Obstetric Violence

What rights and protections are pregnant women and people entitled to during pregnancy and birth?

The World Health Organization (WHO) highlights that:

Every woman has the right to the highest attainable standard of health, which includes the right to dignified, respectful health care throughout pregnancy and childbirth, as well as the right to be free from violence and discrimination. Abuse, neglect or disrespect during childbirth can amount to a violation of a woman’s fundamental human rights.^[1]

The Eupean Convention on Human Rights^[2] sets out minimum rights which were incorporated in the UK Human Rights Act of 1998^[3]. These include:

• The right to autonomy and integrity which means that no medical procedure should be performed unless you have given informed consent. For further detail and an explanation of informed consent see our webpage Making decisions about your maternity care.

• The right to private life which includes the right to make choices about where and how you give birth.

• The prohibition of ‘degrading or inhuman treatment’.

• The prohibition of discrimination.

There is more information about your rights and tools to help you get them respected in our book AIMS Guide to Your Rights in Pregnancy & Birth (principal author Emma Ashworth.)

What is obstetric violence?

Obstetric violence is any action which results in the violation of the above rights during pregnancy and childbirth. Unfortunately, there is no UK legal definition of obstetric violence nor is there a settled and accepted international one.

The United Nations has defined obstetric violence as “mistreatment and violence against women experienced during facility-based childbirth.” However this definition is not ideal or inclusive. Although typically considered a form of gender-based violence or violence against women, obstetric violence can be carried out on anyone who becomes pregnant. It can also occur outside of “facility-based childbirth.” In other words, obstetric violence can occur wherever birth takes place, including during a homebirth.

AIMS defines obstetric violence as “any form of disrespectful or abusive treatment carried out by maternity services staff during pregnancy, childbirth or shortly after birth.” See our position paper on Obstetric Violence.

There is very little research on obstetric violence. However, WHO recognises that some people are more likely to experience obstetric violence than others. This includes younger pregnant women, those from ethnic minority groups, migrants and women who they describe as having a “low socio-economic status.” To date, there is no evidence base relating to LGBTQ+ people.

Sometimes people use the term ‘birth trauma’ to describe obstetric violence but they are not the same. Birth trauma implies that the trauma is caused by the act of giving birth (which may sometimes be the case) however much ‘birth trauma’ is a result of the abuse a person experiences whilst giving birth - in other words, is due to obstetric violence. This abuse is usually carried out by healthcare staff, most notably doctors and midwives, but can also be structural, resulting from policies and procedures (see below). Of course, people can experience both birth trauma and obstetric violence, but obstetric violence specifically relates to the abuse people may suffer during pregnancy and birth.

What does obstetric violence look like?

It should be noted that although obstetric violence includes the word ‘violence,’ it is not limited to violent acts or the use of force. Often obstetric violence is linked to consent (or the lack of it) during pregnancy or childbirth. It can occur whenever medical interventions are carried out without the pregnant woman or person being given the information and support to make an informed decision, or despite them wishing to decline. This could include interventions such as:

• Vaginal examinations

• Membrane ‘sweeps’

• Artificially breaking the waters (also known as rupturing of the membranes)

• Episiotomies (cutting the vaginal opening/perineum)

• Administration of drugs

• Caesarean birth

Obstetric violence is also the refusal of a doctor or midwife to respect when a person withdraws consent after a procedure has started. Whilst there will be some instances where it would be impossible for a doctor or midwife to discontinue what they have begun (for example during a caesarean) in other cases it will be more straightforward, for example during a membrane ‘sweep’ or vaginal examination.

Sometimes people can be coerced into medical interventions that they would otherwise have declined. This undermines pregnant women and people’s autonomy and bodily integrity and may include:

• Bullying or threats.

• Threats of Children’s Services (formerly known as Social Services) referral if a pregnant woman or person does not submit to a medical intervention.

• Manipulation or deceit such as withholding information from a person so that they agree to an intervention without knowing all of the facts. An example could include a midwife telling a person only the perceived benefits of an induction of labour, but not informing them of any potential risks.

