problems for people’s autonomy. In rare cases when a pregnant person’s medical choices threaten to endanger her unborn child’s life or health, courts have demanded the performance of C-sections, forced hospital detentions, and other intrauterine procedures against the person’s will (Flanigan Reference Flanigan2016). This legal practice violates the patient’s individual autonomy, personhood, medical rights, and even the autonomy of the health professional forced to perform the procedure. Some studies in the US have also documented that lawsuits for negligence and malpractice are typical strategies patients use to gain large amounts of money in different health situations (Mann Reference Mann2004). As a response, some obstetricians have opted for “defensive medicine,” which often implies manipulating their patients’ decisions to choose what they consider the less risky situation. Defensive obstetric care is one of the explanations for the high rate of C-sections worldwide (Mann Reference Mann2004) and the perpetuation of unnecessary procedures, such as routine episiotomies, prolonged fasting, and limitation of movement without medical justification.

Among many other structural barriers, racism, economic inequality, and defensive medicine due to legal surveillance negatively impact people’s individual and relational autonomy, manipulate the decision-making process, and increase the informed consent gap. In the last section, I propose a strategy to counter some of the problems present during obstetric informed consent. I follow Bhandary’s (Reference Bhandary2020) suggestion to cultivate autonomy and caregiving skills and apply them to the informed consent process of pregnant and birthing people. The proposal highlights the role of doulas and midwives in transforming the technocratic model of birth into a humanistic one (Davis-Floyd Reference Davis-Floyd1992). Implemented with other structural changes, autonomy and caregiving skills are crucial to achieving more satisfactory and just care.

4. Autonomy and caregiving skills: towards a humanistic model of birth and informed consent

Foundational feminist and anthropological work on birth and reproduction has demonstrated that birth is shaped by its geographical and historical contexts. The birth model reflects systems of knowing, beliefs, and practices of the community, often reproducing existing power relations (Kay Reference Kay1982; Jordan Reference Jordan1983; Ginsburg and Rapp Reference Ginsburg and Rapp1991; Van Hollen Reference Van Hollen1994). With the emergence of modern obstetrics, the knowledge and control over childbirth moved from midwives to specialized doctors, confining obstetric care to the hospital walls (Wertz and Wertz Reference Wertz and Wertz1977; Ehrenreich and English Reference Ehrenreich and English1973; Gopal Reference Gopal2017; Basile Reference Basile2019). The resulting model of birth was based on vigilance and interventionism over patients’ bodies, normalizing routinary painful technologies like forceps and vacuum extractions (Davis-Floyd Reference Davis-Floyd1992; Martin Reference Martin1987; Van Hollen Reference Van Hollen2003; Inhorn Reference Inhorn2009).

In Birth as an American rite of passage, Davis-Floyd (Reference Davis-Floyd1992) describes the different Western birth models that became popular in the transition of childbirth from home to hospital: “The industrial model of birth and its successor, the technocratic model, metaphorize and conceptualize the human body as a machine and treat it as such” (60). In these models, “the female body has long been viewed as an abnormal, unpredictable, and inherently defective machine” (Davis-Floyd Reference Davis-Floyd1992, 61), and the woman’s reproductive tract is treated like a birthing apparatus that doctors can control and manipulate. According to Davis-Floyd (Reference Davis-Floyd1992), the technocratic model of birth and healthcare has 12 tenets, including mind-body separation, objectification of the patient, alienation of practitioners from their patients, and standardization and hierarchical organization of care. Of special interest for this paper is the seventh tenet: the authority and responsibility are inherent in the practitioner, not the patient (Davis-Floyd Reference Davis-Floyd1992, 73). In the technocratic model of birth, physicians and institutions hold the power, and when this happens, the patient lacks agency.

Davis-Floyd (Reference Davis-Floyd1992) also explains that, since the emergence of humanism as an ideology in the 1970s, some nurses and physicians have made efforts to humanize technomedicine, leading the way to a new model of birth. The humanistic model follows evidence-based medicine—“the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett et al. in Davis-Floyd Reference Davis-Floyd1992, 78). Some of the tenets of this model include the mind-body connection, the patient as a relational subject, a focus on disease prevention, and the information, decision-making, and responsibility shared between patient and practitioner (Davis-Floyd Reference Davis-Floyd1992). In a deeply humanistic model of birth, the doctrine of informed choice is a fundamental pillar for any medical intervention. Midwives, community health workers, and doulas have been crucial in transforming the technocratic model of birth into a humanistic one, but there is still much to be done.

