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DISCUSSION

Moving beyond disrespect and abuse: addressing the structural


dimensions of obstetric violence
Michelle Sadler,a Mrio JDS Santos,b Dolores Ruiz-Berdn,c Gonzalo Leiva Rojas,d
Elena Skoko,e Patricia Gillen,f Jette A Clauseng
a Assistant Professor, Departamento de Antropologa, Universidad de Chile, Santiago, Chile.
Correspondence: msadler@uchile.cl
b Research Assistant, Instituto Universitrio de Lisboa (ISCTE-IUL), CIES-IUL, Lisboa, Portugal
c Assistant Professor on History of Science, Department of Surgery and Medical and Social Sciences, University of Alcal,
Alcal de Henares, Spain
d Assistant Professor, Escuela de Obstetricia y Puericultura, Universidad de Santiago de Chile, Santiago, Chile
e Independent Researcher, Laboratorio Multimediale di Comparazione Giuridica, Dipartimento di Scienze Politiche,
Universit degli Studi Roma TRE, Unit di Ricerca Diritti Umani nella Maternit e Nascita, Roma, Italy
f Head of Research and Development for Nurses, Midwives and AHPs, Southern Health and Social Care Trust, Belfast, United
Kingdom; Lecturer, School of Nursing, Institute of Nursing and Health Sciences, Ulster University, Belfast
g Senior Lecturer, Metropolitan University College, Copenhagen, Denmark

Abstract: During recent decades, a growing and preoccupying excess of medical interventions during
childbirth, even in physiological and uncomplicated births, together with a concerning spread of abusive and
disrespectful practices towards women during childbirth across the world, have been reported. Despite research
and policy-making to address these problems, changing childbirth practices has proved to be difcult. We argue
that the excessive rates of medical interventions and disrespect towards women during childbirth should be
analysed as a consequence of structural violence, and that the concept of obstetric violence, as it is being used
in Latin American childbirth activism and legal documents, might prove to be a useful tool for addressing
structural violence in maternity care such as high intervention rates, non-consented care, disrespect and other
abusive practices. 2016 Reproductive Health Matters. Published by Elsevier BV. All rights reserved.

Keywords: human rights in childbirth, non-evidence-based practice, medicalisation, violence against


women, structural violence
Introduction interventions in women who do not have a clin-
The World Health Organization (WHO) has shown ical need, thereby putting normal birth rmly
concern about the excessive medicalisation of on the agenda for the 21st century.2
birth since 1985, when it recommended the It has been suggested that unnecessary
appropriate use of technologies for birth, urging interventions could be reduced through the
administrators and health personnel to review clarication of and adherence to the basic legal
protocols and continuously investigate the rele- principle of informed consent,3 including the
vance of certain practices, while promoting right to refuse medical interventions.4 The princi-
respect for womens autonomy and perspective ple of informed consent is not new, with United
when making judgements.1 Yet, since then, the States court papers from the 19th century advocat-
rates of non-medically justied obstetric inter- ing for the right of each person, in particular
ventions have increased in middle- and high- women, to have their dignity respected and the
income countries without dramatic improve- unlawful touch of a stranger being deemed an
ment in perinatal and maternal mortality and assault or trespass.5 More recently, the United
morbidity. Moreover, there is increasing concern Nations Educational, Scientic and Cultural Orga-
about the iatrogenic effects of obstetric nisation (UNESCO), through its Universal

