The alarming rate of obstetric violence in Spain and worldwide
I chose this image because it illustrates how disturbing medical interventions can be during birth that are unnatural and negatively affect mother and child. For example, Cesarean birth rates are far above 10% of all births, which the WHO recommends. The baby should be immediately placed on the mother’s chest to comfort mother and baby, stimulate oxytocin and milk production, and delayed umbilical cord clamping is recommended to prevent infant anemia. And lastly, look at how they are holding this baby who has just entered into this cold world with little reverence or respect.
The horrifying rate of obstetric violence during pregnancy and childbirth remains largely undocumented or talked about, yet luckily some recent studies are bringing to light this humans rights issue that greatly needs to be researched more and prevented.
Obstetric violence is defined as verbal or physical abuse or disrespect during pregnancy, childbirth and postpartum period— a particularly vulnerable time for any woman— which unsurprisingly leads to long-term adverse effects for both mother and infant. Moreover, women who are adolescent, unmarried, of low socio-economic status, from ethnic minorities, migrants or living with HIV are at greater risk of suffering disrespectful and abusive treatment (1).
According to a World Health Organization (WHO) report:
Reports of disrespectful and abusive treatment during childbirth in facilities have included outright physical abuse, profound humiliation and verbal abuse, coercive or unconsented medical procedures (including sterilization), lack of confidentiality, failure to get fully informed consent, refusal to give pain medication, gross violations of privacy, refusal of admission to health facilities, neglecting women during childbirth to suffer life-threatening, avoidable complications, and detention of women and their newborns in facilities after childbirth due to an inability to pay.
Obstetric violence in Spain
A recent article was published in the International Journal of Environmental Research and Public Health about the alarming rate of obstetric violence in Spain (2). In this retrospective study, researchers analyzed 17,541 questionnaires from January 2018-June 2019 which were filled out by women who received care from the public and private healthcare systems throughout Spain. The researchers report:
38.3% of the women reported suffering obstetric violence
44.4% believed they were submitted to unnecessary interventions
83.4% stated that the medical professionals that treated them did not ask them for informed consent.
The authors of the study concluded that Spain has a serious public health problem with respecting women’s rights in relation to obstetric violence. They state:
It is fundamental to stress lack of confidence, fear or typical vulnerability of some processes in the perinatal stage, which mean that women do not voice their doubts about, or fears of, interventions. This means that women may unconsciously allow OV [obstetric violence] to perpetuate. So reflecting on obstetric practices and asking women for informed consent, who feel completely dominated by the healthcare staff’s technical–scientific authority and the patriarchal authority of structural violence, is necessary.
And people call me crazy for giving birth at home in Spain! Read my recent blog post about how I’ve been treated like a little child during my pregnancies.
Obstetric violence worldwide
Ghana, Guinea, Myanmar, and Nigeria
A 2018 study published in the Lancet that was funded by the WHO and UNICEF followed 2,016 women during labor and interviewed 2,672 women after childbirth from 2016-2018. The study concluded that 41.6% of women during labor and 35.4% of women after childbirth suffered from physical or verbal abuse, or stigma or discrimination (3).
Verbal abuse peaked 30 minutes before birth and 15 minutes after birth.
75.1% of women did not consent to episiotomy while 56.1% did not consent to Cesarean births.
Young, uneducated and unmarried women were most likely to suffer from obstetric violence.
Can you imagine being yelled at or physically abused during the most vulnerable and important times of your life????
Northwest Ethiopia
A 2019 study in 409 women concluded (4):
75.1% women reported that they had been subjected to at least one form of obstetric violence during labor and delivery including non-consented care (63.6%), non-dignified care (55.3%), physical abuse (46.9%), non-confidential care (32.3%), neglected care (12.7%) and discriminated care (9.3%).
Central and Latin America
A literature review of 24 publications from 2007-2017 of studies worldwide reported that 80% of the publications from 2015-2017 reported obstetric violence suggesting that this could be a more recent phenomena, but I would argue that it’s been going on for decades and has only recently been documented.
In response to the abuse and unnecessary interventions affecting women, Venezuela became the first country in the world to enact the Organic Law on the Rights of Women to a Life Free of Violence in November 2006 which characterizes obstetric violence as the appropriation of the female body and reproductive processes by health professionals.
