Author: Valentine Hallard, MA & MSc
August 22, 2024
“I had, without warning, been taken back to the scene of a crime—a rape. My daughter’s birth contained all the elements of a rape. I was taken to a strange place and told what to do. My clothes and personal possessions were taken from me. I was forced into an uncomfortable position and bound. I was threatened (it’s hospital policy, don’t make trouble). I was drugged and knocked unconscious. I was sexually assaulted: My vagina was cut and a man’s tool (forceps) was inserted into my body. I was robbed. That which was most precious to me, my baby, was taken from me. All this was done against my will. Like most rape victims, I dried my tears, stuffed my pain and proceeded to get on with my life. Like many rape victims, I didn’t report the crime nor did I seek help. I also didn’t have a clue how profoundly or for how long these acts of violence would affect my life”.[1]
Introduction
Over the past decades, childbirth has become increasingly medicalized. Widely recognized as the safest and most secure choice, giving birth at a hospital has become the norm in most Western countries – for example, 98.4% of pregnant people gave birth at a hospital in the United States in 2017.[2] However, a growing body of studies shows that many people across the globe experience mistreatment, disrespect, and abuse during pregnancy and childbirth in health facilities (i.e., Silal et al., 2021; Small et al., 2002; d’Oliveira et al., 2002). The World Health Organization (WHO) has acknowledged that “many women across the globe experience disrespectful, abusive or neglectful treatment during childbirth in facilities”.[3] The findings of the Giving Voice to Mothers study (Vedam et al., 2019) indicate that one in six women (17.3%) experienced mistreatment during pregnancy and childbirth, including physical abuse, verbal abuse, and discrimination. The rate of mistreatment varies widely depending on race, ethnicity, economic background, age, gender non-conformity (Ibid).
Throughout the years, several terms have emerged to describe this phenomenon. This includes mistreatment, disrespect, abuse, and obstetric violence. The World Health Organization (WHO) identifies seven dimensions of mistreatment during childbirth: 1) physical abuse, 2) sexual abuse, 3) verbal abuse, 4) stigma and discrimination, 5) failure to meet professional standards of care, 6) poor rapport between women and providers, and 7) health system conditions and constraints.[4] Examples of abuse and violence during childbirth include, but are not limited to: a lack of information about the different procedures performed, unnecessary cesarean sections, deprivation of the right to food and walking, routine and repetitive vaginal exams without justification, frequent use of oxytocin to accelerate labor, episiotomy without consent. Individuals who experience mistreatment during childbirth can suffer from physical injury, trauma, disrupted newborn bonding, future avoidance of the healthcare system, and in some cases, death due to neglect (Garcia, 2020; Vedam et al., 2019). Obstetric violence is a more comprehensive term. In addition to focusing on mistreatment, obstetric violence is understood as a structural form of violence and a violation of human rights (i.e., Chadwick, 2021; Garcia, 2023; Jardim & Modena, 2018; Savage & Castro, 2017).
In this article, I take a comprehensive approach to addressing the issue of obstetric violence. I draw on a variety of sources –academic research, laws, historical reports– to examine the factors that allow harmful behaviors and practices to take place in the context of prenatal care and childbirth. I also offer an overview of the legal framework for reproductive health care, before showing that reproductive injustices are historically situated and need to be considered within broader social and political structures of power. Finally, I explore strategies to prevent obstetric violences and ensure that individuals' reproductive rights are respected. Although reproductive injustice is considered as a global issue, this article emphasizes the different manifestations, effects, and responses to obstetric violence across countries. The article primarily focuses on the United States. It also includes examples of countries which approach prenatal care and childbirth from a different perspective.
Human Rights, Reproductive Rights, and Obstetric Violence
The concept of obstetric violence has progressively emerged in Latin American and the Caribbean. The term was popularized by global activists, medical staff, NGOs, and local feminist movements to denounce acts of violence committed against pregnant and birthing people. Today, obstetric violence is recognized as a violation of women’s fundamental human rights in internationally adopted human rights standards and principles.
The human rights-based approach to obstetric violence in health facilities was given international attention in 2007, when Venezuela introduced obstetric violence as a legally recognized form of violence in the “Organic Law on the Right of Women to a Life Free of Violence.” The law states that “the appropriation of women’s bodies and reproductive processes by health professionals through dehumanizing treatments, abuses in medicalization, or the pathologizing of natural processes, leading to loss of autonomy and decision-making capacity over their bodies and sexuality, negatively affects women’s quality of life”.[5] The term obstetric violence thus establishes a basis for acknowledging the violence perpetuated toward women during pregnancy and childbirth as part of the more general, widespread violence of which women are victims in patriarchal societies.