Contents online: www.rhm-elsevier.com Doi: 10.1016/j.rhm.2016.04.002 47


M Sadler et al. Reproductive Health Matters 2016;24:4755

Declaration of Bioethics and Human Rights, recog- example, we can look at the two most widespread
nised that health does not depend solely on scien- interventions in childbirth, which are surgical in
tic and technological research developments, but nature and are often used in healthy women with
also on psychosocial and cultural factors. Further- little or no justication: episiotomy and caesarean
more, it stressed that autonomy and the right to section.
make decisions should be respected.3 Restricted use of episiotomy is associated with
However, it is necessary to acknowledge the better outcomes when compared with routine
aws in the assumption that women fully use.10 Yet, episiotomy rates vary immensely in
understand their options and are always able to European hospitals with rates as high as 70% in
make free, adequate choices about the nature of Cyprus, Poland and Portugal, 43-58% in Wallonia,
medical care. This question was strongly raised in Flanders, the Czech Republic, and Spain, and
1993, with the Changing Childbirth report, calling 16-36% in Wales, Scotland, Finland, Estonia,
for women-centred care and stressing the France, Switzerland, Germany, Malta, Slovenia,
importance of choice during childbirth.6 Further Luxembourg, Brussels, Latvia, and England.11 In
reports have continued to highlight that women 2010, the lowest reported rates of episiotomy were
should be the focus of maternity care, being able in Denmark (4.9%), Sweden (6.6%), and Iceland
to make decisions based on their needs, having (7.2%).11 However, in some countries, rst time
fully discussed matters with the professionals mothers are routinely given episiotomies,11 despite
involved.2 But women worldwide continue to be the lack of evidence to support this practice.10 A
excluded from participating in the design and hospital-based descriptive study which analysed
evaluation of maternity care. Despite being data from 122 hospitals in 16 Latin American
invited to develop birth plans and exercise countries between 1995 and 1998 showed that
autonomy, the range of choices presented to 87% of the hospitals had episiotomy rates higher
women by the medical profession may be lim- than 80% and 66% had rates higher than 90%,12
ited.7,8 Furthermore, the available healthcare and a study in Mexico carried out in 2005-2006
system might not provide appropriate, evidence- reported episiotomy rates of 84%.13
based care. The use of unnecessary caesarean sections is also
These limitations seem particularly evident in well documented. The World Health Organization
(WHO) conrms that caesarean section rates higher
countries that have legislation making it illegal
than 10% are not associated with lower maternal
or close to impossible for healthcare providers
and newborn mortality on a population level.14
to offer home birth services or midwifery-led
Nevertheless, according to the Organisation for
birth centres. Even in settings where out-of-
Economic Co-operation and Development (OECD)
hospital births are not illegal, planning and
the Nordic countries (Iceland, Finland, Sweden
experiencing one can be a challenging task for
and Norway), Israel and the Netherlands had the
families and professionals. The existing evidence lowest caesarean section rates in 2013, ranging
that many medical interventions are overused, from 15% to 16.5% of all live births; while Turkey,
while structural and social interventions are Mexico and Chile had the highest, with rates
often underused, has had limited impact on ranging from 45% to 50%.15 Latin America is the
practice.9 region where the highest rates of caesarean
sections in the world are concentrated, with several
countries above 40%,15 and Brazil leading the trend
Non-evidence-based practices with 54%.16
It is a fact that in many countries, including If the huge variations in caesarean section
high-income ones, the best available evidence is between countries raise questions about the
not always used to inform maternity care; rather appropriateness of interventions that may not
practice is driven by local beliefs about childbirth, be medically required, the differential rates
and professional or organisational cultures. This is across regions and hospitals within the same
country can be even more alarming.15 In Canada,
particularly visible when taking into account the Finland, Germany and Switzerland, caesarean
variations in intervention rates between and within section rates vary by up to two times across
countries, and even between institutions and regions, and by more than three times across
health practitioners in the same country. As an Spain and six times in different regions of Italy.17

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M Sadler et al. Reproductive Health Matters 2016;24:4755

