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Why obstetric violence needs to be considered within frameworks of gender-based violence
By Nicole Moran and Ophelia Chatterjee
December 10th marks Human Rights Day and is the closing day of the annual 16 Days of Activism against gender-based violence (GBV). While the 16 Days of Activism campaign sheds light on the shadow pandemic that is gender-based violence, there are some forms of violence that are often neglected in mainstream understandings of GBV. One such form is obstetric violence and the violation of the right to respectful maternity care.
Obstetric violence is a prevalent form of gender-based violence which impacts birthing people during and immediately following the childbirth period. Pregnant and birthing people too often face unnecessary health risks and rights infringements which manifest as disrespectful care, unnecessary medical procedures, and disregard of their choices – all of which violate their right to “the highest attainable standard of health” (WHO Constitution, 2020). Obstetric violence encompasses a wide range of mistreatment, from disrespectful and autonomy-denying care such as not being allowed to move during labour, being denied a birthing companion, and verbal abuse, as well as extreme negligence that puts lives at immediate risk.
Myriad of physical harm
This form of gender-based violence can lead to a myriad of physical harm to both birthing people and their babies, as well as psychological harm, including an increase in likelihood of postpartum depression, PTSD and feelings of worthlessness and humiliation (Tagizadeh et al., 2021). Furthermore, dissatisfaction with the level of care received and fear of repeat experiences can influence pregnant people’s decisions in delaying or avoiding the use of health services in subsequent pregnancies and births, resulting in potential mortality.
Obstetric and pregnancy-related violence is a global issue, evident everywhere we have access to the relevant data, and is closely linked to systems of oppression (especially misogyny, classism, and racism) and rights violations. It occurs in wealthier, low-, and middle-income countries, often disproportionately affecting those who already suffer from racial and socio-economic disadvantages and discrimination. In many contexts such as the UK, where black and Asian women are respectively four and two times more likely to die in pregnancy and childbirth than white women, these disparities are large and widening (Birthrights, 2022; Knight et al., 2021).
Other recent studies have revealed troubling ethnic disparities in maternal morbidity in many other high-income countries. For example, here in the Netherlands birthing people of migrant backgrounds were found to be at a three time elevated risk of maternal mortality compared to white Dutch women (Zwart et al., 2021). Likewise, in the U.S. it has been found that the quality of obstetric care varies widely and that racial and ethical disparities in obstetric and perinatal outcomes persist (Howell and Zeitlin, 2017).
While the forms and scale of obstetric violence are contextual, and tend to differ from those seen in high-income countries, similar trends can be identified in low- and middle-income countries. For example in SriLanka, research found that vulnerable groups such as the youngest and most economically disadvantaged birthing people are also among the most vulnerable groups for experiencing obstetric violence (Perera et al., 2022). Similarly, in Ethiopia several studies have linked rural residence, low educational status, and low socioeconomic status with the likelihood of experiencing disrespectful and abusive maternity care (Mengesha et al., 2020). These findings were echoed by a large-scale study from Mexico, which showed that younger people and those of lower socioeconomic status were more likely to be subjected to obstetric abuse and violence (Castro and Frías, 2019).
Despite the known prevalence of obstetric violence and the associated negative health outcomes, the topic continues to receive insufficient attention. One reason for this is the “gendered, structural, and institutional nature of obstetric violence” which perpetuates the normalisation of obstetric violence and contributes to it being deeply embedded in healthcare systems and accepted norms (Khalil et al., 2022). Furthermore, since obstetric violence is so deeply entrenched in obstetric care, it can be difficult to recognise, particularly for health professionals themselves (ibid.). As it often impacts those who are already experiencing multiple systems of oppression, birthing people may not feel empowered to speak up about their experiences.
To address the issue of obstetric violence, it needs to be considered holistically under the mainstream understanding of gender-based violence. More attention and better evaluation processes are needed to measure obstetric quality, and all birthing people should be made aware of what obstetric violence can look like. Special attention should be given to more at risk groups, and better reporting and support mechanisms are needed to help those who do experience obstetric violence. Until this global issue is better recognised, monitored, and addressed, people giving birth will continue to face dangerous and dehumanising treatment that puts the health of both them and their babies at risk.