Abstract
Obstetric violence is a term that has sparked considerable debate. It represents a range of harmful practices around unwanted intimate examinations. This article explores the contested boundaries of obstetric violence, examining both overtly abusive actions and more routine, yet potentially harmful, medical practices during childbirth and beyond. By delving into the underlying patriarchal and misogynistic structures within healthcare, the article challenges traditional understandings of care in childbirth. It argues for a broader, more nuanced recognition of obstetric violence, emphasising its connection to gender-based violence and the need for a more context-sensitive approach in both legal and medical frameworks. The aim is to expand the discourse on obstetric violence to include often overlooked and normalised practices that contribute to the mistreatment and dehumanisation of women, birthing people, and transgender people receiving gender-affirming care.
Key messages
Obstetric violence involves overt and subtle mistreatment during childbirth, often tied to patriarchal healthcare structures.
Traditional views are challenged by highlighting the complex and disputed boundaries of obstetric violence.
A broader understanding of obstetric violence is needed, emphasising its connection to gender-based violence.
Introduction
Academic literature on obstetric violence is at a nascent stage. Indeed, the very term is controversial, even confronting to some. As Dixon puts it ‘The very pairing of the terms obstetric and violence is unexpected, jarring, and provocative’ (Zacher Dixon, 2015: 452). Professionals working in obstetrics are normally doing everything they can to care for women and birthing people during labour in the pursuit of delivering a healthy child. Perhaps as a result, those working in obstetrics struggle to describe what they are doing as violent (Grilo Diniz et al, 2018). Yet, it is clear from the accounts of many birthing women and birthing people that they experience violence during the birth process.1 The terminology of obstetric violence captures well the reality for them and gives validation to what they have been through (Pickles, 2023).
Even where the term ‘obstetric violence’ is accepted its precise remit is hotly disputed. What forms of conduct constitute violence in this context? Or is that not the right way to frame the question: should obstetric violence be defined by the experience of the person subjected to it? Where are the boundaries of obstetric violence? Does the behaviour have to take place in a hospital or medical care setting? Must the conduct be ill-motivated?
It is not the purpose of this special theme to answer these questions or to provide a definition of obstetric violence. Rather, the articles presented here explore topics at the shadowy boundaries of obstetric violence and do not necessarily fall within core understandings of obstetric violence. The topics covered in this issue involve ‘routine’ medical practices (vaginal and rectal examinations), ‘unmedicalised’ births at home, and gender-affirming care. These might be seen as separate from obstetric violence or only tangentially related, but by examining such issues we believe these articles provide some important insights into our broader understanding of obstetric violence.
We offer some brief comments on the standard approach to obstetric violence before introducing the issues raised by the articles.
Defining obstetric violence
Many women across the globe experience disrespectful, abusive or neglectful treatment during childbirth in facilities. … While disrespectful and abusive treatment of women may occur throughout pregnancy, childbirth and the postpartum period, women are particularly vulnerable during childbirth. Such practices may have direct adverse consequences for both the mother and infant. (WHO, 2014)
Obstetrical and gynaecological violence is a form of violence that has long been hidden and is still too often ignored. In the privacy of a medical consultation or childbirth, women are victims of practices that are violent or that can be perceived as such. These include inappropriate or non-consensual acts, such as episiotomies and vaginal palpation carried out without consent, fundal pressure or painful interventions without anaesthetic. Sexist behaviour in the course of medical consultations has also been reported. (PACE, 2019)
The kinds of abuse suffered as part of obstetric violence include sexual, physical, verbal and/or emotional abuse by healthcare professionals (Bohren et al, 2015). Many commentators also include a failure to provide services to women. A recent traumatic example of that in England occurred in HMP Bronzefield, where an 18-year-old prison inmate was left alone in her cell to give birth. Her calls for help went unanswered and she was left alone for 12 hours. After giving birth, she bit through the umbilical cord. Tragically, the baby was found dead, although the coroner was unable to establish whether the baby was born dead or died as a result of failure to receive medical care or both (Taylor, 2023). The woman described it as ‘the worst and most terrifying and degrading experience of my life’. Indeed, the impact on women generally of these experiences of obstetric violence can be profound, with long-term psychological impact.
Not all obstetric violence is quite so obviously grievous. More common forms of abuse are simply failing to listen to the woman or birthing person during the birth, overriding their wishes, objectifying women, and treating women and birthing people as a mere means to produce a healthy baby. Painful procedures are performed without appropriate pain relief, care and compassion. A whole book has been dedicated to the issue of unwanted vaginal examinations during obstetric care (Pickles and Herring, 2020). Unwanted vaginal examinations are a good example of ‘routine’ obstetric violence because it is commonly presumed that regular vaginal examinations are necessary and that consent for them can be assumed. But, as that book highlights, neither of these things is true. Concepts such as privacy, dignity and autonomy, which should be central to patient care, are too readily ignored during childbirth.