The Statute of Violence against Women in Argentina defines obstetric violence as cruel, dishonorable, inhuman, humiliating, threatening treatment by health professionals, causing physical, psychological and emotional harm to assisted women.
The Perseu Abramo Foundation survey revealed that one in four women in Brazil has suffered some type of obstetric violence during childbirth care. The “Being born in Brazil” survery concluded that 36.4% of the 23,894 women interviewed received stimulant medication for childbirth; 53.5% were subjected to episiotomy; 36.1% received mechanical maneuvers to accelerate birth; 52% underwent unnecessary cesarean sections; 55.7% were kept restricted to the bed; 74.8% were subjected to fasting and 39.1% underwent amniotomy (5).
United States of America
Obstetric violence doesn’t just occur in non Western countries. The US also has a major problem with obstetric violence and high infant mortality rate, especially among black women.
A 2019 study from the journal Reproductive Health concluded that of the 2,700 women surveyed from the U.S., one in six women experienced one or more types of obstetric violence including loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help. Interestingly, the place of birth resulted in big differences in suffering from this treatment. For example, only 5.1% of women who gave birth at home experienced obstetric violence compared to 28.1% who gave birth in hospitals.
The authors concluded that women who had a vaginal birth, a midwife, were white, older than 30, gave birth to more than one baby, or had a community birth were less likely to suffer from mistreatment. Indigenous, Hispanic and black women were the most mistreated (6).
Another recent study concluded that the total number of cases of obstetric violence in the US is unknown because it is under reported and not named as such in the scientific literature including in the keywords, title or abstract which illustrates how this prevalent healthcare and humans rights issue remains hidden so that it can perpetuate behind closed doors. It further provides evidence that this the term obstetric violence needs to be used as a way to convey a subset of gender-based violence rather than use mixed terminology (7). Therefore, obstetric violence remains largely under documented.
Causes of Obstetrical Violence
Source: Garcia LM. A concept analysis of obstetric violence in the United States of America. Nursing Forum. 2020. https://onlinelibrary.wiley.com/doi/abs/10.1111/nuf.12482
According to researcher Loraine Garcia, one of the main causes is the hierarchy that establishes due to the medical professional’s knowledge which therefore equates into power over the woman (7).
Sadly, female nurses and doctors seem to be the worse offenders which can make it more difficult for the healthcare professional to identify herself as the violent offender and over time this type of gender specific mistreatment has been normalized worldwide.
The health professional excuses that attempt to justify their violence often includes: work overload, scarce human resources, physical and mental exhaustion, dangerous conditions for care, and lack of adequate infrastructure in institutions. Therefore, this is a societal and institutional issue.
Also, many women don’t know their medical or reproductive rights. For example, in Spain at least, a woman can deny any medical intervention or test while she is pregnant and postpartum but most are not told this so pregnant women feel coerced into following through with every intervention their OBGYN suggests.
The issue of the over medicalization of birth
Source: http://www.may28.org/obstetric-violence/
An estimated 140 million births take place every year worldwide, and while most occur without complications, healthcare professionals have increased the use of interventions that were previously only used to avoid risks or treat complications, such as oxytocin infusion to speed up labor or caesarean sections over the past 20 years (8).
I believe obstetric violence is a serious problem worldwide due to the over medicalization of birth— which is a natural biological process that ALL women are capable of doing and physiologically women’s bodies know how to give birth without any doctor or midwife telling us what to do. The desire to incorporate unnecessary medical interventions in pregnancy and childbirth stem from the switch to the ancestral matriarchal tradition of birth to the domineering patriarchal control of women’s health in healthcare systems that started in the early 20th century when births moved from ocurring primarily in the home to hospitals.
There are several books written about this topic such as Gentle Birth, Gentle Mothering: A Doctor’s Guide to Natural Childbirth and Gentle Early Parenting Choices by Sarah Buckley, MD and Ina May’s Guide to Childbirth, that go in depth about the negative consequences of medical interventions during pregnancy and birth that have now become common practice such as ultrasounds, fetal heart monitoring, epidurals, early induction with Pitocin, elective cesarean births, limited food intake during labor, restricting movement during labor and reclined position during labor (you know all those dramatic movie scenes where the woman is lying on the hospital bed screaming).
