Over at Vice yesterday, Rachael Sigee has an article that is worth a look: When Domestic Abuse Destroys Your Childbirth Plan. The subtitle? “Over a third of domestic violence gets worse or starts during pregnancy. Two women break down what it’s like to survive abuse while giving birth.”

Sigee writes:

Despite having had a traumatic emergency caesarean with her first child, Selina’s husband thought she should have a VBAC (vaginal birth after caesarean) for her second. Specifically, a water birth at home with no pain relief. She recalls telling his family she did not want him at the birth, but “they thought I was this crazy, hormonal, pregnant woman.”

It was only when Selina’s mother intervened that her now ex-husband drove her to A&E. Once there, he continued to insist: “You can do this naturally. The medicine is bad for the baby. You are so strong.”

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Like many comments from abusers who specialize in controlling and manipulating their targets, this has what philosophers and linguists call “attributional ambiguity”: it could be motivated by concern and admiration but it could also be motivated by utter disregard for the person’s own stated preferences and identity. Only the pattern of behavior tells us which it might be. For Selina, that pattern revealed a desire to control and manipulate and included a not-uncommon (for abusers) diversion of services intended for her, from her, to him.

“This went on for about 30 hours,” Selina remembers. “I didn’t have any pain relief and at that point I told the doctor, ‘Give me everything you have.’” In fact, her husband was secretly helping himself to her gas and air.

During their nine-year relationship, Selina, now in her early thirties, was subjected to physical, psychological and financial abuse. His controlling behaviour pulverised her autonomy. It also extended to her birth plan. “At the time I didn’t think of it as pushy or sinister,” she says. “It was very encouraging and persuasive.”

Her story exists under the umbrella of coercive control, which became a crime in England and Wales in 2015. Signs include isolating someone from friends and family, depriving them of basic needs, monitoring their time and activities and humiliating, degrading or dehumanising treatment.

Head over to the article and read it in full for more on this issue, which is underattended in the literature on informed consent. It’s pretty easy to see how this is a problem for the kind of individualistic isolated autonomy perspective that dominates bioethics. But things get usefully nuanced when we ask, how can we make sense of this violation of autonomy from a feminist relational autonomy perspective? And how can this context help us think about similar manipulation/coercion by providers with respect to the decision-making of laboring or pregnant patients?