Camilla Pickles has written that obstetric violence ‘is a concept that lacks a coherent theoretical basis and continues to elude precision in terms of what is and is not obstetric violence’ (Pickles, 2022). This points at a difficulty described by Vorobej that ‘we can’t effectively control violence … if we can’t discuss violence … in some reasonably coherent fashion. In order to tackle the problem, we need to know what the problem is. We need to know what we are talking about’ (Vorobej, 2016). While clearly that is correct, it is also important to be aware of the conceptual limitations of strict definitions: they firmly in- and exclude and tend to simplify their subject. A strict definition of obstetric violence might exclude a substantial part of the topics discussed in this issue.
As Camilla Pickles notes, ‘“obstetric violence” definitions are relative to the contexts in which they emerged, and their definitional scope tends to be broader in more contemporary law reform efforts’ (Pickles, 2023: 632). The discussion regarding defining obstetric violence is of particular relevance to lawyers: for lawyers especially, there are challenges to whether the concept of obstetric violence is useful for legal purposes if it cannot be defined and specially defined with sufficient precision for use in a courtroom. Yet, we need to recognise the limits that such a definition would create. The law requires realities and knowledge to be transformed and reconstructed through the legal process and rules of evidence so they become ‘legal truths’ or ‘legal knowledge’ (King and Piper, 1990, drawing on Gunther Teubner’s writing, for example, Teubner, 1989). There is no space here to fully explore those topics, but the articles in this issue can show the challenge in seeking to find the kind of precise, water-tight definition of obstetric violence that the law requires. The topics raised in the articles in this issue include challenges to a ‘mainstream’ understanding of the place, experience, silencing, and care in and of obstetric violence and unwanted intimate examinations. These challenges are briefly introduced in the following.
Place
Obstetric violence is typically imagined to be performed in a hospital or healthcare setting. Indeed, one way of understanding obstetric violence is to see it as a particularly blatant example of the exercise of medical power. That is where the power structures of the medical profession and patient are formalised, and the subservient ‘patient role’ is taken on by the pregnant women and birthing persons. This might lead to a claim that obstetric violence is limited to healthcare settings. Indeed, Pickles claims ‘“obstetric violence” names a previously unnamed and widely unrecognised harmful social phenomenon: violence and abuse during childbirth in healthcare facilities’ (Pickles, 2024).
Gemma McKenzie’s article in this issue explores obstetric violence within the context of home birth. She identifies issues around lack of consent, threats and intimidation, and breach of confidence even when the birth is at home and is a ‘free birth’. This might seem surprising to some. However, two explanations may be found in McKenzie’s article. The first is that the root of obstetric violence may not ultimately lie in the power of the medical profession but rather in patriarchy. As McKenzie notes, ‘obstetric violence is emblematic of a society imbued with misogynistic tendencies, and where violence against women is normalised’. With that in mind, it is less surprising that obstetric violence can be found wherever birth takes place. Given the power of patriarchy it is hard, perhaps impossible to escape the ‘dehumanisation of women, overmedicalisation, the pathologisation of birth and the manipulation of women both physically and psychologically’ (McKenzie, 2024).
The links to domestic violence are laid bare, particularly in reference to the fear women experience in their own homes and the way this environment can become a site for physical and psychological abuse. Women’s homes are no longer a refuge and as the examples highlight, a homebirth does not guarantee respectful, ethical and lawful care.
This challenge to the typical understanding of obstetric violence as limited to hospital-based births invites considering an expansion of the term by abandoning geographical restrictions that might be imposed by a strict definition.
Experience
A second challenge of capturing the experience of obstetric violence is that, as with other forms of violence against women, the ‘moment’ of abuse takes place within a lifetime of suffering under patriarchy. An abusive remark by a medical professional, for example, echoes and reinforces the negative messages about women found online, on the street, within pornography and so on. Indeed, simply looking at the single incident of obstetric violence it may appear trivial when considered individually: a somewhat rough examination, a rather off-colour joke, or a failure to listen to what the birthing person is saying may not be understood as serious forms of violence. However, even if isolated incidents might not seem to be very serious violations, these take on meanings and significance of their own in the context of widespread violence and abuse against women.
