Obstetric violence: what is it? (Part 1)

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To what extent do women experience violence? In short: we don’t know. Right now, experiences are hidden out of sight, and will continue to be until we pin a suitable label on them and highlight their existence to others. In a two-part series, Camilla Pickles (Assistant Professor at Durham Law School (Durham University)), reflects on what ‘violence’ means in the context of ‘obstetric violence’. Important to explore, because there is a mismatch between how we understand violence more generally and what violence actually means in the context of obstetrics. In this first part she focuses on the origin of ‘obstetric violence’ and our limited understanding of the definition. 

A large portion of feminist work on violence is focused on naming and (re)defining different forms of violence against women. This is a key issue for women because the ‘usual’ way of understanding violence rarely reflects women’s lived experiences. Women and their allies continue to make significant gains in developing and improving our broader understanding of the different forms of violence that women experience in societies shaped by racist, patriarchal and classist norms. These efforts are especially obvious in the areas of sexual violence and domestic violence, for instance. Clarifying the meaning of obstetric violence should help to promote awareness and to make it more identifiable for those on the receiving end of it. Improved visibility can then support demands for the restructuring of care during childbirth in hospital.

“Listening to more people from different contexts will help our understanding of violence in childbirth”

The origin of the definition
Obstetric violence is usually defined as the medical appropriation of women’s bodies and reproductive processes during childbirth which causes a loss of autonomy and denies women their rights to make decisions about their bodies and sexuality. It is a form of violence that occurs in healthcare settings which is perpetrated by ‘hospital personnel’ broadly defined to include nurses, midwives, doctors, trainees, healthcare institutions and training facilities. So, ‘obstetric’ in ‘obstetric violence’ refers to the context of facility-based childbirth, and not only to obstetricians. Part of the reason why ‘obstetric’ is emphasised is because the term ‘obstetric violence’ originates from Latin American countries where midwifery did not exist and births were supported by physicians within hospital environments. It is also worth emphasising that all genders can commit this type of violence, it is not limited to men violating women and people with the capacity for childbirth. Also, obstetric violence is recognised as gender-based violence: women are subjected to violence because they are women and/or because they are the majority of those affected, thus reflecting underlying gender inequalities. These features of obstetric violence certainly help to set the scene but they do not shed light on what violence means in this context.

A limited recognition
Existing legal frameworks are not particularly helpful in establishing the meaning of violence. For example, Venezuelan law recognises only five manifestations of obstetric violence: failure to adequately respond to obstetric emergencies, forcing women to give birth on their backs, preventing early mother/baby bonding and breastfeeding, altering the physiological process of childbirth by using different acceleration techniques without women’s informed consent and performing unnecessary caesarean section procedures without women’s informed consent. It is important to acknowledge the fact that these five forms of obstetric violence represent only a fraction of the way in which obstetric violence can manifest during childbirth and this law’s limited recognition of different types of obstetric violence should not hamper women’s efforts to gain improved insight into this phenomenon. While we may turn to the law for guidance on whether something is ‘right’ or ‘wrong’, I would encourage women to look beyond existing legal definitions because these do not recognise all different manifestations of this form of violence. Research shows that women’s experience of abuse and violence go far beyond these five manifestations.

“The scope and flexibility are something to celebrate because it offers women a powerful lens”

Not a closed list
Researchers and activists use obstetric violence to describe a wide range of abuses during childbirth. These can vary from one country to the next and the violence can manifest differently between women with different sociodemographic characteristics. Obstetric violence can include denying women their right to practise important cultural rites during childbirth, outright physical and verbal abuse, coercion to gain compliance with medical advice or hospital protocols, routine provision of interventions that lack an evidence base and without women’s informed consent and ignoring women’s requests and refusals. Recently, the United Nations Special Rapporteur on Violence against Women recognised a range of medical processes as forms of violence against women. According to her report, abuse and violence include forced symphysiotomies, forced and coerced sterilisations, physical restraint of women during childbirth, and detention of women and their newborns because women are unable to settle hospital bills related to care during childbirth. Other recognised violence and abuse includes the overuse and routine provision of episiotomies and vaginal examinations without voluntary and informed consent, ‘husband stitches’, suturing vaginal tears or episiotomies without pain relief, and overuse of synthetic oxytocin to encourage uterine contractions and speed up the birth process. Again, this list is not a closed list and many more practices will continue to surface as we develop our understanding of violence against women in childbirth and as we expand our platforms and listen to more women and people from different contexts.

“Some things during ‘normal’ facility-based childbirth shouldn’t be accepted as normal”

Normalised
‘Obstetric violence’ provides women with the vocabulary to label and describe the ‘malaise that many women feel after childbirth, even though society tells them that everything is alright and all that is important is that the baby is alive’. The scope and flexibility of the concept of obstetric violence is something to celebrate because it offers women an enormously powerful lens which can be used to interrogate all facility-based procedures that are sold to women as a ‘normal’ way to give birth. Interrogation is essential because ‘violence against women in childbirth is so normalised that it is not (yet) considered violence against women’. ‘Obstetric violence’ reveals that some of the things that women are subjected to during ‘normal’ facility-based childbirth should not be accepted as normal. It exposes these interventions and protocols as harmful human rights violations and it identifies these practices as a manifestation of violence against women. When we recognise something as ‘violence’ (as opposed to a mistake) we can demand that perpetrators’ actions must be explained and justified. We can demand that authorities do something to address and prevent it. However, the effectiveness of ‘obstetric violence’ to challenge ‘normal’ is dependent on how we understand ‘violence’ and our collective ability to recognise it in the particular context of childbirth in hospital settings. This means that we need to take a step back and ask: what does violence mean? Camillia covers this in part two of her series on obstetric violence.

If you feel you have been subjected to obstetric violence, please reach out to Birthrights and/or AIMS, or contact your GP about access to Improving Access to Psychological Therapies (IAPT) services. The British Association of Counselling Psychologists and the British Psychological Society offer helpful directories of accredited therapists and counsellors too.