As many pregnant people still give birth in a technocratic model of healthcare, finding others who can advocate for their rights, provide emotional and physical support, and ensure their individual and relational autonomy is vital. This is where midwives and doulas become key allies for pregnant/birthing people and their families (Doenmez et al. Reference Doenmez, Jaime Cidro, Hayward, Wodtke and Nychuk2022; Salinas et al. Reference Salinas, Salinas and Kahn2022). According to Ford (Reference Ford2021), doulas are “supplementary providers who play a key role in improving maternity care” (114). They are people trained to provide nonmedical physical, emotional, and informational support during pregnancy, childbirth, and postpartum. In contrast to midwives, physicians, or nurses, a doula’s presence during labor and birth is continuous and uninterrupted (Basile Reference Basile2019). One of the main objectives of doulas is to rehumanize the birth experience, acting as kind and compassionate caregivers (Mahoney and Mitchell Reference Mahoney and Mitchell2017). Both doulas and midwives recenter the knowledge of birthing people and help them to advocate for their bodily autonomy in institutional settings. These workers disrupt the biomedical authoritative knowledge, privilege connection, and place value and priority on the everyday nonmedical bodily knowledge, intuition, and experiences of birthing people (Davis-Floyd and Davis Reference Davis-Floyd and Davis1996; Basile Reference Basile2019).

Radical doulas and radical midwives are a subgroup within the birth movement that draws on several perspectives of reproductive justice and third-wave feminism: intersectional theory, postmodernist, and postcolonial feminism, celebrating the multiplicity and contradiction of youth culture activism (Basile Reference Basile2019). Radical doulas “serve as a bridge between the political act of care and the legal practice of consent. In many ways, they ‘translate’ between these, helping clients discover their capabilities and desires and then acting as clients’ ‘voice,’ advocating for their interests, and mediating consent” (Ford Reference Ford2021, 118). The bridging role of doulas and midwives is similar to that of HIV/AIDS educators and rehabilitation counselors in health systems across the world (Chiu et al. Reference Chiu, Boomer and Conyers2019) or the mediation that rape advocates perform during forensic nursing investigations (Mulla Reference Mulla2014). All these supporting figures ultimately defend patients’ rights and interests in healthcare settings, fighting against institutional barriers, medical violence, and other forms of mistreatment and abuse.

Importantly, not only midwives and doulas work towards a humanized model of birth. Rodrigues Duarte et al. (Reference Rodrigues Duarte, Rosário Soanno Marchiori, Vidal Vieira Guerra and Machado Pimentel2020) explored the role of obstetric nurses working under a woman-centered care approach, protecting the relational autonomy of patients during childbirth. Their study showed that nurses’ performance was “based on practices that respected the physiology of childbirth, such as welcoming, physical and emotional support to the parturient woman,Footnote ¹³ stimulating non-invasive and non-pharmacological pain relief practices … and encouraging the companion of the woman’s choice” (907). Their actions resulted in a better quality of care, a reduction in episiotomies, and fewer instrumental deliveries. Davis-Floyd and Premkumar (Reference Davis-Floyd and Premkumar2023) also showed that some obstetricians globally have shifted from technocratic to humanistic practices, opening the path for “deeply humanistic” models in countries like Brazil, India, Hungary, Canada, and Turkey. However, none of these figures should be seen as inherently good caregivers. Fraser (Reference Fraser1998) showed that midwives—and I would add, other “superficial humanist” birth workers (Davis-Floyd and Premkumar (Reference Davis-Floyd and Premkumar2023)—could also reproduce medical power structures, perpetuate white racial purity ideas, and suffer from the oppressive actions of state agents that dismiss their authority.

Despite the coercive nature of birth workers’ regulation by the medical establishment, doulas, midwives, and other humanistic health workers can make an important difference in pivoting towards a humanistic model of birth. One plausible strategy consists of deeply humanistic workers nurturing autonomy skills in pregnant/birthing people and caregiving skills in health providers who still work under technocracy. According to Bhandary (Reference Bhandary2020), “liberal dependency care requires that existing societies support the cultivation of autonomy capacities, or skills” (97). Society must intend to achieve a high level of autonomy and caregiving skills throughout the population as a matter of justice “because they are a precondition for the veracity of judgments about justice” (98). These skills are also fundamental to function as a society, safeguard us against oppressive structures, and provide dependency care, which is “direct care that must be provided by a care-giver to the person needing care (the charge) for the continued survival of the charge” (Bhandary Reference Bhandary2016, 43). All human beings require dependency care to survive during the first years of life, and many people benefit from it when they experience any disease, temporary injury, or permanent physical or mental disability (Bhandary Reference Bhandary2016). I consider that people during pregnancy, labor, and postpartum benefit from dependency care.