Detrimental health effects for mother and baby
Additionally, several studies have been published illustrating the rise in unnecessary medical interventions during pregnancy and birth. Sadly, indigenous, low income and women of color are more likely to be subjected to unnecessary medical interventions in low risk pregnancies and births (9).
Hospital births are far more likely to perform medical interventions (10), and cesarean births and labor inductions have been on the rise in high income countries since 1970 (11). These interventions can lead to poor health outcomes for mother and baby which causes trauma that can last a lifetime. These outcomes include: maternal and perinatal mortality, Apgar score below 7 at 5 min, postpartum hemorrhage and obstetric anal sphincter injury (11).
A Lancet study concluded that of the approximately 500,000 home births analyzed, no deaths were reported and women were less likely to experience: caesarean section; operative vaginal birth; epidural; episiotomy; 3rd or 4th degree tear; oxytocin augmentation, maternal infection, and less postpartum hemorrage (12). These outcomes can have long lasting effects for mothers who have a harder time recovering physically and emotionally during the postpartum period, and as a result the baby also suffers some of the effects. To compound matters, most women feel ashamed about abnormal postpartum recovery such as extreme inconstinence, organ prolapse, poor pelvic floor recovery and unresolving diastasis recti that are often due to birth interventions (read The Third Trimester by Kimberly Johnson).
A 2018 Australian study concluded that infants who experienced an instrumental birth after induction or augmentation had the highest risk of jaundice, compared with spontaneous vaginal birth. Children born by cesarean delivery had a statistically significantly increased risk for infections, eczema, and metabolic disorder, compared with spontaneous vaginal birth. Children born by emergency cesarean delivery had highest association for metabolic disorder. Additionally, babies born cesarean are not exposed to their mother’s vaginal microbiome and therefore are born with a less rich and diverse microbiome which has been associated have been linked to allergies, inflammatory diseases, among other health issues compared to babies born vaginally (13).
Moreover, women who has a traumatic birth experience and obstetric complications (14, 15) have a much more difficult postpartum period and is more likely to suffer postpartum depression, though I believe that this is severely underreported.
In addition to postpartum depression, other forms of psychological trauma including mood disturbances, personality changes, PTSD, impaired bonding with the newborn, negatively altered family dynamics, impaired sexuality and sexual function, and choosing not to have any more children are other consequences of obstetric violence which can result in unnecessary medical interventions (7).
On an energetic level, the womb is a vessel that holds onto energy very easily— the good, the bad and the ugly. Unless the woman knows how to release unwanted energies from that space, energy can remain stuck there causing energetic, spiritual, hormonal and physical imbalances. The womb also never forgets. Any physical, emotional or energetic trauma that affects the womb is often difficult to release and can cause a lifetime of psychological and physical problems. Birth trauma and obstetric violence creates the perfect storm to know the energetic balance of the womb off kilter at a time when it is extremely open and vulnerable to outside energies.
Preventing obstetric violence
Sadly, it will likely take decades for public healthcare systems to catch up and protect women’s rights. For this reason, although I am no expert on this topic other than from what I’ve read and experienced through my pregnancies, I believe women first and foremost need to be educated on their reproductive and health rights as well as the pros and cons of any medical intervention. Unfortunately, few OBGYNs offer informed consent to their patients forcing women (many of whom are busy, overworked, stressed, overwhelmed and may not have access to proper resources) to do their own investigative research.
Some other considerations:
On a global and humanitarian level, women need to be respected and we need to reclaim our ancestral knowledge about birth and trust in our body’s innate ability to give birth freely.
On a worldwide public healthcare level, more attention needs to be placed on obstetric violence and this term should be used unanimously in order to create a consensus on the severity of this issue.
A first do no harm approach needs to be taken among all healthcare professionals in which informed consent is of the utmost priority.
A priority needs to be placed on creating a system for properly tracking cases of obstetric violence.
Public healthcare policies need to be implemented immediately that protect a woman’s rights and aim to educate a woman on her rights during fertility treatments, pregnancy, birth and postpartum.
Unfortunately, birth classes only focus on breathing and pushing but offer scant information in regards to a woman’s rights and the negative side effects of medical interventions.
A detailed birth plan should be encouraged and demanding informed consent from all medical professionals should be heavily stressed.
The use of midwives and doulas should be the norm and highly encouraged so that the mother will have a supportive team of advocates.