A particularly good example of this can be the obstetric violence experienced by transgender people giving birth. There, seemingly relatively ‘minor’ wrongs such as misgendering can take on a greater significance within the context of gender-based violence and the continuum of violence that transgender people experience on a daily basis. Dylan Kukard’s article highlights the significant issue of abuse within gender-affirming care in South Africa, particularly in the context of bodily reconstruction (Kukard, 2024). While not directly related to the context of childbirth, Kukard’s work brings out well the broader boundaries of obstetric violence. The article discusses unwanted intimate examinations that occur during gender-affirming procedures, shedding light on how these practices can mirror the violations experienced in more traditionally understood obstetric contexts. This examination is vital for expanding our understanding of where and how obstetric violence can take place, particularly when considering the vulnerabilities inherent in gender-affirming care. The article demonstrates the ongoing challenge of transgender people. The abuse described by those receiving what should be life-affirming care is horrific. As Kukard notes, for those receiving gender-affirming care too often, ‘the body is treated as a site for physical, psychological and structural harm’. Appreciating the context of a long-standing failure to respect transgender people’s rights is fundamental for fully understanding the abuse faced by transgender people giving birth.
Kukard’s article is also a powerful reminder that obstetric violence is itself one example of a wider range of failures to respect people’s psychological, physical, sexual and emotional integrity. We can see this too in the links Shabot Cohen and Taylor make in their article on rectal examinations during labour with sexual violence (Shabot and Taylor, 2024). They see these as including ‘the epistemic hindrance preventing their recognition as violence, the shared problem of consent, and how they both transform women from embodied subjects into dehumanised objects’. Again, we see here that obstetric violence is a subset of broader ways in which sexual humiliation and objectification of women take place.
Obstetrics is not a neutral body of scientific knowledge, but is entangled with histories of racist violence in which Black and indigenous women’s reproductive and birthing bodies have been subjected to experimental modes of obstetric violence, and continue to suffer the adverse effects of racist stereotypes and mythologies. (Chadwick, 2021)
While isolated instances of obstetric violence could appear to be relatively minor to an onlooker, the challenge identified here as ‘experience’ demonstrates that a definition of obstetric violence that was to limit the issue to very serious independent acts of violence, may be too narrow. Abuse is not experienced as an isolated event by the person subjected to it. It should be understood in the context of abuse that a person may experience during other parts of the received obstetric care and as well as in other parts of their lives.
Silencing
A dominant theme of the literature on obstetric violence is the way it is ‘silenced’ (Chadwick, 2021; Salter et al, 2021). A very dramatic example of this is in the article in this issue by Nathan Emmerich and Zoe Watkins (Emmerich and Watkins, 2023). That article explores intimate examinations undertaken while women are anaesthetised and unaware of what has happened to them. The women subjected to these intimate examinations cannot give an account of what was done as they were rendered incapable of doing so. This is echoed in the difficulties many women have of being heard in describing their experience of obstetric violence. A range of mechanisms can combine to do this. In some cases, like that discussed by Emmerich and Watkins, women are simply prevented from knowing what has been done to them, be that through the use of anaesthetics or by being lied to or simply not being told what is being done to their body. But more subtle means are often used to silence. Examples of this can be the overwhelming respect owed to the medical profession and the language of care (to which we will return shortly). These can mean that no believable account is possible in which medical professionals would be seen as being capable of engaging in abuse. Another difficulty is that, as already mentioned, an incident can only fully be understood in the wider context and history of the particular woman or birthing person, making the story too complex to tell or too hard for others to relate to or grasp.
This theme can also be found in the article in this issue by Sara Cohen Shabot and Dianna Taylor (Shabot and Taylor, 2024). There, considering the issue of rectal examination, they highlight the role that ‘guilt, self-blame, shame, and sexual humiliation’ can play in silencing women. The silencing of those who have experienced obstetric violence obscures the full scope of unwanted intimate examinations.
This suggests that if obstetric violence is understood in a way that is dependent on women and birthing people coming forward with a claim of their experience, the issue of obstetric violence may be defined too narrowly. Experiencing obstetric violence or unwanted intimate examinations (as noted in the challenge given earlier) does not necessarily translate into a claim of having been wronged.
