Turbin sent her video to a group called Birth Without Fear, which she came across while searching for online breastfeeding forums. They brought it to the attention of Dawn Thompson, the founder and president of an advocacy organization, Improving Birth. In many ways, it was the case Thompson had been waiting for. She had tried to raise awareness about ‘obstetric violence’ for years, but one of the biggest obstacles was skepticism that such a thing actually existed. The video meant Turbin’s story could be proved. There was no doubt that she said no and the doctor proceeded anyway.
‘There are thousands of stories like Kim’s, but hers was caught on video,’ says Thompson. ‘Just before she reached out to us, I had been saying that we needed to find documentation, a video, of a doctor being abusive to substantiate the case, so people would know that this is not unusual. Kim’s story is an extreme version, but it’s an issue everywhere.’
Disregard of consent during childbirth and the use of unwarranted interventions are more common than one might like to think. In the Listening to Mothers III survey, a 2013 study of maternity care in the US, 59 percent of participants who had experienced an episiotomy said they did not have a choice about having the procedure. Between 8% and 23% of mothers also reported experiencing pressure for a range of other interventions, including labor induction, epidurals and C-sections. The same pattern holds in the UK. Over 12% of women said they did not give their consent to examinations or procedures in a 2013 survey conducted by Birthrights.
Research from the Harvard School of Public Health has found that bias, prejudice and stereotyping by healthcare providers can contribute to decreased agency for patients and the delivery of lower-quality care. In the Listening to Mothers survey, about one in five black and Hispanic women reported poor treatment from hospital staff due to race, ethnicity, cultural background or language, as compared to one in 12 white women.
‘Women face many violations during maternity care and it is as if their human rights — dignity, bodily and psychological integrity, privacy, equality — do not exist,’ says Camilla Pickles, who studies obstetric violence and the law at the University of Oxford. ‘Subjecting them to a cascade of medical interventions unnecessarily and without informed consent is wrong, harmful to their overall wellbeing and can be dangerous.’
In an ideal world, physicians would only recommend or perform interventions when medically necessary and the necessity of those interventions would be clear. That, however, is not the world we live in. Research shows that the prevalence of certain childbirth interventions has far more to do with where and when the physician was trained, the culture of the hospital, and even the time of day or day of the week. A labor that one doctor views as too slow, another may view as slow but safe.
‘There could be ten women with the same clinical chart and they could make ten different decisions,’ says Hermine Hayes-Klein, founder and executive director of Human Rights in Childbirth. ‘There is so much medical uncertainty with childbirth — the decision-making is not black and white.
‘Underneath the idea that childbirth is somehow complicated or different compared to other kinds of informed consent is the idea that somehow because a woman is pregnant, she has less authority over her body than other people.’
There is a long line of precedent establishing that all competent patients, including those who are pregnant, have the right to decline unwanted medical procedures. In practice, this can be overshadowed by the idea that doctors know better than their patients what is right. If a doctor says something is best, the impulse is generally not to push back.
‘We have this cultural ideal about pregnant women and women in labor as hysterical,’ says Holly Fernandez Lynch, professor of bioethics at Harvard. ‘There is a hierarchy in medicine and you don’t have much control over [what happens]. Then after the fact, people say you are overblowing this. It’s a symptom of how deeply ingrained the idea is that the doctor wouldn’t do anything to harm you.’
Fernandez Lynch adds that there could theoretically be an ethical gray zone if a mother was refusing an intervention that would save the life of her baby, but these cases are exceptionally rare because women in labor are not, in practice, inclined to make choices that put their babies in danger. A situation may be confusing and progressing fast, but physicians still have an ethical duty to inform their patients fully and honestly about what is happening and involve them, to the extent possible, in the decision-making process.
Turbin’s case did not appear to exist in this gray zone. The video of the birth does not indicate that she or the baby were in danger. This is backed up by her medical notes, in which Abbassi wrote: ‘She progressed as per usual… and she delivered a baby boy… spontaneously.’
These records show that some of her wishes were followed: ‘The patient refused any surgical intervention and vacuum, so the 2nd stage was prolonged.’ But then, Abbassi noted, without further explanation, ‘it was necessary to perform episiotomy under local anesthesia.’
In the months following her son’s birth, Turbin struggled with emotional and physical trauma. She was in serious pain and found it difficult to do basic things, like sit down. She bought pillows to sit on and changed her entire diet so that going to the bathroom would be less painful.
‘I bought a NutriBullet and basically only ate blended fruits and vegetables because I was so scared to use the bathroom,’ she says. ‘It was horrible.’
After talking to Thompson and Improving Birth, Turbin filed a complaint with the hospital and met with its director of women’s services. She also filed a complaint with the Medical Board of California. Not satisfied with the responses she was getting, she decided to move forward with a lawsuit for assault and battery.
I feel like the nurses, doctors and hospital only did what was in their best interest, not mine
However, Turbin and her supporters couldn’t find anyone to take the case. They talked to 80 different lawyers over the course of 18 months, and were repeatedly turned down. Either the lawyers thought it should just be a medical malpractice case or they were not willing to work pro bono. Some didn’t think Turbin had a case at all because her baby was fine and her own injuries were not as pronounced as, say, those of Caroline Malatesta — an Alabama woman who suffered a debilitating nerve injury after nurses held her son’s crowning head inside her for six minutes while waiting for the doctor to arrive. With the statute of limitations on assault and battery drawing to a close, Turbin filed the complaint herself.