Bhandary adapted her set of autonomy skills from the feminist autonomy theory of Diana Tietjens Meyers (Reference Meyers1989, Reference Meyers2002) and the thought of John Stuart Mill (Reference Mill and Collini1989a–b). From Meyers, Bhandary (Reference Bhandary2020) takes “the skills of communication, introspection, memory, analytical reasoning, imagination, and self-nurturing” (108), and from Mill, the “critical capacities of observation, perceptual parsing, and discriminating among possibilities” (107).Footnote ¹⁴ Autonomy skills allow individuals to identify when a policy or practice affects their individuality and decision-making, in addition to “articulate in their own ways who they are and what they value” (Bhandary Reference Bhandary2020, 101). Bhandary’s (Reference Bhandary2020) autonomy skills are “compatible with a wide range of ways of life and personal choices” (104). They do not require that people live in any particular way in their private lives but remain critical enough to protect people against being manipulated by dominant discourses and norms (Bhandary Reference Bhandary2020). Autonomy skills are valuable on many levels and help people make rational decisions about relationships, work, economy, religion, group affiliations, study, and others.

The Meyersian autonomy skills of imagination and self-nurturing are particularly valuable (Bhandary Reference Bhandary2020) for the case presented in this article. Pregnant people can use imaginative skills to envision other possibilities—like a more humanized and respectful model of care during labor—which is crucial for inspiring and developing new laws and clinical protocols. Additionally, self-nurturing enables patients denigrated by the medical establishment to maintain their sense of self-worth, which is generally lost under violent obstetric scenarios, and to regain their physical and psychological equilibrium after facing traumatic birth experiences.

Recognizing and fighting against structural oppressions like the ones mentioned in this article is essential for providing free, informed consent and safeguarding pregnant/birthing people from unconsented, violent medical practices. Structural change is difficult, but autonomy skills can make a positive impact, especially when considering autonomy as choice and action rather than a universal feature and ideal for all people (Westlund Reference Westlund2009). For example, through her autonomy skills, an Indigenous pregnant woman belonging to a community that performs rituals with the placenta could identify that a hospital protocol that discards placentas as biological waste violates her individuality and cultural traditions. She may identify that these protocols are not culturally sensitive and may have a racial bias that coerces people’s decision-making about the final disposition of what was once part of their bodies. Furthermore, she might act by filing a complaint against the hospital, which ultimately can trigger the implementation of a more humanized birth protocol.

Through nurturing autonomy skills in their patients, doulas and midwives can shorten the gap between the objectified passive subject of the technocratic model of birth and the autonomous, relational subject of the humanistic model. Following the example above, the birthing Indigenous woman would probably not manage the language of medical protocols and would require the assistance of someone trained in culturally sensitive care. A doula or midwife in the health team can be the opportunity to advocate for this woman’s communication, capacity of observation, and discrimination among possibilities. Nurturing autonomy does not mean that the humanistic health worker will speak for the pregnant/birthing person, a situation that can easily fall into violent silencing. Instead, they make the patient and their family the center of the care process, reinforcing their individual and relational autonomy to evaluate, consent, or deny any intervention. Ideally, patients and family members should receive reinforcement of autonomy skills during the preconception visit (suggested for planned pregnancies), prenatal controls, and postpartum. The language of this training should be accessible to patients, avoid medical jargon or confusing physiological explanations, and ideally, it should include everyone expected in the delivery room.

Regarding caregiving skills, Bhandary (Reference Bhandary2020) states that “Most people have a natural ability to care, but this ability is differentially cultivated through social expectations, formal training, experience, and apprenticeships” (142). Based on the work of care ethicists like Tronto, Ruddick, Noddings, and Kittay, Bhandary (Reference Bhandary2020) proposes two basic and generalizable caregiving skills necessary for any form of dependency care: attentiveness and responsiveness. “Attentiveness is noticing the needs of the person cared for, which includes a grasp of life from the charge’s point of view, including the charge’s abilities, physical location, and feelings. Varying degrees of empathy are included within the skill of attentiveness” (Bhandary Reference Bhandary2020, 143). Attentiveness requires paying attention to the other person, being receptive, and putting one’s arrogance aside. “Responsiveness is a skill of acting in response to the needs of the dependent person, and it includes a volitional component: the person has to muster the will to act. This skill is functionally secondary to attentiveness, because if a caregiver responds to needs that have been incorrectly grasped, then they will not provide good care” (Bhandary Reference Bhandary2020, 143–44). Under responsiveness, any intervention that the patient has not properly consented, even if coming from the “good intention” of the health team, will not be good care.