• Repeated and unwanted emphasis of risks and use of emotive language to exaggerate risks.

• Unnecessarily bringing additional and often senior people into the room, or threatening abandonment, in order to intimidate.

• Prohibiting someone from leaving the premises.

• Unnecessarily separating parents from their baby.

Obstetric violence also incorporates abusive, cruel and neglectful treatment. This may include being:

• Sutured (stitched) without anaesthesia.

• Left unaware that care is being used as a teaching opportunity, for example, additional staff being admitted into the birthing room solely to witness a breech vaginal birth without a person’s knowledge or consent.

• Denied pain relief.

• Physically restrained.

• Verbally abused or disrespected (e.g. making degrading comments about a person’s body; telling them to stay quiet while labouring or in pain).

• Left alone by staff (if they do not wish to be) during labour, induction, birth or immediately after giving birth.

• Denied the presence of their chosen supporter(s) during antenatal appointments or scans, labour, induction, birth or while on a postnatal ward.

• Touched without consent.

• Denied food or drinks during labour without clinical justification.

Sometimes obstetric violence is structural. This means that there are policies and procedures in place that undermine pregnant women and people’s human rights. Examples include:

• Policies that require accepting tests or interventions in order to access care. For example access to ‘delivery suite’ or certain forms of pain relief only after a certain cervical dilation; meaning that a person has to undergo a vaginal examination e.g. in order to access this care. Such rules can be coercive and therefore undermine informed consent.

• Policies in which women will only be provided with a homebirth service if they agree to certain interventions such as submitting to vaginal examinations during labour. This again undermines a person’s right to informed consent.

• Policies in which food and drink are restricted without clinical justification.

• Birthing rooms and practices which do not support birth physiology, for example requiring or encouraging people to birth on their backs or in stirrups.

• Policies which lead to unnecessary medicalisation of birth, for example restrictions on access to birth centres or homebirth.

• Use of continuous fetal monitoring without clinical indication, which may mean that pregnant women and people are forced to adopt static positions and restrict their ability to move freely.

All these forms of obstetric violence can lead to both physical and psychological injuries for the woman or birthing person that can last a lifetime, as well as having serious consequences for the whole family.

Complaints and legal challenges

In the UK, law, policy and professional guidance all prohibit violence against women within the maternity setting. On paper therefore, it would appear that there are some accountability mechanisms to provide redress to women who have experienced obstetric violence. However, the reality is very different.

In the UK, there is no specific crime of obstetric violence. However, there are criminal laws relating to battery and assault. These centre around unwanted touching and the type of harm caused by this. Pregnant women and people have the right to decline medical intervention and this must be respected. The only exception to this is in the rare situation where a mental capacity assessment has been carried out, and there is proof that someone lacks the mental capacity to make a decision. The fact that someone is making a decision with which their midwife or doctor disagrees is not evidence that they lack mental capacity. In effect, therefore, any medical intervention without informed consent is potentially a criminal battery or an assault. However, AIMS is not aware of anyone who has successfully brought criminal proceedings against a doctor or midwife for allegations of obstetric violence.

Sometimes women try to bring civil proceedings against a hospital trust for obstetric violence. This is different to a criminal case, which would ordinarily be investigated by the police. Civil proceedings occur when somebody sues a person or an organisation. If successful, that person would receive some form of compensation, usually money, for the damage they have experienced. In AIMS’ experience it is very difficult for people to sue a midwife, doctor or hospital trust for obstetric violence. Often women find it difficult to find a solicitor who will take on their case.

Even if a person just wishes to make a complaint to their hospital trust, these are not always taken seriously. There are many reasons why this may occur and includes the presumption on the part of those reviewing the complaint that:

• The maternity staff’s version of events ‘must be true’, even when it conflicts with the account of the woman or birthing person and their supporters.

• Obstetricians and midwives would never intentionally harm pregnant women or people so any action they took must have been medically necessary.

• Obstetricians and midwives are the experts in birth and therefore pregnant women and people should always do what the doctor or midwife tells them.