And then finally, towards the end of 2015, Thompson connected with Mark Merin, a prominent civil rights lawyer in Sacramento, who agreed to accept Turbin’s case. With episiotomy, Merin says, ‘there is a tendency to defer to a doctor as the expert about what is needed or not needed. It’s rare that a woman will assert her autonomy and say no.’ He believes that other lawyers initially thought, ‘What is this woman complaining about? This is a doctor’s decision, not a woman’s decision.’
Even Turbin’s mother, who was in the delivery room with her (and filming), took the doctor’s side and encouraged her daughter to allow the episiotomy, saying ‘He has to do his job’ over Turbin’s protests of ‘No, don’t cut me.’ The decision, however, was Turbin’s, which is why she wanted to bring an assault and battery suit rather than medical malpractice. She and her supporters felt it was a more accurate reflection of what had happened. In a medical malpractice suit, the plaintiff alleges that the doctor behaved in a way that a reasonable doctor would not — by messing up a procedure, performing below standard, or neglecting to get a patient’s full consent. Battery, in contrast, requires proof that the defendant made physical contact with the plaintiff in a harmful or offensive manner against their will.
‘A battery is a pretty extreme characterization of a doctor’s actions,’ says Merin. But, he adds, Turbin was ‘restrained’ and she said the procedure was ‘performed against her will.’
In June 2016, Judge Benny Osorio ruled in the Superior Court of California that Turbin v. Abbassi was properly constituted as a battery lawsuit. In his court order, Osorio wrote that Turbin had ‘alleged a battery based on a deliberate decision to ignore the scope of the plaintiff’s consent, not a negligent failure to disclose a potential complication.’ This meant Californian courts were willing to try incidents like this as potential acts of assault.
This is why it’s so significant. The judge acknowledged the possibility that a doctor performing an episiotomy without the patient’s consent could be committing an act of violence, as opposed to just medical malpractice. Thompson hopes Turbin’s case will have national implications about legal rights during childbirth. It raises awareness about the issue of consent and authority, and shows that there are opportunities for recourse for those who believe they have been subjected to obstetric violence.
‘This is one of the first cases ever of calling it assault and battery,’ Thompson says. ‘Dr. Abbassi is essentially a symbol for me. Women are constantly thanking Kim for standing up for them because they weren’t able to do it for themselves.’
Ultimately, however, Turbin’s case did not reach a full trial. By January 2017, mediation was underway and what turned out to be the last meeting in the process was emotional — the culmination of a journey that had unfolded over many years, one that Turbin was desperate to be done with. When Merin told her that taking the case to trial could take years, she put her head down on the table in despair. The prospect of waiting for a trial and then recounting the entire experience for a judge and jury was overwhelming.
‘Mentally, I was done,’ she recalls. ‘I don’t even know how I got that far. I felt like crying, but I also felt like I made my point.’
Abbassi and Turbin agreed to settle out of court. He had already relinquished his medical license in 2015, having acknowledged that his cognitive functioning meant that he could not continue to safely practice medicine. Despite several attempts to contact Abbassi to hear his side of the story, I was unable to reach him either directly or through his lawyer.
Turbin’s case is extreme, by any measure, but it is an extreme on a spectrum. Around one-third of women experience trauma while giving birth. A recent study published in the journal BMC Pregnancy & Childbirth asked 943 of these women from around the world about their experiences with birth trauma. Two-thirds of them said that their trauma related to the way they were treated by medical professionals. Their statements were startling.
‘I begged not to have a C section, neither I nor my baby were in distress or danger, but because the doctor was ready to go home, he did a terrible section that resulted in almost a year of recovery,’ one woman said.
‘I was steamrolled with unnecessary intervention and didn’t get to speak with a doctor about my options, risks vs. benefits… I feel like the nurses, doctors and hospital only did what was in their best interest, not mine… It was a nightmare,’ said another.
Shared decision-making is supposed to be a part of giving birth, but pressure, manipulation and coercion are not uncommon in the delivery room. In most cases, this is not due to malicious intent. If physicians think a certain course of action is best, it is their duty to express that. However, it is ultimately the patients who have the right to decide what happens to their bodies. Pregnancy does not eclipse agency, but many of those approaching childbirth do not know this. They don’t know that they can say no, or they don’t understand why there might be a need to.
As Turbin discovered when sharing her experience with the people around her, this type of treatment is considered normal in some communities and there can be minimal accountability. Her refusal to accept this response, her willingness to share a deeply intimate video with the world, and her drive to keep pursuing her case through four years of rejections and dismissals all stem from a conviction that no woman should have to endure what she did, especially not without the right to hold those responsible to account. She realized that too many women go through similar experiences and never speak up, which allows the pattern to continue.
‘What’s most unusual about this case,’ says Hermine Hayes-Klein, ‘is that she made it into court. Thousands of women behind her did not have that kind of access.’
More than four years after the birth of her son, Turbin is still coping with the physical and emotional effects. She has suffered through sustained and acute pain, struggling to find a doctor who could help her on public insurance. When she visited a family healthcare clinic that accepted Medi-Cal, looking for help with the vaginal pain, they gave her lubricant and told her to try anal sex. She has also dealt with PTSD, depression and anxiety as a result of the trauma, compounded by her memories of rape.
‘My son has a sad mom sometimes or someone who gets frustrated because she’s in pain,’ she says. ‘I was supposed to be okay and it went completely upside down.’