In 2023, the Inter-American Court of Human Rights set new standards to protect women during pregnancy, childbirth, and postpartum. In a case involving a pregnant Argentinian woman whose death resulted from inadequate medical treatment, the Court applied for the first time the concept of obstetric violence. The ruling states that “women have the right to live a life free of obstetric violence and States have the obligation to prevent it, punish it and refrain from practicing it, as well as to ensure that their agents act accordingly” (Inter-American Court of Human Rights, 2023).
Every woman has the right to the highest attainable standard of health, which includes the right to dignified and respectful health care throughout pregnancy and childbirth, as well as the right to be free from violence and discrimination (Universal Rights of Childbearing charter). Therefore, abuse, neglect or disrespect during childbirth can amount to a violation of a woman's fundamental rights.[6]
Structural form of violence in reproductive healthcare
The problem of obstetric violence must be regarded within the broader context of structural gender-based violence and violence against marginalized and racialized people. As Chadwish (2021) argues, obstetric violence is a form of violence that is “rooted in social relations of patriarchal, racist, medical, and colonial power” where “the enemy is not individual persons but unjust structures, repressive hierarchies, and unequal relations of power” (2021: 6).
Institutionalized violence against women
According to Jardim and Modena (2018), there is a causal relationship between gender ideology and the occurrence of obstetric violence. In societies that are highly medicalized, childbirth is almost exclusively managed by medical authorities, heavily influenced by capitalist and patriarchal values.
Throughout the years obstetricians have progressively taken over responsibility for natural birth, and medical interventions have become the norm in childbirth, without evidence of effectiveness. In most Western countries, women who have normal pregnancy are subjected to unnecessary interventions. For example, worldwide cesarean section rates have risen from about 7% in 1990 to 21% in 2021 (WHO, 2021). [7] The rate of cesarean section deliveries in the United States was 32.4% in 2023, (CDC).[8]
The medicalization of childbirth has been described as the transfer of women’s control over reproduction, power, and responsibility to medical authority (Davis-Floyd, 1992). Maternity care has become an area where women are required to comply with doctors’ instructions and the use of their technologies. Women’s self-determination and autonomy are continuously violated, and their ability to make informed decisions is limited, making them disciplined and passive recipients of medical care (i.e., Cahill, 2001; Jardim, & Modena, 2018; Aguiar & d’Oliveira, 2011; Shabot, 2016).
In societies where childbirth is managed by masculinized medical institutions, women are viewed as physically, mentally, and morally inferior to men. Technical and scientific expertise prevail over other forms of knowledge, such as women’s expertise and experiences of pregnancy and birth. Physicians make assumptions about women’s health based on male-centered medical knowledge, research, and practice. The inequality women encounter in healthcare institutions is exacerbated by power imbalance resulting from race, ethnicity, socioeconomic background, and gender non-conformity (Vedam et al. 2019).
Obstetric violence and medical racism
Medical racism occurs when the patient’s race influences the decision made by medical professionals regarding medical diagnostics, treatment, or prescription, placing the patient at risk. The term obstetric racism is at the intersection of medical racism and obstetric violence and addresses the many ways in which racism shapes the medical encounters between non-white people and medical professionals during pregnancy and childbirth (Davis, 2019).
In the United States, Black women are distrusted and dismissed even more systematically than their white peers during pregnancy and childbirth and they are significantly more likely to suffer from obstetric violence (Davis, 2019; Vedam et al., 2019). According to the PN View Moms survey, 1 in 3 Black mothers reported mistreatment during maternity care, as compared to 1 in 5 white mothers (Mohamoud et al., 2023). Similarly, Vedam et al, (2019) show that having a Black partner increases reported mistreatment regardless of maternal race. The widest disparity is seen in the maternal mortality rate, where Black women are 2 to 3 times more likely to die of pregnancy-related causes than white women (Petersen et al., 2019).
Historical perspective on obstetric institution
To understand and act upon obstetric violence, it is important to situate the issue of reproduction and medical racism in the broader historical context.
Gender and racial inequalities in healthcare have a long history. The control over women's sexuality and reproduction is embedded within structures of power and oppression such as capitalism, colonialism, and slavery. Using the example of witch-hunting which began in the 15th century, Federici (2004) argues that the oppression of women can be linked to the emergence of capitalism. With the introduction of private property and class societies, women’s bodies, their labor, their sexual and reproductive capacity were placed under the control of the state and transformed into economic resources. Because men control the sphere of production, monogamous families became the means by which property could be passed down from generation to generation. To ensure social reproduction and capital accumulation, men needed to control women’s sexuality and the conditions of pregnancy and maternity. Non-procreative sexuality, or any practice seen as interfering with reproduction between married couples, was criminalized as it contradicted the need of capitalism.
