Caitlin Larson’s first labor was proceeding smoothly. She’d had a healthy pregnancy, and she said her son had come down the birth canal “beautifully.” She’d only been in labor for eight hours. But the mood in the delivery room changed when her baby started to crown.

Larson didn’t know her doctor or nurses, and she was exhausted. At one point, she started hyperventilating.

“They said if I didn’t control my breathing, they’d take me to the operating room” for a c-section, Larson said. “Of course that’s terrifying.”

Although her baby had only been crowning for 20 minutes and wasn’t showing signs of distress, her doctor said her son was “stuck,” as her skin hadn’t stretched enough. He announced he was going to cut her.

“I just said, ‘OK,’” Larson said in an interview with Rewire.News, and her doctor went ahead with the episiotomy. Although the procedure used to be somewhat routine, conducted in 65 percent of vaginal deliveries during the late 1970s, research has shown it is unnecessary in most births. Now, episiotomies are used in under 12 percent of cases, typically when either a baby’s shoulders are stuck behind the pelvic bone, the baby is in distress, or the doctor needs to use forceps or a vacuum.

Larson was 22 when she became pregnant, and her mindset was to do whatever the doctors said; she didn’t know she had other options. That meant when they wanted to do cervical checks—which are used to check whether the cervix is starting to dilate and are optional if a pregnancy is healthy—she let them. On top of the physical unpleasantness, Larson also has trauma in her past that made such procedures triggering.

“I definitely wish that I would’ve been offered the option to not have cervical checks,” Larson said. “You just feel like you’re not supposed to be challenging your doctor. You don’t want to to be a problem or an inconvenience, and you don’t feel educated enough to really question these things that are done, but they’re also not explained.”

Larson’s labor and delivery had a happy ending: a healthy boy who’s now 4 years old. But her experience illustrates the need for meaningful, informed consent for medical procedures, which requires information disclosure, competence, and comprehension in addition to the act of saying “yes.” Without it, labor and delivery for people giving birth can be traumatic: One study found that the most common factor behind traumatic births was a lack or loss of control. And traumatic births—which up to a third of women experience, according to one study—can lead to postpartum depression, anxiety, and post-traumatic stress disorder. Given the rising maternal mortality and morbidity rate in the United States, especially among Black women, activists and experts stress the importance of addressing this problem head on.

Some have started using the term “obstetric violence” to describe the kind of situation Larson experienced. They say the prevalence of this trauma is, in part, driven by a legal environment that pushes physicians to conduct unnecessary interventions and make decisions that disregard a pregnant person’s desires. Farah Diaz-Tello, senior counsel for the SIA Legal Team, an organization that works to decriminalize self-induced abortions, says that although a definition for obstetric violence is in flux within U.S. legal circles, usually it includes the use of threats or coercion to enforce medical opinion.

“The medical/legal concerns and fears of malpractice liability often mean that obstetric violence is used as a form of defensive medicine,” Diaz-Tello said. To be sure, awareness of malpractice liability does not always lead to violence, and plenty of obstetricians provide care while respecting a pregnant person’s right to informed consent and refusal. Lawsuits are also meant to be an avenue for redress and a way to protect patients from malpractice.

The threat of malpractice lawsuits comes from both the high frequency of suits obstetricians face and the expensive payouts of successful claims, driven by the high cost of caring for a child with a lifetime of health problems. Obstetricians, says Dr. Mark Landon, chair of the department of obstetrics and gynecology at Ohio State University, are especially aware “they may be held liable for an abnormal outcome, whether or not it was indeed preventable,” impacting to some extent the clinical practice of obstetrics, he said.

When obstetricians are sued for bad birth outcomes, the cases almost always revolve around a failure to act, such as failing to perform a timely cesarean, says Elizabeth Kukura, visiting assistant professor of law at Drexel University. She says because of this environment, doctors have understandably absorbed the message that the risks of a lawsuit are higher if they do nothing than if they do something, regardless of what the pregnant person wants.

In other words, the choice between a battery suit, which can result from harm to the pregnant person, and a negligence suit for an infant who is harmed and may have a lifetime of health-care problems, is easy, Diaz-Tello says.

“It’s a no brainer for somebody who’s doing that kind of cost-benefit analysis,” Diaz-Tello said.

Like Larson, Amy Butz was having a great pregnancy. At 38 weeks, her baby was hiccuping in her womb, and she and her husband had painted a pond-themed playroom because she had been dreaming about frogs.