Care
caring … is a form of oppression and an expression of prejudice. Empowerment means choice and control; it means that someone has the power to exert choice and therefore maximise control in their lives (always recognising that there are limits to how much control any of us have over what happens in our lives). Care – in the second half of the twentieth century – has come to mean not caring about someone but caring for in the sense of taking responsibility for. People who are said to need caring for are assumed to be unable to exert choice and control. One cannot, therefore, have care and empowerment, for it is the ideology and the practice of caring which has led to the perception of disabled people as powerless. (Morris, 1997)
What these quotes capture is the way that ‘caring for another’ can readily amount to an exercise of power. The ‘carer’ identifies the need of the ‘cared for’ and then decides how to meet it. Indeed, this echoes concerns of infringements of women’s autonomy in the delivery room (Villarmea, 2020). Zygmunt Bauman warns that ‘the impulse to care for the other, when taken to its extreme, leads to the annihilation of the autonomy of the other, to domination and oppression’ (Bauman, 1993: 11).
a complex layering of authority, encompassing the authority of the finding of the vaginal examination itself, the authority of the routine and the (constrained) authority of the individual clinician as practitioner of the routine. If vaginal examination is itself the means of setting the routine of labour care, then that presents a challenging climate indeed for a woman or birthing person wishing to say no. The clinician who wishes to support a person saying no may be similarly constrained in their ability by the practical and normative expectations of their own compliance with this authoritative routine (Brione, 2024: 6).
As this quote captures well the ‘caring’ nature of the examination may make it hard for the birthing person to refuse to consent, but also hard for the professional not to offer, or then insist, on its performance. This issue of fusing abuse with care also feeds back into the challenges of obstetric violence silencing its victims. Not only is care hard to refuse, it is also difficult to speak out against as a form of violence after the fact. Within obstetric violence, the notion that care may not always be ‘good’ matters to help illuminate the connection between the elements of ‘obstetrics’ and ‘violence’ that might otherwise be perceived as ‘jarring’ (Zacher Dixon, 2015).
Conclusion
It is not the intention of the special theme in this issue to produce a definition of obstetric violence. Rather, we look at the hinterlands of obstetric violence to consider the concept. We suggest the articles in this issue have some light to throw on the question.
The first is that we cannot draw sharp boundaries. Obstetric violence is all about the unwanted harmful experiences of birthing women and people in the context of labour and giving birth. Yet these experiences cannot be understood in isolation from the broader social context and cannot be tied to place or person. This is because the harms of obstetric violence often draw on, reinforce and reflect wider patriarchal forces. Indeed, obstetric violence is often a particularly powerful example of violence against women more generally.
Second, patriarchy operates where and how it can. As new technologies develop, it takes no time for them to be taken up for oppression of women (for example, in pornographic deepfakes (Khan and Rizvi, 2023) and image-based abuse (Goudsmit, 2021)). Domestic abusers use a bewildering array of methods to coercively control their partners, relying on the particular characteristics of the woman concerned (Herring, 2011). Patriarchy will flow where it can to control and dominate women. It defies definition because it works how it will, without restriction on form and method. It operates over, beyond and between times. This is a key reason to be hesitant and contingent about definition and not to be overly worried that lack of a concrete definition is problematic.
This issue aims to invite discussion on obstetric violence and unwanted intimate examinations in a wider context than limited to what may perhaps be understood as the core understandings of obstetric violence as ‘vaginal examinations in hospital-based childbirth’. The articles presented here draw attention to aspects of obstetric violence at the penumbra of strict definitions.
Note
The term ‘birthing people’ is used here to acknowledge the experience of people who have a womb, who can and do experience pregnancy and birth, but who do not identify as women.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Conflict of interest
The authors declare that there is no conflict of interest.
References
Bauman, Z. (1993) Postmodern Ethics, Oxford: Blackwell.
Bohren, M.A., Vogel, J.P., Hunter, E.C., Lutsiv, O., Makh, S.K., Souza, J.P., et al. (2015) The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review, PLoS Medicine, 12(6): e1001847. doi: 10.1371/journal.pmed.1001847
Brione, R. (2024) A challenging climate: authoritative speech and saying no to routine vaginal examination in labour, Journal of Gender-Based Violence, 8(3): 312–20. doi: 10.1332/23986808Y2024D000000036
Chadwick, R. (2021) Breaking the frame: obstetric violence and epistemic rupture, Agenda, 35(3): 104–15. doi: 10.1080/10130950.2021.1958554
Cohen Shabot, S. and Taylor, D. (2024) Rectal examinations in childbirth: the violence and humiliation of a silenced practice, Journal of Gender-Based Violence, 8(3): 321–36. doi: 10.1332/23986808Y2024D000000025
Emmerich, N. and Watkins, Z. (2023) Should Australian states enact statutes that explicitly ban unconsented intimate exams performed by medical students for educational reasons?, Journal of Gender-Based Violence, 8(3): 371–81. doi: 10.1332/23986808Y2023D000000013
Ferguson, M. (2019) A caring society?, Phi Delta Kappan, 101(3): 62–3. doi: 10.1177/0031721719885925
Goudsmit, M. (2021) What makes a sex crime? A fair label for image-based sexual abuse, Strafblad, 2: 67–75. doi: 10.5553/Bsb/266669012021002002005
Grilo Diniz, C.S., Rattner, D., Lucas d’Oliveira, A.F.P., de Aguiar, J.M. and Niy, D.Y. (2018) Disrespect and abuse in childbirth in Brazil: social activism, public policies and providers’ training, Reproductive Health Matters, 26(53): 19–35. doi: 10.1080/09688080.2018.1502019
Herring, J. (2011) The meaning of domestic violence: Yemshaw v London Borough of Hounslow [2011] UKSC 3, Journal of Social Welfare and Family Law, 33(3): 297–304. doi: 10.1080/09649069.2011.626254
Herring, J. (2013) Caring and the Law, Oxford: Hart Publishing.