Around the globe, caesarean section rates tend social dynamics of inequality and uneven power
to be higher in private settings and for women between groups.23
with higher economic status. In Chile, caesarean Amid the growing debate, in 2014 the World
section rates were 39% in public health and 72% Health Organization released a powerful state-
in private health settings in 2012, with big varia- ment on Prevention and elimination of disrespect
tions within systems.18 Even more interestingly, and abuse during facility-based childbirth, where
in public hospitals with the same staff of obste- the right of every woman to access dignied and
tricians and midwives, a woman who pays a respectful health care was highlighted. 24 A sys-
bonus to access private care will triple her
tematic review by Bohren and colleagues
chance of having a caesarean section.19
followed on mistreatment of women during
The variations in caesarean section rates are
childbirth, presenting a new typology of mis-
linked to supply and demand related factors,17
treatment organised in seven themes: physical
and most directly to economic factors. As stated in
abuse, sexual abuse, verbal abuse, stigma and
an article in The Economist in 2015, the global rise discrimination, failure to meet professional
of caesarean sections is being driven not by medical standards of care, poor rapport between women
necessity but by growing wealth and perverse nan- and providers, and health system conditions and
cial incentives for doctors.20 Malpractice liability constraints.25 The authors discuss how mistreat-
concerns are high among the main non-medical fac- ment can occur at the level of interaction
tors that are inuencing excessive interventions.8,15 between the woman and provider, as well as
Even when women are requesting caesarean sec- through systemic failures at the health facility
tions, questions should be asked about the quality and health system levels.25
of the information they have received, acknowledg- Jewkes and Penn-Kekana argue that clear
ing that only a minority of women in a wide variety parallels between the mistreatment of women in
of countries express a preference for caesarean childbirth and violence against women (more
delivery.21 broadly) can be drawn from Bohren and collea-
gues systematic review, highlighting that the
essential feature of violence against women is
Disrespect and abuse during childbirth that it stems from structural gender inequality.26
The concerns about non-evidence-based inter- A recent editorial from the International Journal
ventions are one of the reasons for the growing of Gynecology and Obstetrics, entitled The unn-
international attention and debate on the problem ished agenda of womens reproductive health,27
of disrespect and abuse of women during child- states:
birth. In the last years, there have been several
As the clinical indicators of maternal health improve,
attempts to structure the discussion on the topic.
we begin to focus more on quality of care and this has
In 2010, Bowser and Hill proposed seven categories
raised the gender-related issue of disrespect and abuse
to group disrespect during childbirth: physical
that women in labor tend to suffer at the hands of both
abuse, non-consented care, non-condential care,
male and female care givers.
non-dignied care, discrimination based on patient
attributes, abandonment of care, and detention in In fact, gender has been central to the
facilities.22 Freedman and colleagues argued that conceptualisation of the term obstetric violence.
those categories lacked a denition in terms of the Although it has been often used as a synonym
characteristics of healthcare provider behaviour, for disrespect, abuse and mistreatment during
facility conditions or other factors that could childbirth, we argue that obstetric violence has
be constructed as disrespectful and abusive.23 the potential for addressing the structural dimen-
They proposed a model to assess the individual, sions of violence within the multiple forms of dis-
structural, and policy level interactions that shape respect and abuse.
the problem, and dened disrespect and abuse in
childbirth as the interactions or facility conditions
that local consensus deems to be humiliating or Obstetric violence as violence against
undignied, and those interactions or conditions that women
are experienced as or intended to be humiliating or Despite being cited in records from the 19th
undignied, acknowledging its links with the wider century,28 the concept of obstetric violence has only