• Birth is unpredictable and a person complaining of obstetric violence must have had expectations that are too high.

• Birth is naturally bloody, painful and traumatic and therefore what the person complaining of obstetric violence has experienced is simply a ‘normal’ aspect of birth.

Obstetric violence is wrong and there needs to be an overhaul of maternity services and a huge cultural shift within healthcare and society for it to be eradicated.

What can I do if I have experienced obstetric violence?

• Consider making a complaint to your Trust/Board and/or the relevant professional body if you have experienced obstetric violence.

• Write to your Maternity Voices Partnership (MVP), Maternity Services Liaison Committee (MSLC) and/or your Hospital Trust/Board to make them aware of your experience.

• If you need help to find resolution after experiencing obstetric violence the AIMS Guide to Resolution After Birth contains helpful information.

What can I do to challenge obstetric violence?

• Share this webpage information and our Position Paper to raise awareness of this issue.

• Share the AIMS Birth Information page Making Decisions about your Maternity Care with maternity service users who need this information.

• Write to your Maternity Voices Partnership (MVP), Maternity Services Liaison Committee (MSLC) and/or your Hospital Trust/Board if you are concerned about the behaviour of staff and/or Trust/Board policies and guidelines which may be causing cases of obstetric violence to occur.

• Join AIMS to support our campaigning on this issue.

Further practical information

For information on your rights and consent see: the AIMS Guide to Your Rights in Pregnancy and Birth

For information on making a complaint see: the AIMS Guide to Resolution After Birth

For information on consent see: Birthrights Consenting to Treatment www.birthrights.org.uk/factsheets/consenting-to-treatment

For information on mental capacity see: Birthrights Mental capacity and maternity care www.birthrights.org.uk/factsheets/mental-capacity-and-maternity-care

General information on obstetric violence

Durham University has started a blog which explores obstetric violence. Although quite academic, it may be of interest to people who want more information on the law and to understand the type of research that is currently being carried out on the subject. The blog can be found here: https://duracuk-lb01-production.terminalfour.net/research/institutes-and-centres/ethics-law-life-sciences/about-us/news/obstetric-violence-blog

Birth Monopoly is a US organisation working to challenge obstetric violence. It can be found here: https://birthmonopoly.com. The organisation is creating a documentary on the subject and the trailer can be watched here: http://mothermayithemovie.com

In 2019 the United Nations Special Rapporteur wrote a report on obstetric violence. It can be found here: https://undocs.org/A/74/137. This is the AIMS Submission to the UN review.

Academic studies on obstetric violence

There are very few academic studies on obstetric violence. Those that exist usually have an international focus. A few articles that may be of interest are provided below:

Diaz-Tello, Farah (2016) Invisible wounds: obstetric violence in the United States, Reproductive Health Matters, 24:47, 56-64 www.tandfonline.com/doi/pdf/10.1016/j.rhm.2016.04.004?needAccess=true

Castro, Arachu (2019) Witnessing Obstetric Violence during Fieldwork: Notes from Latin America Health Human Rights. 21(1): 103–111 www.ncbi.nlm.nih.gov/pmc/articles/PMC6586976

Sadler M, Santos Mário JDS, Ruiz-Berdún Dolores, et. al (2016) Moving beyond disrespect and abuse: addressing the structural dimensions of obstetric violence, Reproductive Health Matters, 24:47, 47-55, www.tandfonline.com/doi/full/10.1016/j.rhm.2016.04.002

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References

^[1] World Health Organization (2014) The prevention and elimination of disrespect and abuse during facility-based childbirth http://apps.who.int/iris/bitstream/handle/10665/134588/WHO_RHR_14.23_eng.pdf;jsessionid=A4D93B468924E4915BF0253733C994D0?sequence=1

^[2] Dubravka Šimonović (2019) A human rights-based approach to mistreatment and violence against women in reproductive health services with a focus on childbirth and obstetric violence https://undocs.org/A/74/137

^[3] See above at (i)