Are Institutionalization and fear of litigation the root causes of obstetric violence?

Abusive practices in obstetric health care settings have been reported for over 70 years. It is only in the last 10-15 years that this issue has been identified as being a significant problem, occurring across high, middle and low-income countries.

The concept of obstetric violence originated from Latin America and Spain, from activism aimed at humanizing and de-medicalizing childbirth, as well as empowering women during pregnancy and labor. There are various definitions and terms used, but the main understanding of obstetric violence is it is ‘a specific type of violation of women’s rights, including the rights to equality, freedom from discrimination, information, integrity, health and reproductive autonomy.’ The WHO simply puts it as “the abuse, neglect or disrespect during childbirth.” There are different types of obstetric violence across the world. This ranges from violent speech and unnecessary procedures (as documented in Brazil), institutional unpreparedness and non-compliance with obstetric protocols, disempowerment/lack of autonomy in highly medicalized societies, turning patients away who cannot pay and gender-based violence where women are discriminated against (as reported in India, Papua New Guinea and Zimbabwe ) and forcing women in prison to give birth in shackles (United States). 

The rise in obstetric violence appears to mirror the rise in institution based obstetric care, where women feel less in control of their birthing experience. The push to reduce maternal mortality globally has placed an emphasis on institutional delivery. Delivering in a hospital with a health professional is regarded as much safer than not. Yet evidence is emerging that the quality of patient care is questionable, and although institutional care may be safer from a strictly clinical outcomes perspective, it is in fact violent.

There are specific parts of the world where obstetric violence is deeply rooted in gender discrimination. However, it can also be said that globally, obstetric violence is rooted in the provider’s intense fear of complications and litigation, which drive them to act in ways that can be seen as violent. There is a significant amount of pressure that healthcare professionals feel to deliver a healthy baby and ensure the mother does not suffer from severe complications. This often leads to tunnel vision, whereby professionals see these two outcomes as a priority over everything else. I know this feeling well and it was the root cause of the violence in the labor wards that I saw firsthand. It can severely compromise the holistic care we give to our patients and compromise patient autonomy. It is worse for women that are refugees or immigrants who do not speak the same language as providers or understand the culture.

Most professionals are unfamiliar with obstetric violence and only understand it in a superficial way. They do not realize they are even partaking in it, although they can recognize when their colleagues are committing some type of obstetric violence. As the push for institutional delivery increases and extra demands are placed on publically funded health systems such as the one I worked in in the UK, there are various structural conditions that fuel obstetric violence, such as lack of material resources, increased demands on healthcare providers, shortage of healthcare providers and lack of space. These stressors on providers can seep into the care that they give their obstetric patients and can manifest as violence. By no means is this a ‘get out of jail card’ to justify the way providers act, but it is important to note that limitations placed on providers as a result of poor health system infrastructure is also a root cause of violence. This desperately needs to be addressed to ensure that above all, patients get the care that they deserve and are treated with respect and dignity.

The Maternova team believes that more attention could be paid to categorizing obstetric violence by type  (psychosocial versus physical) and by level (e.g. levels 1-4) and to facility-level audits examining the quality of care inclusive of obstetric violence of all types.

By Shreya Patel

Photo Credit:

Martine Perret

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