Obstetric violence is a global health problem, and one that seems to be on the rise. It’s not known if this is due to increased reporting by women who have been victims, or because the number of cases is growing.
In spite of the worrying trend, there isn’t a global consensus on how violence against women during pregnancy, childbirth, and post-partum care should be defined and measured. This makes reporting as well as prevention incredibly challenging.
Obstetric Violence: What Is It, and Where Is It?
Obstetric violence is generally defined as gender-based violence perpetrated by health professionals, including general practitioners, midwives, nurses, gynecologists, pediatricians, and even medical and nursing students. Gender-based violence is defined as “violence directed against a person because of that person’s gender, with women being disproportionately affected by this type of violence.” This type violence is not limited to physical abuse, but also includes disrespect, mistreatment and coercive behavior. Gender-based violence can take various forms, but this is one form that disproportionately affects women.
One theory as to the origins of obstetric violence has to do with gender bias in society and within its legal framework in general; at worst, women are de-facto second class citizens in certain patriarchal societies. At best, their rights to make decisions regarding their own medical care are frequently overridden, or laws are put in place to make these decisions for them.
The United Nations Populations Fund is an agency whose mission is to improve maternal health and reproductive health on a global scale. It recognizes that the lack of international consensus on how this kind of violence is defined and measured in the context of giving birth in a medical facility is part of the problem.
In July 2019, the UN General Assembly issued a report that recognized the global problem of obstetric violence. The percentage of women who say they suffered at least once instance of obstetric violence in surveyed countries ranged from 18.3% in Brazil to 75.1% in Ethiopia. Contributing causal factors included low economic status, social stratification, inequality, discrimination, race, age, insufficient training and education, patients’ lack of awareness about individual rights or protections, and a lack of respect for women’s equality and human rights.
The short and long-term effects on women can include post-traumatic stress disorder, postpartum depression, slower healing from the physical effects of giving birth, problems breastfeeding, a negative impact on the mother’s ability to bond with her newborn, and on the woman's sexuality or desire to have more children. The participation in and/or witness of obstetric violence by health care providers also takes its toll, in the form of secondary traumatic stress, compassion fatigue, and a desire to leave the medical profession entirely.
It is important to take into consideration that obstetric violence is not the same thing as a complicated childbirth or one that requires medical intervention. The World Health Organization (WHO) offers a definition of a positive birth experience, which includes “giving birth to a healthy baby in an environment free of clinical and psychological risks, and receiving emotional support.” This support includes being attended by competent, compassionate medical personnel, who carry out any required medical interventions with the fully informed consent of the patient.
The Women’s Health Observatory in Spain is currently at work on a new Strategy for Normal Childbirth Care within the National Health System.
The Spanish Health System and Obstetric Violence
In Spain, 38.3% of women have self-identified as having suffered obstetric violence. Most of these cases occur during the process of delivery, and most often have to do with a lack of informed consent with regard to medical procedures and treatment of the infant and mother after birth. This can cause harm not only to women’s health, also to their psychological well-being by undermining women’s dignity and sense of autonomy; this not only harms individual patients, but also contributes to gender inequality and inequities across society as a whole.
Economic inequities and inadequate resources can lead to uncertain outcomes for expectant mothers. The decentralization of Spain’s public healthcare system began in 2003; some scientific studies have suggested this to be a contributing factor to the prevalence of obstetric violence in that country, especially in regions with fewer resources, but the results are inconclusive. In 2010, the Spanish Health Ministry published its non-binding Clinical Practice Guidelines for Normal Birth, with the intention of standardizing clinical practices across the autonomous communities when it comes to childbirth, but its practical impact has been unclear.
Jaume I University conducted a study in May and June 2021 through in-depth interviews of medical professionals on the subject of obstetric violence. (The subjects ranged in age from 22 to 70 years old and were 80% female and 20% male.) The aim of the study was to “explore current information and knowledge about obstetric violence within the Spanish healthcare context, as well as to develop a theoretical model to explain the concept of obstetric violence, based on the experiences of healthcare professionals and students.”
The study’s goals included how to identify and define obstetric violence by understanding its characteristics; how to apply new information to previously accepted data; and how to create strategic prevention plans on both a micro- and macro- level.