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recently gained popularity among childbirth women and pregnant women in particular in
activists movements in Latin America. Brazil the healthcare system and in society. Since 2014,
pioneered the discussions in 1993 with the ve Obstetric Violence Observatories led by civil
foundation of the Network for the Humanization society groups have been founded, in Chile, Spain,
of Labour and Birth (ReHuNa), which recognised Argentina, Colombia and France, and in March
the circumstances of violence and harassment in 2016 they released a common statement declaring
which care happens.29 A landmark event for the that obstetric violence has been one of the most
region was the First International Conference for invisible and naturalised forms of violence against
the Humanization of Birth, held in Brazil in 2000, women and that it constitutes a serious violation
where a cohesive group of Latin American activists, of human rights.34 This institutionalisation of the
researchers and health professionals gathered concept is an acknowledgement of the critiques of
in response to the high rates of childbirth the medicalisation of maternity care settings and
interventions and growing recognition of abuses the violation of sexual and reproductive health
toward birthing women. The RELACAHUPAN (Latin rights.35
American and Caribbean Network for the The denition of obstetric violence, besides
Humanization of Childbirth) was founded in this focusing on dehumanised treatment, highlights its
meeting, leading the debate on womens right to obstetrical dimension, from the roots of this
respected childbirth within the region.30 medical speciality to contemporary education and
In 2007, Venezuela became the rst country structures of power.36,37 It frames the discussion
to formally dene the concept of obstetric of abuse and disrespect within the broader eld
violence through the Organic Law on the Right of structural inequalities and violence against
of Women to a Life Free of Violence,31 where obste- women.
tric violence is codied as one of the 19 kinds of
punishable forms of violence against women. In
article 15, obstetric violence is described as: Making structural violence visible
The appropriation of womens body and reproduc- It is of the utmost importance to analyse obstetric
tive processes by health personnel, which is violence separately from other forms of medical
expressed by a dehumanising treatment, an abuse violence, acknowledging the differences between
of medicalisation and pathologisation of natural the mistreatment of women in childbirth and
processes, resulting in a loss of autonomy and abil- the overall mistreatment of patients. Obstetric
ity to decide freely about their bodies and sexuality, violence has particular features demanding a
negatively impacting their quality of life. (Authors distinct analysis: it is a feminist issue, a case of
translation) gender violence; labouring women are generally
Furthermore, article 51 species the acts that healthy and not pathological; and labour and birth
constitute obstetric violence: untimely and can be framed as sexual events, with obstetric
ineffective attention to obstetric emergencies; violence being frequently experienced and
forcing the woman to give birth in a supine position interpreted as rape.38 Biomedicine is a social and
when the necessary means to perform a vertical cultural system, a complex historical construction
delivery are available; impeding early attachment with a consistent set of internal beliefs, rules and
of the child with his/her mother without a medical practices,39 which responds to and reproduces
cause; altering the natural process of low-risk gender ideologies across health professions, the
labour and birth by using augmentation techniques, legal system and the state. However, the biomedical
and performing caesarean sections when natural culture has been overlooked. The power of
childbirth is possible, without obtaining the biomedicine in health systems is a common but
voluntary, expressed, and informed consent of the unnamed element, and its hegemony seems to
woman.31 erase the need to report its existence.
The concept of obstetric violence has been These discrete mechanisms can be analysed as
promoted by civil society groups across borders. forms of structural violence, invisible manifestations
Argentina32 and some states in Mexico33 have also of violence that are built into the fabric of society,
framed obstetric violence within the broader producing and reproducing social inequalities across
legislations concerning gender inequalities groups.40 In fact, obstetric violence has been placed
and violence, stressing the unequal position of on the feminist and public policy agendas, but it has

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been mainly overlooked by professionals and The contributions of the social sciences
institutions.29 Keeping in mind the discussed limits Social scientists have produced a considerable body
of informed consent, and that women often have of research on the medical management of
little choice but to acquiesce to the power of childbirth as a reex of asymmetric gender powers
professionals,7 explicit and deliberate forms of and as a process where female bodies are
violence and mistreatment in maternity should not objectied. In the dawn of obstetrics, the masculine
be discussed regardless of their context. Centring medical profession regarded male physiognomy
the debate on individual malpractices has the
and physiology as the norm, which had particular
potential to generate unproductive hostility towards
repercussions in the establishment of this
the discussion of disrespect and abuse in childbirth,
medical specialty, in the professionalisation of
especially among health professionals, which is why
midwives,36,46,47 and in womens health.48,49 As a
Jewkes and Penn-Kekana argue there is a need to
avoid blaming the health workers as a group.26 consequence, the female body and its natural
One of the reasons why the term obstetric processes were and continue to be portrayed
violence is not more widespread is that health as abnormalities, diseases or deviances.
professionals resist the use of the concept of Professional and lay discourses referring to the
violence, which is contrary to their ethos. As Diniz diagnosis of pregnancy, to pregnancy symptoms
and colleagues explain, this made ReHuNa in and to the pregnant womans return to the normal
Brazil deliberately decide not to talk openly about state after birth are some of several discrete markers
violence during the nineties, favouring terms like of the male normalisation.46
humanising childbirth and promoting the Former philosophical and social sciences
human rights of women. Nonetheless, the same perspectives have positioned medicalised
authors acknowledge that signicant changes childbirth within the scope of objective and
have occurred after the debate started to be systematic violence. Foucault describes the
framed as a matter of violence and human rights emergence of the control of childbirth by
violation.29 normalising institutions, such as the church, the
This reinforces the need for a broader analysis, state and, later, medicine, and how the female
centred in the cultural and social dimensions body was rst objectied and studied through its
embedded in the phenomenon of obstetric differences and deviances from the male
violence, which can allow a shift from the limited norm.43,50 Today, obstetric violence can indeed
focus on victims (women) and victimisers (health be seen as a reection of how female bodies in
professionals), to the acknowledgement of labour are perceived as potentially opposing to
the ubiquitous socialisation of men and women femininity violence is thus necessary to
into naturalised, and thus invisible, forms of dominate them, restoring their inherent
violence and power dynamics between groups. feminine submission and passivity. It becomes a
The power structures embedded and reproduced tool for disciplining the undisciplined body in
in biomedicine should be made visible. The hidden labour, in order to re-feminise and re-objectify
curriculum in health professionals education and the body.38 In fact, despite the common
practice should be included in the international references to care and femininity, childbirth at
agenda on obstetric violence, where the acceptance the hospital is frequently depicted through a chain
of norms, corporate discipline and punishment of patriarchal forces the participants trying to
plays a central role,4143 while the emotional coach and control the labouring women, and the
dimensions of care are neglected.44 The poor hospital trying to control both members of the
working conditions of many health professionals couple.51
should also be framed as forms of disrespect and Male symbolic domination and female symbolic
abuse, as well as the consequences of being submission can be performed not only through
socialised within and driven to exercise violence. force, but also, and mainly, through these discrete
Evidence shows that health personnel exposed to mechanisms, completely naturalised within the
violence in childbirth may suffer secondary normal order of things.52 Although embedded in
traumatic stress or compassion fatigue, understood society, they are laboriously reproduced in everyday
as a secondary exposure to extreme traumatic life. In the line of Bourdieus arguments, obstetric
stressors similar to those experienced by patients violence must be approached as more than the
with primary exposure.45 mere act of mistreatment it is surrounded by