Recommended reading
Gentle Birth, Gentle Mothering: A Doctor’s Guide to Natural Childbirth and Gentle Early Parenting Choices by Sarah Buckley, MD
Pushed by Jennifer Block
Doing Harm by Maya Dusenbery
Women’s Body’s, Women’s Wisdom by Christiane Northrup, MD
The Fourth Trimester by Kimberly Johnson
The Postnatal Cure by Dr. Oscar Serrallach
Birthing from Within by Pam England and Rob Horowitz
Natural Health after Birth: The Complete Guide to Postpartum Wellness by Aviva Romm, MD
References
The World Health Organization. The prevention and elimination of disrespect and abuse during facility-based childbirth. October 2015. https://apps.who.int/iris/bitstream/handle/10665/134588/WHO_RHR_14.23_eng.pdf;jsessionid=7EC7944CCFE745E4ADF04AEAD7C69617?sequence=1
Mena-Tudela D, et al. Obstetric Violence in Spain (Part I): Women’s Perception and Interterritorial Differences. Int. J. Environ. Res. Public Health 2020, 17(21), 7726; https://doi.org/10.3390/ijerph17217726
Bohren MA, et al. How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys. Lancet. 2019; 394 1750–63. https://doi.org/10.1016/ S0140-6736(19)31992-0. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2819%2931992-0
Mihret, M.S. Obstetric violence and its associated factors among postnatal women in a Specialized Comprehensive Hospital, Amhara Region, Northwest Ethiopia. BMC Res Notes 12, 600 (2019). https://doi.org/10.1186/s13104-019-4614-4. https://bmcresnotes.biomedcentral.com/articles/10.1186/s13104-019-4614-4
Jardim, Danúbia Mariane Barbosa, and Celina Maria Modena. “Obstetric violence in the daily routine of care and its characteristics.” Revista latino-americana de enfermagem vol. 26 e3069. 29 Nov. 2018, doi:10.1590/1518-8345.2450.3069
Vedam, S., Stoll, K., Taiwo, T.K. et al. The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reprod Health 16, 77 (2019). https://doi.org/10.1186/s12978-019-0729-2
Garcia LA. A concept analysis of obstetric violence in the United States of America. Nursing Forum. July 2020. https://doi.org/10.1111/nuf.12482
WHO. Individualized, supportive care key to positive childbirth experience, says WHO. 2018. https://www.who.int/mediacentre/news/releases/2018/positive-childbirth-experience/en/
Fox, H., Callander, E., Lindsay, D. et al. Evidence of overuse? Patterns of obstetric interventions during labour and birth among Australian mothers. BMC Pregnancy Childbirth 19, 226 (2019). https://doi.org/10.1186/s12884-019-2369-5
de Jonge, A., Peters, L., Geerts, C. C., van Roosmalen, J., Twisk, J., Brocklehurst, P., & Hollowell, J. (2017). Mode of birth and medical interventions among women at low risk of complications: A cross-national comparison of birth settings in England and the Netherlands. PloS one, 12(7), e0180846. https://doi.org/10.1371/journal.pone.0180846
Seijmonsbergen-Schermers A, de Jonge A, van den Akker T, et al. Variations in childbirth interventions in high-income countries: protocol for a multinational cross-sectional study. BMJ Open 2018;8:e017993. doi: 10.1136/bmjopen-2017-017993
Reitsma A, et al. Maternal outcomes and birth interventions among women who begin labour intending to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses. Lancet 2020; 21: 100319. DOI:https://doi.org/10.1016/j.eclinm.2020.100319
Peters LL, et al. The effect of medical and operative birth interventions on child health outcomes in the first 28 days and up to 5 years of age: A linked data population‐based cohort study. Birth Issues in Perinatal Care 2018; 45:4. https://doi.org/10.1111/birt.12348
Zinga D, et al. Postpartum depression: we know the risks, can it be prevented? Rev. Bras. Psiquiatr. 2005; 27: 2 http://dx.doi.org/10.1590/S1516-4446200500060000
Taghizadeh, Z., Irajpour, A., & Arbabi, M. (2013). Mothers' response to psychological birth trauma: a qualitative study. Iranian Red Crescent medical journal, 15(10), e10572. https://doi.org/10.5812/ircmj.10572