As Bhandary (Reference Bhandary2020) recognizes, “Caregiving requires additional skills and knowledge that vary based on the specified activity. Consequently, the skills of responsiveness and attentiveness have to be supplemented by relevant knowledge for the task at hand and corresponding practice-specific skills” (144). Nurses and doctors, for example, require medical knowledge and technical competence to perform procedures, which constitute the base of Western medical/nursing schools. However, to provide humanistic care during childbirth, I argue that health professionals must learn—at least—the caregiving skills of attentiveness and responsiveness. Doulas and midwives are often trained under a different, more holistic/humanistic model of care that already recognizes the relevance of these skills (Davis-Floyd Reference Davis-Floyd1992). Thus, they are essential to teach other health team members the need to develop these additional skills for providing good care.

In her Theory of Liberal Dependency Care, Bhandary (Reference Bhandary2020) proposes that public education must design a curriculum that teaches children basic autonomy and caregiving skills. Developing autonomy and caregiving skills takes time, so this should be a combined effort between school, family, and other institutions. For obstetric settings, I propose that doulas, midwives, and other humanistic birth workers assume the responsibility of reinforcing these skills to pregnant/birthing people, their families, and the rest of the healthcare team. Nurturing autonomy and caregiving skills is a crucial strategy to respect individual and relational autonomy, counter the elevated incidence of obstetric violence, and return the agency of childbirth to pregnant/birthing people and their families. It is a way of moving from the technocratic to a humanistic model of birth.

Following the approach of restorative justice, health professionals working under technocracy have a moral duty to learn caregiving skills and respect their patients’ autonomy. This is a way to repair the harm that the medical establishment has caused to pregnant/birthing people over time. “When put into practice, the restorative process itself can vary considerably, but typically requires bilateral dialog between offender and victim (and sometimes representatives of the affected community) who attempt to find a shared understanding of the harm done and how to recover from it” (Okimoto et al. Reference Okimoto, Konradt, Krys and Dawson2022, 63). Doulas and midwives can be the bridges between health professionals and patients in this restorative justice process of birth model transformation.

Even though autonomy and caregiving skills are valuable resources to battle obstetric violence and protect patients’ autonomy and consent, there are many other strategies that health systems must implement to stop violence and transform the birth model. For example, scholars have proposed a restructuration of the healthcare professions’ curriculum, a revision of the bureaucratic institutional procedures limiting access to health services, and the implementation of birthing teams with decolonial, intersectional, and feminist caregiving approaches (Urrea-Mora Reference Urrea-Mora2014; Diaz-Tello Reference Diaz-Tello2016; Davis Reference Davis2018). I believe that a joint effort of all these strategies can help reduce the cases of traumatic births and increase favorable healthcare experiences for pregnant and birthing people.

In this article, I presented the relationship between autonomy, consent, and violence in obstetric care settings. I explained the relevance of individual and relational autonomy to provide informed consent in healthcare and described some of the structural barriers that manipulate this process, including obstetric racism, socioeconomic disparities, and legal coercion. Finally, I presented the nurturing of autonomy and caregiving skills as a strategy to face obstetric violence and ensure the free exercise of people’s autonomy in the decision-making processes regarding their obstetric health. It is important to address that autonomy, relational or not, has been a powerful ideal in the Western context since the Enlightenment. However, autonomy is not “a universal ideal of human agency that provides the standard by which to judge a person’s status as a full agent and a fortiori his or her deservingness of our respect as an equal” (Herr Reference Herr2018, 208). For non-Western societies that do not embrace autonomy as a hyper-good or that function under alternative models of care, other categories might be more useful (Herr Reference Herr2018).

It is also essential to acknowledge that historical misinterpretation of women’s bodies and their capacity for reasoning continues to influence how health professionals interact with their patients and doubt their judgment. Even though some health personnel interpret the critical moment of birth as an emergency, influenced by pain and cognitive changes during pregnancy, we must remember that ACOG states that pregnancy and labor are not exceptions to the principle of decision in capable patients. Furthermore, “forced compliance [to any medical intervention] raises profoundly important issues about patient rights, respect for autonomy, violations of bodily integrity, power differentials, and gender equality” (ACOG 2016, 1). In other words, any medical intervention performed on a patient without informed consent violates their rights and can be experienced as violent.

Other scholars have explored the causes and consequences of obstetric violence but have paid less attention to the ontological dimensions of autonomy, decision-making, and relationality in healthcare. Through this paper, I have engaged with philosophical and anthropological perspectives on autonomy, theories of care, and bioethics to contribute to the literature on gender and medical violence. Further studies, especially those that explore the meaning of autonomy in different populations and cultures, more accurate ways of measuring it, and good ways of teaching autonomy and caregiving skills are necessary to expand our understanding of this phenomenon. Health personnel working in obstetric care must recenter patient autonomy as a core principle of ethical practice, including the relational, cultural, and contextual aspects of the decision-making process. Recentering autonomy in the informed consent process can be an effective way of preventing obstetric violence.