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socially constructed symbolic meanings.52 It may Recommendations for action


imply the consent of both dominant and Obstetric violence is a multi-faceted complex
dominated, within a social relationship where the phenomenon which requires a multidimensional
knowledge shared amongst all actors only allows approach and contributions from different disci-
framing the violence itself as if it were a natural, plines. In order to advance the debate and effect
expected and accepted part of life. In such a context, change, it is vital that there are international and
violence is not only accepted, but also reproduced national initiatives to address structural violence in
and reinforced by all actors involved: women, childbirth.
families, professionals, and decision-makers. As At the legislative and economic level each
such, obstetric violence can be remarkably country needs to develop relevant legislation that
functional, reinforcing a biased gender narrative in can drive organisations to address obstetric
sexual and reproductive health care, and structur- violence, including the fallacy of informed choice
ing maternity care. and consent, and the provision of non-evidenced-
Research, policies and guidelines, professional based care. In particular, perverse nancial incen-
and academic education, and social movements tives need to be addressed. Legal barriers for
failing to address the structural dimensions are access to maternity care services including out of
deemed to tackle only the micro- and meso-level hospital services must be identied and tackled.
symptoms, but not the macro-level causes of these Furthermore, the gap between perceived barriers
forms of violence.40 Obstetric violence is a useful and legal barriers must be addressed. The identi-
concept that can help us better understand those cation of successful initiatives that have addressed
macro-level causes, and has the potential to obstetric violence and effected lasting change may
reframe the problem of overused interventions,
help to identify best practice and provide a road
non-consented care and abusive practices, and to
map for other maternity services and countries to
trigger new calls for action. Having its origins in
follow.
grassroots movements, the concept should be
At the organisational level we suggest mandatory/
central to the discussion as it represents the voices
statutory involvement of womens groups and
of women. There is, however, a need to develop
members of civil society movements in decisions
a more accurate denition of the concept to
about maternity care including the design, planning,
place the appropriation of womens body and
delivery and evaluation of care. This could be
reproductive processes, as dened in Venezuelan
achieved through introducing similar legislation and
law,31 in health systems more than in health
monitoring of Personal and Public Involvement
personnel, stressing that this is a phenomenon
(PPI) in Health Care such as in the United Kingdom53
that is inherent to the structural dimensions of
and other EU countries. If maternity care providers
maternity care provision.
are to truly engage and involve women and their
families in decisions, it is important to explore
their understanding and experiences of obstetric
Conclusion violence.
Moving beyond the focus on the interactional Healthcare authorities should ensure that
dimensions of disrespect and abuse in childbirth all women have access to evidence-based and
makes way for an integrated perspective over unbiased information about interventions. Published
this global issue. A dynamic dialogue between and oral information should be evaluated on a regu-
health and social sciences, mobilising the existing lar basis. We furthermore suggest implementation of
knowledge about the structural dimensions of reporting systems that allow women and health
obstetric violence and recognising this phenomenon professionals to report instances of obstetric violence
as a particular form of violence against women, and to assess the complete range of medical interven-
naturalised within health care systems, can set the tions during childbirth. Maternity units should be
ground for structural improvements in maternity supervised and certied when giving the appropriate
care. As such, the concept of obstetric violence can standards of care, as has been proposed in the 2015
be used as a tool to potentially reframe the FIGO Guidelines for Mother-baby friendly birthing
international agenda on disrespect and abuse in facilities.54
childbirth, and to contribute to change in maternity At the educational level, the principles
care worldwide. of human rights in childbirth and the

