What is Obstetric Violence?

There's growing global momentum to address the issue of disrespectful care, including facility-based abuse. The result of disrespectful care is what women often call "birth rape" and it leads to birth trauma, postpartum PTSD, postpartum depression and anxiety, and suicidal ideation and suicide attempts. The expression "obstetric violence" has been defined by various laws and has been incorporated into our everyday lexicon to identify those behaviours that violate the patient's human rights, legal rights, consent, bodily autonomy, sexuality, and dignity. Obstetric violence refers to the obstetric client rather than the particular profession of the one perpetuating the violation of the client.

Venezuela's 2007 Organic Law on the Right of Women to Live a Life Free of Violence defines obstetric violence as:

"The appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanised 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 following behaviours on the part of care providers is considered obstetric violence:

• Untimely and ineffective attention of obstetric emergencies; 
• Forcing the woman to give birth in a supine position, with legs raised, when the necessary means to perform a vertical delivery are available; 
• Impeding the early attachment of the child with his/her mother without a medical cause, thus preventing the early attachment and blocking the possibility of holding, nursing or breastfeeding immediately after birth; 
• Altering the natural process of low-risk delivery through the use of acceleration techniques, without obtaining voluntary, expressed, and informed consent of the woman; 
• Performing delivery via cesarean section when natural childbirth is possible, without obtaining voluntary, expressed, and informed consent from the woman. (Pérez D’Gregorio, 2015)

Seven categories have been further identified as abuse in facility-based childbirth (Bowser & Hill, 2010):

1. Physical abuse, including slapping or hitting, routine episiotomies, manually tearing the perineum, painful vaginal exams, vaginal suturing without anaesthesia, forcefully pushing on the client’s abdomen, or excessive physical force to pull the baby out.
2. Non-consented clinical care, including any procedure done without the client’s knowledge or consent, or procedures performed under duress, or threats to the client or the baby.
3. Non-confidential care, including obtaining patient information where other patients can hear the answers.
4. Non-dignified care, including verbal abuse, humiliation, scolding, blaming or shaming.
5. Discrimination based on specific patient attributes, including age, weight, race, ethnicity, marital status, health status, economic or educational status.
6. Abandonment of care, including refusal to attend to a client in labour, leaving them alone during labour or birth, or failure to intervene in life-threatening situations.
7. Detention in facilities, including keeping a client or baby in the facility until they can pay the bill, or keeping a well baby in the NICU until certain demands are met.

More recently, an analysis of 65 studies from 34 countries identified a set of abusive behaviours that was consistent across all geographic regions and country income levels (Bohren, 2015).

• Physical abuse, inflicted by physicians, nurses, and midwives.
• Verbal abuse, more commonly perpetrated by nurses and midwives, followed by doctors and administrators, reported in all regions in every income level. Migrants, ethnic minorities, or lower socioeconomic status women often experience racial and derogatory slurs. Threats of a poor outcome, commonly called the "dead baby card",  or withholding treatment were common. Women reported being mistreated for non-compliance or not doing as they were told. Inappropriate comments about a client's sexual activity, particularly adolescents and unmarried women were frequent. 
• Stigma and discrimination, biased and negative treatment based on ethnicity, race, or religion, age, socioeconomic status, and medical conditions, including obesity, permeate all regions.
• Failure to meet professional standards of care, including failure to obtain consent, maintain confidentiality, neglect, abandonment of patients, improper examinations and treatments.
• Poor rapport between care provider and client, citing ineffective communication, lack of supportive care, and loss of autonomy for the patient.

The traumatic birth experiences of mothers were studied and there were 4 common behaviours on the part of the care provider that were identified as contributing to the traumatic experience (Reed, 2017): 

1. Prioritising the care provider's agenda, including the care provider's time, desire to stick to usual practices, perform interventions for the purpose of increased income, or including others to observe them.
2. Disregarding embodied knowledge, including disregarding clients' observations of their own bodies in favour of their personal experience, telling a mother what position to labour or birth in despite it being more painful or difficult for the mother.
3. Lies and threats, including lies about hospital policy, the condition of the mother or baby, staff availability, or dilation. The most common threat was the "dead baby threat" in order to gain compliance from the client. Threats also include calls to child services to apprehend the baby or other children for non-compliance.
4. Violation, the most common violation identified is procedures done to the mother against her explicit wishes, including membrane sweeping, artificial rupture of membranes, augmentation, forced supine delivery, forced confinement to bed for monitoring, and digital cervical exams. Violation also included the provider not stopping a procedure once the client had withdrawn consent.

Every woman has the right to the highest attainable standard of health, which includes the right to dignified, respectful health care. 

Many women experience disrespectful and abusive treatment during childbirth in facilities worldwide. Such treatment not only violates the rights of women to respectful care, but can also threaten their rights to life, health, bodily integrity and freedom from discrimination. This statement calls for greater action, dialogue, research and advocacy on this important public health and human rights issue. (World Health Organisation, 2015)

You can review the references for the above information here.