What does ‘violence’ mean in obstetric violence? (Part 2)

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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’. In part 1 she writes that ‘obstetric violence’ reveals that some of the things that women are subjected to during ‘normal’ facility-based childbirth should not be accepted as normal. 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. So, Camilla concludes, this means that we need to take a step back and ask: what does violence mean?

The word ‘violence’ typically inspires images of gruesome crimes, intentional infliction of visible trauma or aggressive eruptions of force against another person or groups of people. These images of violence are aligned with the dictionary meaning of violence: ‘violent behaviour that is intended to hurt or kill somebody’ or ‘physical or emotional force and energy’. This definition has become our ordinary understanding of violence because it is visible: we can see it and know that we are seeing it. However, violence as the intentional use of physical force to harm someone is only one way of understanding ‘violence’. 

“In some healthcare contexts being ‘with women’ has morphed into the complete mechanical appropriation of childbirth”

Ignoring harm
Indeed, violence is a complex phenomenon with multiple definitions. An understanding of violence only as intentional force against another is not universally supported because it ignores too much harm. It does not include emotional and psychological harms, unintentional behaviours that cause just as much harm as intentional ones, neglect or denial of support, silent but overpowering exchanges, or gentle but very intrusive touches. It does not include the harms caused to women because of the way healthcare institutions are structured and run. In some healthcare contexts being ‘with women’ has morphed into the complete mechanical appropriation of childbirth and the objectification of women for the sake of smooth-running schedules and efficient healthcare facilities. Obviously, ‘violence’ in ‘obstetric violence’ is much more than the intentional use of force to inflict harms on women and it is therefore based on a different definition and understanding of violence.

Violation
‘Obstetric violence’ is more closely aligned with the school of thought that defines violence in terms of ‘violation’. Violence means ‘to violate’: to infringe, transgress or exceed a norm and it focuses on the victims’ perspective. That is, for purposes of identifying violence, we do not look at what the perpetrator intended but at the consequences of their behaviour as experienced by the person on the receiving end of it. The violation experienced by the victim is the defining feature of ‘violence’. If violence is defined in terms of violation, we need to ask: what needs to be violated for there to be an instance of violence? Some theorists suggest that violence involves a violation of the victim’s human rights but this has serious limits as there is no uniform approach to human rights. Some human rights might not exist in some countries and not everyone will have equal access to the benefits of rights that are recognised. For instance, in some countries women are denied rights because they are women and sometimes only citizens and registered residents can claim their rights. This leaves many people without access to rights. Sometimes governments might define certain human rights in ways that permit violations. This can be seen in the context of state-sanctioned slavery, corporal punishment, and the death penalty, for instance. Obstetric violence violates a range of human rights but this does not always help to identify the violence. For instance, the violation caused by subjecting a woman to routine vaginal examinations during labour without her informed consent will be experienced as a violation irrespective of whether her country recognises the relevant human rights or how it defines those rights. Nevertheless, there is a definition of violence that overcomes this issue. 

“We are working with a system that is based on violence against women”

Integrity
Violence can be defined in terms of the violation of the victim’s integrity and this approach appears to reflect the ‘violence’ that ‘obstetric violence’ refers to. Here, ‘integrity’ means something that is ‘intact’ or not broken and violence disrupts this pre-existing unity. ‘When a person becomes the victim of an act of violence, it is someone’s integrity as a person that is being infringed, since in the process of being violated they are reduced to a lesser being in physical and/or psychological terms’. A violation of integrity can involve an undoing of the self, it can cause a radical disruption in the mind and/or of the body and it can change how we see ourselves and the world, and how we relate to those in the world.  The language women use to describe some of their childbirth experiences reveal that we are confronted with a violation of their physical and/or psychological integrity: ‘I actually felt myself leave my body’; ‘humiliated’; ‘belittled’; ‘treated as a piece of meat’; ‘violated and damaged’; violated and scared and disgusting’. These descriptions (and many more not included here) tell us, quite clearly, that women were treated as ‘lesser beings’ during childbirth and this means that whatever caused these experiences constitutes obstetric violence and therefore making visible what was invisible, defining as unacceptable what was acceptable, and insisting that ‘normal’ is a problem.

Pinpointing the problem
Women’s integrity can be violated in many ways during childbirth. ‘Obstetric violence’ captures all the different ways that this might manifest, and this means that ‘obstetric violence’ is very broad in scope. In fact, it is astounding to see so much potential for violence in childbirth and it can be rather difficult to fully comprehend the breadth of this term because it might appear contradictory. For instance, a doctor bemoans: ‘Today anything you do with the patient can be viewed as obstetric violence. If you have a normal birth, it is violence, if you have a caesarean, it is violence’. It is true that obstetric violence is omnipresent but that does not mean that this concept is flawed simply because it makes this problem blatantly visible. The omnipresent nature of obstetric violence means that we are working with a system that is based on violence against women. Obstetric violence does not refer to everything that happens during facility-based childbirth, it refers to those interactions with healthcare personnel or healthcare systems that violate women’s integrity. Violation of integrity pinpoints where the violence lies: a vaginal birth can become a manifestation of obstetric violence if during that process a woman’s integrity is compromised. We do not ask if her doctor or midwife intended to hurt her, if there are physical injuries, or if they used excessive force. To identify obstetric violence, we ask: Was she treated as a ‘piece of meat’? Was she listened to? Was she included in the decision-making process? Did she have a say about who could touch her, where she could be touched or when she could be touched? Was she objectified?

“It has taken me 10 years to realise I experienced obstetric violence too when I gave birth ”

The key
I have been working on women’s rights during pregnancy and childbirth for many years; seven of which have been dedicated to obstetric violence. Despite having three law degrees and several publications dedicated to women’s rights it has taken me 10 years to recognise, label and accept that I experienced obstetric violence when I gave birth to my daughter. My limited understanding of violence impeded my ability to see all the different kinds of violence that can occur in hospital settings and I was left without a name to label and describe my experiences and demand that the wrong be seen by others. There is more than one way of defining violence and this fact is the key that unlocks our consciousness on this subject and it provides a foundation to support united calls for system reform and individual accountability.

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.