Herring, J. (2020a) Ethics of care and disability rights: complementary or contradictory?, in L. Gelsthorpe, P. Mody and B. Sloan (eds) Spaces of Care, Oxford: Hart Publishing, pp 165–82.
Herring, J. (2020b) Identifying the wrong in obstetric violence: lessons from domestic abuse, in C. Pickles and J. Herring (eds) Childbirth, Vulnerability and Law, Abingdon: Routledge, pp 67–87.
Khan, Z.A. and Rizvi, A. (2023) Deepfakes: a challenge for women security and privacy, CMR University Journal for Contemporary Legal Affairs, 5: 203–227.
King, M. and Piper, C. (1990) How the Law Thinks About Children, Aldershot: Gower.
Kukard, D. (2024) Violence during transition: accounts of gender-affirming care in South Africa’s public health system, Journal of Gender-Based Violence, 8(3): 354–70. doi: 10.1332/23986808Y2024D000000042
McKenzie, G. (2024) Learning from obstetric violence in UK births at home: reaffirming and challenging current understanding of abuse during the maternity period, Journal of Gender-Based Violence, 8(3): 337–53. doi: 10.1332/23986808Y2023D000000014
Morris, J. (1997) Care of empowerment? A disability rights perspective, Social Policy & Administration, 31(1): 54–60. doi: 10.1111/1467-9515.00037
PACE (Parliamentary Assembly of the Council of Europe) (2019) Resolution 2306 (2019) Obstetrical and Gynaecological Violence, Strasbourg: PACE.
Pickles, C. (2022) Rachelle Chadwick: Bodies that Birth: Vitalizing Birth Politics, Dordrecht: Springer Nature, pp 245–49.
Pickles, C. (2023) ‘Obstetric violence,’ ‘mistreatment,’ and ‘disrespect and abuse’: reflections on the politics of naming violations during facility-based childbirth, Hypatia, 38(3): 628–49. doi: 10.1017/hyp.2023.73
Pickles, C. (2024) ‘Everything is obstetric violence now’: identifying the violence in ‘obstetric violence’ to strengthen socio-legal reform efforts, Oxford Journal of Legal Studies, 16(5): 1–29. doi: 10.1093/ojls/gqae016
Pickles, C. and Herring, J. (2020) Women’s Birthing Bodies and the Law, Oxford: Hart Publishing.
Salter, C.L., Olaniyan, A., Mendez, D.D. and Chang, J.C. (2021) Naming silence and inadequate obstetric care as obstetric violence is a necessary step for change, Violence Against Women, 27(8): 1019–27. doi: 10.1177/1077801221996443
Scully, J.L. (2023) Feminist bioethics and disability, in W.A. Rogers, J.L. Scully, S.M. Carter, V.A. Entwistle and C. Mills (eds) The Routledge Handbook of Feminist Bioethics, Abingdon: Routledge, pp 181–94.
Taylor, D. (2023) ‘Serious failings’ contributed to baby’s death in 12-hour lone prison birth, The Guardian, 28 July.
Teubner, G. (1989) How the Law Thinks: Toward a Constructivist Epistemology of Law, Florence: European University Institute.
Villarmea, S. (2020) When a uterus enters the room, reason goes out the window, in C. Pickles and J. Herring (eds) Women’s Birthing Bodies and the Law, Oxford: Hart Publishing.
Vorobej, M. (2016) The Concept of Violence, New York: Routledge, Taylor & Francis Group.
WHO (World Health Organization) (2014) The prevention and elimination of disrespect and abuse during facility-based childbirth, https://www.who.int/publications/i/item/WHO-RHR-14.23.
Zacher Dixon, L. (2015) Obstetrics in a time of violence: Mexican midwives critique routine hospital practices, Medical Anthropology Quarterly, 29(4): 437–54. doi: 10.1111/maq.12174