But a routine check up in July 2011 turned Butz’s happy pregnancy into an emotional and physical nightmare after her midwife stripped Butz’ membrane, separating the amniotic sac from the uterine wall and sending her into labor.

“As soon as she did it, I knew exactly what she did. And we had just talked about it,” Butz said.

Her birth plan outlined her desire to wait until her son was ready to come out, even if that meant going beyond the 40 weeks; her own mother had had longer pregnancies with her and her brother too.

“I had just said I’m willing to go way past my due date, and I trust my body and I trust my baby, and then she did that.”

Hours later, in the hospital and after Butz accepted pitocin to speed up her labor, nothing was happening. Her doctor stopped by and asked to check how she was progressing. What he didn’t tell her, she says, was that he was also implanting an internal fetal monitor, even though her birth plan said she didn’t want one and she was already receiving intermittent reads from an external monitor, which is acceptable in South Carolina hospitals.

“Nobody told me what was going to happen until I had this wire hanging out of my vagina,” Butz said. “Right after that happened, I told my husband, ‘I feel like I’ve been raped.’ It felt like I had been violated because I didn’t give consent to that.”

Diaz-Tello says when there’s a disagreement between someone giving birth and their doctor, there can be a tension between a doctor’s expertise and a pregnant person’s individual knowledge of their own body and circumstances.

“When you layer over that sexism and racism and classism and all of the systems of oppression that we face in our country, we have a real disparity in the relationship, and those types of disparities in relationships where somebody holds power and holds power over another person are really susceptible to coercion and even to violence,” Diaz-Tello said.

The moment Butz took back control during her labor was when she asked for a cesarean, saying, “No, I’m not doing this anymore. Just cut me open … and get my baby out.”

After her baby was born healthy, Butz and her husband never wanted to have kids again. She tried to go to the dentist afterward, but when he laid her back in the chair and turned the light on, she says she had flashbacks of being strapped down during her c-section, feeling the cuts and tugs, and she started screaming and crying.

“It was just a snowball effect of, ‘I don’t want this but I’m letting them do it anyway. Why am I letting them do [these interventions]?” Butz said of her labor and delivery. “Then you have to live with the guilt of I let that happen because I allowed myself to do what they told me to do. And all this is going through your mind when you should just be able to be in your moment.”

Kukura says that to have meaningful informed consent, doctors need to be able to respect a person’s informed refusal of treatment. However, this is something courts have yet to recognize, leaving doctors legally responsible for fetal injuries that may happen if a pregnant person refuses treatment.

When “we see courts willing to enforce an informed refusal of treatment and say to a woman … ‘This was the decision that you made,’ we might see more physicians following that women’s informed refusals in a more faithful way,” Kukura said.

While advocates and professional organizations can encourage reconfiguring the legal environment, doctors can also take a few steps to provide consensual care. The first is improving communication and building trust between physicians and patients.

Kelly Aten, a certified nurse midwife, says in emergency situations she takes an extra 30 or 40 seconds to explain why she is making a recommendation that may go against a pregnant person’s original plan. That gives them the chance to feel like they are making decisions, rather than being told what to do. She says midwives are sued less frequently than OBs, presumably because they are used less often or because they establish a trusting relationship with their patients and prioritize communication.

“Most mothers are not going to choose things that actually put their babies in danger,” Aten said.

Pregnant people can create an environment more conducive to the kind of labor and delivery they want by carefully choosing who will be in their birth space, starting with their doctors and nurses. For Larson, who opted for a homebirth with a midwife for her second child, educating herself on her options made a major difference between her first and second pregnancies.

Those who do experience obstetric violence can file complaints with their hospital or licensing board, but “the vast majority of people who experience obstetric violence have no meaningful recourse to anything that approaches justice,” Diaz-Tello said. This is partly because even finding an attorney to take on an obstetric violence case is difficult, said Kukura.

Butz became a birth and bereavement doula because of the trauma with her first pregnancy. When she did become pregnant again, she and her husband agreed on an unassisted home birth—unassisted because midwives aren’t allowed to perform vaginal births after a cesarean in South Carolina. By the time Butz neared the end of her third trimester, with the reassurance of a healthy final checkup, they felt confident and prepared.

Forty weeks came and went, and at 41 weeks she started laboring at home. It took four days. When she was finally at the end of her delivery, she and her husband decided to go into the hospital after all because she was feeling faint. Fifteen minutes after arriving there, she had another healthy baby boy, who is now one of three.

“It was still good because I felt prepared and I felt like I was my advocate and I made all the decisions,” Butz said. “It was very healing and amazing.”