Written by Amruta Bavadekar, M. Sivakami
As the global community observes the 30th anniversary of the Beijing Declaration and Platform for Action (1995), which marked a pivotal moment for advancing women’s rights globally, the annual 16 Days of Activism against Gender-Based Violence (GBV) (November 25–December 10) serves as a reminder of the persistent challenges women face in achieving equity and justice. The 2024 theme, #NoExcuse, calls for a firm stance against all forms of violence and accountability for perpetrators (UN Women, 2024). However, obstetric violence (OBV) a form of mistreatment during childbirth remains largely invisible in these discussions. This gap reflects systemic failures to address violations of women’s autonomy and dignity in healthcare settings. Obstetric violence includes verbal abuse, coercion, non-consensual medical interventions, neglect, and denial of care (Bowser & Hill, 2010). It perpetuates gender inequality and undermines public health efforts to improve maternal outcomes.
Roses Revolution Day, observed annually on November 25th, highlights OBV during childbirth. Initiated in 2011 by women in Spain, the movement protests mistreatment such as non-consensual medical procedures and forced sterilisations (Sadler et al., 2016). Women place pink or red roses outside facilities where abuse occurred, sharing personal stories to break the silence and expose hidden trauma. Yet, this issue remains underrepresented in global activism. Recognising OBV as a critical aspect of GBV is essential to achieving broader gender equity and ensuring healthcare systems are accountable for upholding women’s rights.
Cultural Roots of Obstetric Violence
OBV is deeply rooted in the cultural fabric of healthcare systems, reflecting paternalistic attitudes and systemic disregard for women’s autonomy. Healthcare providers (HCPs) often justify coercive or non-consensual actions as being in the “best interest” of patients, which reinforces their authority and perpetuates harm (Freedman et al., 2014). This paternalism, coupled with societal norms that glorify medical authority, normalises mistreatment during childbirth.
Freedman et al. (2014) argue that HCP’s perception as benevolent actors often shields them from scrutiny, allowing systemic abuses to continue. Women are often expected to comply with medical decisions without question, and their experiences of coercion or mistreatment are often dismissed as necessary for ensuring safe delivery. This dynamic disproportionately affects marginalised women, who face intersecting forms of discrimination based on class, caste, or ethnicity.
Public Health Dimensions of Obstetric Violence
The push for institutional deliveries in India, driven by programs like the Janani Suraksha Yojana (2005), has significantly increased facility-based childbirths, with 88% of women delivering in institutions as per NFHS-5 (2019-21). While this shift has improved maternal and neonatal survival rates, it has also exposed women to systemic mistreatment. Reports from states like Bihar and Madhya Pradesh reveal widespread instances of verbal abuse, neglect, and coercion during labour (Sinha et al., 2020).
Programs such as LaQshya (Labour Room Quality Improvement Initiative, 2017) and SUMAN (Surakshit Matritva Aashwasan, 2019) focus on improving infrastructure and clinical care but fall short in addressing interpersonal aspects of care. This gap perpetuates a culture where women’s dignity and autonomy are routinely compromised, reinforcing OBV as a public health issue.
OBV is not confined to public hospitals alone. Evidence shows that private healthcare institutions also engage in coercive practices and neglect, challenging the assumption that higher costs guarantee respectful care (Sivakami & Shrivastava, 2020). These systemic failures underscore the need to treat obstetric violence as a critical public health issue that requires urgent attention.
Measurement Challenges and Opportunities
The lack of standardised measurement tools hinders efforts to address OBV. Current methods, such as clinical audits and patient surveys, often miss psychological abuse, coercion, and neglect (Bohren et al., 2015). Drawing from the WHO’s development of intimate partner violence (IPV) measurement tools (WHO, 2005), later adapted in India’s National Family Health Survey (NFHS) to capture domestic violence and its health impacts (IIPS, 2021), similar frameworks are needed for OBV to assess both clinical and interpersonal care.
While standardisation is key, qualitative research is essential to capture women’s subjective experiences. Sen (2018) highlights that interviews and narrative accounts reveal emotional and psychological harm, often overlooked in clinical data. Combining quantitative and qualitative methods can provide a fuller understanding of obstetric violence.