Structural racism is a powerful social determinant of maternal health that has roots in a historical system of oppression of women of color. In the United States, the reproductive coercion of women of color dates back hundreds of years. In the 19th century, enslaved Black women’s bodies were used to study obstetrics and gynecology. Experimental gynecologic surgery was performed on enslaved women to advance the study of gynecology, and subsequently, to heal white women and prevent sexual and reproductive health problems (Taylor, 2020). Two centuries later, the expectation that Black women bear more pain is still inherent to obstetrics (Davis, 2019). In 1662, colonial governments incorporated the legal doctrine of partus sequitur ventrem into the laws of slavery. The law made the children of enslaved women the property of slave owners. Because enslaved women’s reproductive capacity allowed the growth of the slave population, reproduction became a source of wealth for slave owners. Slave owners enforced control over enslaved women’s reproduction through various means, such as slave breeding (a practice that involved forced sexual relationships between enslaved men and women), the rape of enslaved women by white people, or small incentives for reproducing and raising children on the plantation (Taylor, 2020). The 20th century was later marked by the institutionalization of eugenics and forced sterilization. As Black population was perceived as a threat to American society, Black women were subject to high social-sexual control. For example, low-income Black women could access social welfare programs only on condition that they used birth control (Ibid).
Throughout history, gender-based violence and medical racism have been integrated into the structure of society, including public policies, institutional practices, and cultural representations that reinforce gender and racial inequality in maternal health. History of forced sterilization, forced pregnancy, forced childbirth, and limited access to necessary reproductive health care continue to influence people’s experience of pregnancy and childbirth.
The way forward
Legal response to obstetric violence
Every pregnant individual has the fundamental right to dignified and respectful health care through pregnancy and childbirth. However, obstetric violence is often overlooked and normalized, which complicates the design of public policies to prevent and eradicate it. Many health professionals are defensive and refuse to recognize their acts as obstetric violence. They consider obstetric practices as natural, justifiable and necessary acts that are performed for the “good” of the patients and their babies, thus legitimizing their actions. As a result, cases of obstetric violence are often discredited, even considered as “jokes” by some health professionals (Bohren et al., 2020; van der Waal et al., 2023).
To overcome this, some authors suggest improving health facilities’ capacity to address and resolve cases of mistreatment (i.e., Jardim & Modela, 2018). This includes creating mechanisms for reporting, confronting, and punishing the different actors involved in cases of obstetric violence. To develop effective systems of accountability and improve the quality of maternal health care, the WHO stresses the need for evidence-based policymaking. Governments, health professionals, and development partners should support the data collection and analysis on maternal care practices and use findings to design initiatives that promote quality and respectful health care and eliminate disrespectful and abusive practices. Savage and Castro (2017) highlight that women’s voices and experiences should be kept central to the development of research initiatives and interventions. Some authors also suggest changing the medical training model to promote practices that are more respectful of pregnant and birthing people (Jardim & Modena, 2018; Diniz et al., 2015; Vedam et al., 2019). According to them, topics like sexual and reproductive rights of women, gender relations, code of ethics, physiological assistance to labor and delivery, humanization of obstetrical care should be part of the academic curriculum of future health professionals.
Raising awareness
Civil society, social justice movements, institutions, and health professionals have an important role to play to address obstetric violence; they can raise awareness and understanding of this issue and share information among the general public, notably about existing laws (Jardim & Modela, 2018). As van der Waal et al. (2023) argue, many women lack knowledge about their sexual and reproductive rights. According to the authors, many women do not realize they have suffered violent acts, partly because they trust health professionals. These women end up accepting procedures without questioning them. They do not express their desires and their concerns and suffer without even knowing they were victims of violence. This lack of knowledge allows the imposition of violent practices by health professionals who judge what is best for their patients, putting them in a situation of powerlessness.
Some authors argue that changes in obstetric care can happen only if obstetric violence is recognized as a form of institutionalized, intersectional, and racialized violence (i.e., Davis 2019; van der Waal, et al., 2023). To challenge obstetric violence, it is essential to reflect on the origin of obstetric institutions, as shaped by gender-based violence and medical racism, and further explore how these institutions function within neoliberal racial capitalism. This requires looking at the intersection of the legacy of slavery, capitalism, systemic racism, and the consequences of patriarchal biopolitics (Davis 2019).
Alternative forms of maternal care
The last few decades have seen an increase in the number of people who choose to give birth outside of obstetric institutions. Simonds et al. (2007) suggest that the increase of ‘natural’ ‘home births’ or ‘midwifery models’ is a response to the medicalization of childbirth. For many women, natural birth is a way to regain control and authority over their bodies and the birth process (Brubaker, 2009). In contrast to highly medicalized childbirth, some countries adopt a midwifery model of care which encompasses a model that is woman-centered and holistic, with no attempt by health care providers to take over control of the birth process. The Netherlands, for instance, has a low intervention birth culture despite having high technological capacities. This obstetric care system emphasizes the normality of childbirth and the idea that it’s a natural physical process (Simonds et al. 2007; Logsdon Smith-Morris 2017).