The results revealed that healthcare professionals and students considered obstetric violence to be a serious concern within their profession, a violation of human rights and a serious public health concern. Research shows that Spain and Ireland are statistically the two European countries with the most instrumental or induced deliveries and episiotomies in the EU, and that these statistics are far above the World Health Organization official recommendations.
Another study funded by the same university from January 2018 to June 2019 surveyed 17,541 participants from across the country. The study stated: “When we refer to obstetric violence we apply a broad concept that includes verbal, physical, psychological and sexual violence, social discrimination, negligence in health care and healthcare professionals’ improper use of procedures and technologies.”
Aside from the 38.3% of surveyed Spanish women who reported they had undergone instances of obstetric violence, 44.4% stated that they had undergone unnecessary or painful medical procedures; 83.4% of these patients were not asked to provide informed consent for these procedures.
This study concluded that it was necessary to reevaluate the Spanish National Health System’s structure and management, as well as healthcare professionals’ training, in order to try to address the issue. Institutional violence inevitably occurs when the administration can’t or won’t dedicate enough human or material resources to guarantee safety and adequate attention during births at their facilities; a lack of adequate staffing and funding was concluded to be a part of the problem.
The World Health Organization (WHO) offers a definition of a positive birth experience, which includes “giving birth to a healthy baby in an environment free of clinical and psychological risks, and receiving emotional support.”
No Change Without Acceptance
Another goal of the 2018-2019 study was to uncover the structural and systemic flaws that contribute to this specific kind of violence against women, rather than over-simplifying the problem by assigning blame only to individual medical care providers. The data collected during the interviews demonstrated that obstetric violence is all too often perpetrated unintentionally by healthcare professionals who aren’t even aware of the damage that they’re causing. This has resulted in certain harmful practices becoming normalized within the medical community; one ray of hope is that it demonstrates that a focus on education and training could be a starting point for changes to be made.
The study demonstrates that the existence and prevalence of obstetric violence is not generally accepted by the majority of Spanish healthcare professionals, nor by Spanish society in general. According to the above studies, many professionals aren’t even aware that they are perpetuating this kind of violence, and this ignorance or lack of awareness has caused certain harmful practices to become normalized. In fact, many within the medical community refuse to acknowledge the existence of obstetric violence, associating the word “violence” with an intentionally harmful, immoral, and/or criminal act; this unwillingness to consider the possibility that serious harm or violence may be done to a patient unintentionally due to a lack of knowledge or lack of empathy was shown to be one of the greatest contributing factors to obstetric violence in Spain.
None of the cases surveyed involved obvious malicious intent nor desire to harm a patient. Instead, a lack of training, lack of consideration for the patient’s physical or emotional needs, and outdated, pseudoscientific, misogynistic tropes about the female mind and body that are still ingrained in Spanish society often resulted in authoritarian attitudes on the part of the health care worker, and the inability to detect when harmful practices were used during pregnancy, the delivery of the child, or postpartum care.
Fear of retaliation from colleagues or superiors can also represent a barrier to taking action. The discussion of obstetric violence in the workplace is often taboo; workers may be unclear as to whether or not violence was perpetrated in the first place, and if so, what the proper reporting procedures are. In short, the Spanish medical system’s overall unwillingness to admit a systemic problem has had a negative impact on patients as well as on members of their own community.
Many within the medical community refuse to acknowledge the existence of obstetric violence. Their unwillingness to consider the possibility that serious harm or violence may be done to a patient unintentionally was shown to be one of the greatest contributing factors to obstetric violence in Spain. Photo by Engin Akyurt, CC0, via Wikimedia Commons
Specific Cases and International Attention: The UN Committee and S.M.F.
The UN Committee on the Elimination of Discrimination Against Women (CEDAW) is an entity composed of twenty-three independent human rights experts in women’s rights from countries around the globe; they serve in their personal capacity and not as representatives of their government or any other state-run organization. The Committee’s job is to monitor UN member states’ compliance with the Convention on the Elimination of All Forms of Discrimination Against Women; an Optional Protocol was adopted in a 1999 resolution that allows them to receive complaints from individuals or groups whose human rights may have been violated according to the framework of the Convention.