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discussion on obstetric violence and its impact Acknowledgements


on professionals, mothers, babies, and their This article is based upon work from COST Action
families should be included in the curriculum in all IS1405 BIRTH: Building Intrapartum Research
relevant educational institutions (legal, medical, Through Health an interdisciplinary whole system
midwifery, nursing, and others), stressing its approach to understanding and contextualising
gender-related dimensions.29 This is a necessary step physiological labour and birth (http://www.cost.eu/
because many aspects of obstetric violence are not COST_Actions/isch/IS1405), supported by COST Grant
questioned, they are taken for granted and number CGA-IS1405-3 (European Cooperation in
naturalised. Science and Technology). The participation of MS and
Finally, at the research level we identify a need GLR in the COST ACTION IS1405 BIRTH is supported by
for robust, interdisciplinary, cross-national FONIS SA13I20259 (National Fund for Research and
research that assists decision makers, maternity Development in Health: Ministry of Health & National
care providers, women and families who access Commission for Scientic and Technological Research,
maternity services to better understand, dene Chile): Perceptions and practices on caesarean section
and challenge this phenomenon. in private and public health in Chile.

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Rsum Resumen
Ces dernires dcennies, un excs croissant et Durante dcadas recientes, se ha reportado un
proccupant dinterventions mdicales pendant creciente y preocupante exceso de intervenciones
laccouchement, mme dans des naissances mdicas durante el parto, incluso en partos
physiologiques et sans complications, paralllement siolgicos sin complicaciones, junto con un
une multiplication de pratiques violentes et preocupante aumento de prcticas abusivas e
irrespectueuses lgard des femmes pendant irrespetuosas hacia las mujeres durante el parto
laccouchement, a t rapport de par le monde. en todo el mundo. A pesar de investigaciones y
En dpit de recherches et de dcisions politiques polticas formuladas para tratar estos problemas,
pour corriger ces problmes, il sest rvl difcile ha resultado difcil cambiar las prcticas
de changer les pratiques obsttricales. Nous relacionadas con el parto. Argumentamos que las
avanons que le taux excessif dinterventions tasas excesivas de intervenciones mdicas y la falta
mdicales et le manque de respect lgard des de respeto hacia las mujeres durante el parto deben
parturientes devraient tre analyss comme analizarse como una consecuencia de la violencia
consquence de la violence structurelle et que le estructural, y que el concepto de violencia obsttrica,
concept de violence obsttricale, tel quil est utilis tal como se utiliza en el activismo relacionado con el
dans lactivisme latino-amricain de laccouchement parto y en documentos jurdicos en Latinoamrica,
et dans les documents juridiques, peut tre un outil podra ser una herramienta til para abordar la
prcieux pour sattaquer la violence structurelle violencia estructural en la atencin materna, tales
dans les soins maternels, comme les taux levs como altas tasas de intervencin, cuidados sin
dintervention, les soins non consentis, le manque consentimiento, falta de respeto y otras prcticas
de respect et dautres abus. abusivas.

55