Conclusion
Recent years have seen an increased interest in the issue of obstetric violence. Civil societies, social justice movements, governmental and non-governmental organizations (NGOs) have called for action, dialogue, research, and advocacy on this important public health and human rights issue. However, further research is needed to understand how institutional structures and processes can be reorganized to provide better woman-centered care, with a strong intersectional focus. Structural dimensions influence mistreatment during childbirth via historical biases, power inequalities, and normalization of poor treatment. We need to understand factors, such as gender and racial inequalities, and promote reproductive justice to resist obstetric violence and reimagine how we care for birth.
Glossary
Autonomy: the ability and right of individuals to make their own decisions and govern their own lives, free from external control or influence.
Capitalism: an economic and political system where private individuals or businesses own and control the means of production, distribution, and exchange of goods and services.
Colonialism: a practice or policy where a country extends its power and dominion over other territories, often by establishing colonies.
Dehumanizing: the process of denying or stripping away the human qualities, dignity, or individuality of a person or group.
Episiotomy: a surgical procedure performed during childbirth where an incision is made in the perineum, the area between the vaginal opening and the anus, to widen the birth canal.
Eugenics: a set of beliefs and practices aimed at improving the genetic quality of a human population through selective breeding and other means.
Forced sterilization: a practice where individuals are sterilized against their will, typically without their informed consent. This procedure is used to control reproduction among certain populations based on eugenic or discriminatory ideologies.
Gender-based violence: harmful acts directed at individuals based on their gender or sex, which perpetuate inequality, discrimination, and power imbalances.
Holistic: considering something as a whole rather than just focusing on its individual parts.
Institutionalization: the process by which practices, behaviors, norms, or policies become established and accepted within an institution or organization, becoming a formal and routine part of its operations.
Institutionalization of eugenics: the process by which eugenic ideas and policies were formally adopted, implemented, and integrated into societal institutions and practices.
Medical authority: the recognized expertise and credibility that a person or institution holds in the field of medicine.
Medicalization: the social process of defining and treating non-medical issues as medical problems, often requiring medical intervention.
Midwifery models: a philosophy and approach to pregnancy, childbirth, and postpartum care that emphasizes a holistic, woman-centered, and personalized approach. This model contrasts with more medicalized approaches, focusing on the natural processes of childbirth and supporting the individual's autonomy and preferences.
Monogamous family: a family structure where individuals have a single, exclusive partner or spouse at any given time.
Oxytocin: a hormone and neurotransmitter that's often associated with social bonding, emotional regulation, and reproductive processes.
Pathologizing: the process of viewing or treating a behavior, condition, or characteristic as a medical or psychological disorder when it might not necessarily be one.
Patriarchal power: a social and institutional system where men hold primary power and authority, and where male dominance is normalized across various aspects of society.
Repressive hierarchy: a social or organizational structure where power and authority are distributed in a way that reinforces control, dominance, and suppression over others.
Structural racism: the ways in which racial discrimination is embedded within the structure and policies of a society. Unlike individual racism, structural racism operates through laws, policies, and cultural norms that perpetuate racial inequality.
Witch-hunting: the pursuit and persecution of individuals, especially women, accused of witchcraft or practicing witchcraft.
Patriarchal biopolitics: describe how patriarchal systems exert control over bodies and reproductive processes through political and social mechanisms.
Footnotes
[1] Cited in Richland (2008).
[2] The National Academic, 2020.
[3] World Health Organization, the Prevention and Elimination of Disrespect and Abuse during Facility-Based Childbirth (2015), http://www.who.int/reproductivehealth/topics/maternal_perinatal/statement-childbirth/en/
[4] See Bohren et al., (2015).
[5] Cited in Sadler et al. (2016).
[6] UN General Assembly. Universal Declaration of Human Rights. UN General Assembly; 1948 Dec. UN General Assembly. Declaration on the Elimination of Violence against Women. UN General Assembly; 1993 Dec. UN General Assembly. International Covenant on Economic, Social and Cultural Rights. UN General Assembly; 1976 Jan.
[7] Caesarean section rates continue to rise, amid growing inequalities in access, WHO, 2021, https://www.who.int/news/item/16-06-2021-caesarean-section-rates-continue-to-rise-amid-growing-inequalities-in-access
[8] Birth Provisional Data for 2023, CDC, 2024, https://stacks.cdc.gov/view/cdc/151797
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