The first time in the Committee’s history that it officially condemned a government for failing to adequately protect the rights of a mother and child occurred in 2018; this was the result of a 2011 case of a Spanish woman who went to a public hospital with a normal pregnancy and ended up suffering mistreatment at the hands of the doctors and nurses who attended her.
The mother, referred to in the official proceedings as S.M.F. to protect her privacy, had her skin, nerves, and muscles around her vagina cut without her permission, and more than ten digital vaginal examinations were carried out without the mother’s consent during the birthing process; one of these resulted in the newborn contracting an infection that required that she stay in the neonatal unit for several days, and S.M.F. was not allowed to see her. The mother said that the process was dehumanizing: she felt like she was a machine being run through a car wash or an assembly line, not a human being giving birth with the help of medical professionals.
The mother sought legal repercussions against the hospital and Spanish State’s Health Administration for a lack of effective protections for women. The Committee’s final decision recognized the negative impact of gender stereotypes and stereotypes about women’s sexuality and their traditional roles in society, as well as the imbalance of power in the dynamic between a team of health professionals and a pregnant woman. It also detailed other factors that contributed to causing harm in this specific case and in cases of obstetric violence in Spain in general.
The Committee also officially recognized that widespread systemic discriminatory practices by health administrations and judicial authorities can cause direct harm to pregnant women and their newborns. Its recommendations of specific steps that the Spanish State should make included ensuring access to adequate, safe obstetric care for all Spanish women; conducting official studies on gender violence and obstetric violence in the country in search of potential solutions; improved training for health professionals in women’s reproductive rights; the guarantee of effective measures to compensate victims in cases of obstetric violence.
This decision, as well as the categorization of this type of situation as a form of gender violence, represented a first step towards a more structured international approach to this global problem.
Nahia Alkorta has made her story public in the book “My Stolen Birth.”
Nahia Alkorta’s My Stolen Birth
As with all serious health issues—death, illness, abuse or injury—the problem is only hypothetical when being discussed in philosophical terms. It feels real when we put a name and a face to it.
In another case in July of 2022, the UN Committee published its findings on the case of a young Basque woman named Nahia Alkorta: she was forced into premature labor and a caesarean section without her consent in a public hospital in Donostia. The woman filed a formal complaint, the second in Spain’s history, stating that she was suffering from mental and physical trauma after her experience giving birth under such circumstances. She even wrote a memoir about the process, called Mi parto robado (My Stolen Birth).
Alkorta had gone to the hospital because her water had broken at 38 weeks of pregnancy. The standard protocol in such cases would be a 24-hour waiting period to assess the various options and to inform the mother of them. The hospital skipped this step and induced labor prematurely, without informing the mother of any alternative possibilities for care. The C-section was performed by a group of residents in training, overseen by their supervising attending physician. Hospital records show that there was no imminent threat to mother or baby that would necessitate such an action.
In addition, the woman was not allowed any food, and had her arms strapped to the bed against her wishes. She was then forced to undergo multiple digital vaginal examinations with no explanation, followed by the premature caesarean section. All of this occurred without giving Alkorta the opportunity to call her husband, or any other family member or friend. She later stated that she was “treated like an animal.”
Research shows that skin to skin contact is beneficial for both mother and infant. Photo taken at William Beaumont Army Medical Center, Public domain, via Wikimedia Commons.
After the baby was born, the woman’s arms remained strapped to the bed, making it impossible for her to touch or hold the newborn. Instead, the baby was immediately taken to see a pediatrics doctor. Research shows that skin to skin contact is beneficial for the mother, as it helps stimulate breast milk and aids with bonding, as well as and especially for the infant, as it helps to regulate their breathing, heart rate and blood sugar. Again, there is nothing in the hospital records that demonstrates or implies that there was any medical reason for separating the mother and baby at this time, nor for keeping Alkorta restrained.
She developed post-partum post-traumatic stress disorder and severe anxiety as a result of her experiences, besides the physical trauma of healing from an unnecessary caesarean section.