Actionable Strategies
Addressing obstetric violence requires systemic reforms that prioritise Respectful Maternity Care (RMC) and hold healthcare systems accountable for violations:
Integrate RMC into National Policies:
Maternal health policies must explicitly include RMC as a fundamental right. Clear guidelines should mandate informed consent, patient-centred care, and protection of women’s dignity during childbirth.
Strengthen Accountability Mechanisms:
Healthcare institutions must establish grievance redressal systems that allow women to report mistreatment without fear of reprisal. Regular audits should assess adherence to RMC standards alongside clinical outcomes, with transparent processes for addressing violations.
Mandatory Training for Healthcare Providers:
Comprehensive training on gender sensitivity and RMC should be mandatory for all medical professionals. This training must address the cultural roots of obstetric violence, emphasising women’s autonomy and informed decision-making.
Community Education and Advocacy:
Empower women to demand respectful care through community-based awareness campaigns. Advocacy efforts should also target families and communities to challenge norms that normalise mistreatment during childbirth.
Develop Robust Measurement Frameworks:
Standardised tools to measure obstetric violence must be developed and integrated into national surveys like NFHS. Qualitative methods, such as interviews and focus groups, should complement these tools to capture the full scope of harm.
Integrating Solutions into Practice
The successful implementation of these strategies requires sustained political will and multi-sectoral collaboration. Governments must allocate resources to enforce RMC guidelines, train healthcare workers, and establish accountability systems. Civil society organisations can play a critical role in advocacy and capacity-building efforts, while researchers need to continue to document and analyse the experiences of women to inform policy and practice.
By addressing the systemic and cultural dimensions of obstetric violence, we can ensure that all women receive respectful, dignified care during childbirth. This shift will not only improve maternal health outcomes but also affirm women’s rights to autonomy and dignity—core principles of gender equity.
References
Bohren, M. A., Vogel, J. P., Hunter, E. C., Lutsiv, O., Makh, S. K., Souza, J. P., … & Gülmezoglu, A. M. (2015). The mistreatment of women during childbirth in health facilities globally: A mixed-methods systematic review. PLOS Medicine, 12(6), e1001847.
Bowser, D., & Hill, K. (2010). Exploring evidence for disrespect and abuse in facility-based childbirth: Report of a landscape analysis. USAID-TRAction Project.
Freedman, L. P., Ramsey, K., Abuya, T., Bellows, B., Ndwiga, C., Warren, C. E., & Kruk, M. E. (2014). Defining disrespect and abuse of women in childbirth: A research, policy, and rights agenda. Bulletin of the World Health Organization, 92(12), 915–917.
International Institute for Population Sciences (IIPS). (2021). National Family Health Survey (NFHS-5), 2019-2021. Mumbai: IIPS.
Rao, S. R. (2021). Obstetric violence in India: The cultural and systemic dimensions of disrespect and abuse in childbirth. Indian Journal of Medical Ethics, 6(3), 157–164.
Sadler, M., Santos, M. J., Ruiz-Berdún, D., Rojas, G. L., Skoko, E., Gillen, P., & Clausen, J. A. (2016). Moving beyond disrespect and abuse: Addressing the structural dimensions of obstetric violence. Reproductive Health Matters, 24(47), 47–55.
Sen, G., Reddy, B., & Iyer, A. (2018). Beyond measurement: The drivers of disrespect and abuse in obstetric care. Reproductive Health Matters, 26(53), 6–18. https://doi.org/10.1080/09688080.2018.1508173
Shrivastava, S., & Sivakami, M. (2020). Evidence of ‘obstetric violence’ in India: An integrative review. Journal of Biosocial Science, 52(5), 610-628. https://doi.org/10.1017/S0021932019000695
Sinha, K., Bhatia, P., & Verma, R. (2020). Assessing disrespect and abuse during childbirth: Evidence from Bihar and Madhya Pradesh. Reproductive Health Matters, 17(1), 57–65.
UN Women. (1995). Beijing Declaration and Platform for Action. Retrieved from https://www.un.org/womenwatch/daw/beijing/platform/
UN Women. (2024). 16 Days of Activism against Gender-Based Violence: #NoExcuse. Retrieved from https://www.unwomen.org
WHO. (2016). The prevention and elimination of disrespect and abuse during facility-based childbirth. Geneva: World Health Organization.
WHO. (2005). WHO multi-country study on women’s health and domestic violence against women. Geneva: World Health Organization.