When Alkorta first brought her case to the Spanish courts, she encountered discrimination and stereotypes; for example, that any psychological distress or damage she might be experiencing was simply a matter of perception, and that the doctor having performed a procedure should be taken as proof that it was medically necessary. After reviewing the facts of the case, however, the UN Committee disagreed with these assessments, stating that “if doctors and nurses had followed all applicable standards and protocols, it might be possible that the victim would have given birth naturally, without having to go through all these procedures that left her physically and mentally traumatized.”
It requested that the Spanish government take specific steps to compensate the woman for the physical and psychological trauma she had endured, and also issued an official recommendation that Spain “provide obstetricians and other health workers with adequate professional training on women's reproductive health rights… [and] provide specific training for judicial and law enforcement officials, as well as to develop, publicize and implement a charter of patients’ rights.”
Regarding legislation, the UN Committee also asserted that “States’ parties have an obligation to take all appropriate measures to modify or abolish not only existing laws and regulations but also customs and practices that constitute obstetric violence… [these measures] must respect women’s autonomy and ability to make informed decisions about their reproductive health by providing them with complete information at every stage of childbirth and by requiring that their free, prior and informed consent be obtained for any invasive treatment during childbirth.”
Incidentally, Francisca Fernández, the lawyer who helped Alkorta bring her case to the attention of the Committee, was also a victim of obstetric violence. Doctors performed what is referred to as the “Kristeller maneuver,” or applying fundal pressure on her uterus during the birthing process—a tactic intended to speed up the birth that has been officially discouraged by the World Health Organization (WHO) and the Spanish Society of Gynecology and Obstetrics (SEGO) for being dangerous to mother and baby. It caused her newborn daughter to asphyxiate and nearly die from lack of oxygen. (Luckily, she survived.) Since then, Fernández has specialized in health law; she handles approximately sixty cases every year.
Doctor performing the “Kristeller maneuver,” (uterine fundal pressure maneuver) on woman in labor, a tactic that has been officially discouraged by the World Health Organization and the Spanish Society of Gynecology and Obstetrics for being dangerous to mother and baby. Photo from Science Direct.
Possible Solutions
The hope is that the growing societal awareness of gender violence and violence against women will contribute to its regulation through legislation, national policy and regulations in Spain and in other countries. Some countries have attempted to control the issue by passing legislation that legally defines what it is, in the hopes that a clear definition of obstetric violence will help with prevention. Venezuela’s 2007 Organic Law on the Right of Women to a Life Free of Violence defines it as “the appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, an abuse of medication, and to convert the natural processes into pathological ones, bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women.”
The World Health Organization has also created a definition of what kinds of acts or behaviors are considered to be inappropriate or abusive; these include verbal or physical abuse, humiliation, coercive medical procedures including the administration of medication, lack of fully informed consent, ignoring pregnant women and/or newborns’ physical or psychological needs, refusal to administer pain medication, forced sedation, neglect resulting in medical complications, dismissal of complaints of pain or discomfort, refusal of admission to health facilities, physical detention in health facilities or separation from the newborn for lack of payment, lack of confidentiality, and gross violations of privacy.
In 2015, the International Federation of Gynecology and Obstetrics (FIGO), the International Confederation of Midwives (ICM), the World Health Organization (WHO), the International Pediatric Association (IPA) and the White Ribbon Alliance (WRA), proposed an initiative based on seven categories identified as disrespect and abuse: physical abuse, non-consented care, non-confidential care, non-dignified care; discrimination based on specific patient attributes, abandonment of care and detention in facilities. This initiative, called the Mother and Baby Friendly Birth Facility (MBFBF) was based on international human rights conventions, and was intended to codify a list of indicators that could be used to designate a healthcare facility as being sufficiently prepared to offer care during the birthing process.
In Spain, organizations of midwives believe that many of the negative impacts of obstetric violence could be avoided by pursuing a patient-centric approach to childbirth within the National Health System, rather than an often dehumanized, hierarchical system with an emphasis on default medical interventions that may not be necessary or appropriate.
The excessive pathologization of the medical processes surrounding childbirth don’t take into account the psychological needs of mother and child, and often involve performing unnecessary procedures in an attempt to standardize care. The Women’s Health Observatory in Spain is currently at work on a new Strategy for Normal Childbirth Care within the National Health System.