INTRODUCTION

From midwives to sophisticated caesarean techniques, childbirth has gone from being part of human nature and essentially female to becoming a procedure whose decision-making is exclusively the health professional’s responsibility. With this, the woman is no longer the protagonist but the object of interventional and medical      procedures.

The advance in science concerning obstetric techniques has undoubtedly, when used appropriately,      contributed to the reduction of risks for both the parturient woman and the newborn. On the other hand, the same procedures can increase maternal-foetal mortality when applied indiscriminately without proven efficacy. Thus, a scenario of violation of rights arises in maternity wards, legitimised by medical knowledge, which leads to the pathologization of childbirth.

The fact is that these interventionist conducts and procedures, routinely adopted without concrete need, are often not perceived by the main subject involved: the woman. And for this reason, obstetric violence becomes an invisible reality.

Woman Giving Birth to a Baby Through Caesarean Section (November 18, 2019)  Photo Source: Jonathan Borba on Pexels    

OBSTETRIC VIOLENCE: What is it?

The process of hospitalisation of childbirth was essential to improve medical knowledge in this area and to reduce maternal and neonatal mortality rates. However, as far as one can recognise the benefits of the institutionalisation of childbirth, one must also admit that this change has led to the establishment of the medicalization of the female body (Nagahama; Santiago, 2005). For Pontes et. al (2014), this process does not reach its primary objective of reducing risks since it creates  other negative impacts on      women’s experience during childbirth, such as verbal violence, imprudence, negligence, humiliation, threats, loneliness, fear, and unnecessary interventions.

For Dip (2013), obstetric violence is characterised by all acts or conduct that are carried out without the explicit and informed consent of the woman, causing death, physical, psychological, or sexual harm to her or the unborn child, to injure her right to choose and the right to physical and mental integrity.

Thus, obstetric violence is multifaceted and can be expressed through the woman’s body (physical), her mental health (psychological), or her intimacy and modesty (sexual), in addition to conduct that hinder access to her rights.

The report Violencia Obstetrica: un Enfoque de Derechos Humanos^[1] (2015), published by the Grupo de Información en Reproducción Elegida, points out two modalities of obstetric violence: physical and psychological. Physical violence expresses itself through invasive practices and the indiscriminate use of medication, as well as the disrespect for the time and possibilities of biological childbirth. Psychological violence, on the other hand, includes harsh and inhumane treatment, discrimination, and humiliation when care or attention is requested during an obstetric procedure.

It should be noted that addressing obstetric violence from a human rights perspective implies attributing responsibilities, since international legislation on human rights establishes a broad list of rights, as well as various obligations that must be fulfilled by the different state authorities  (GIRE, 2015).

1. The Right to Health

The first and broadest human right violated in situations that constitute obstetric violence is the right to health. The (W, which was adopted by the International Conference held in New York on 19 June 1946, defines that “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1946, p. 1).

The Committee on Economic, Social, and Cultural Rights (CESCR), established to monitor the implementation of the ICESCR, has stipulated four basic elements of the right to health: availability, accessibility, acceptability, and quality. Availability is understood as the duty of States to provide a sufficient quantity of public health facilities, goods, and services, as well as programs; Accessibility is about ensuring that health facilities, goods, and services are accessible to all, without discrimination of any kind; Acceptability is about ensuring that all health facilities, goods, and services are respectful of the culture of individuals, peoples, communities, and minorities, as well as being sensitive to gender and life-cycle requirements; finally, Quality refers to the provision of culturally, scientifically and medically acceptable health facilities, goods, and services of good quality (CESCR, 2000).

To understand obstetric violence as a violation of the right to health, it is necessary to consider these four basic elements stipulated by the CESCR. The focus on availability and accessibility is necessary to make visible the precariousness of care and the reduced investment in maternity wards. Closing our eyes to women’s right to integral health care generates one of the most serious public health problems: the pilgrimage for beds. According to Rodrigues et al. (2015), the search for places in maternity wards constitutes obstetric violence because it is closely related to the reproductive process of women and the nullification of their rights. To this is added the risk that this pilgrimage creates for women and their newborns since the search for vacancies begins with the labour and makes it impossible for many women      to be attended to with due urgency.

It should also be noted that any and all violations of women’s and newborn’s rights also constitute a violation of the right to health in its broadest sense, as obstetric violence is related to the appropriation of women’s bodies and reproductive processes, including physical, psychological and verbal abuse, as well as the adoption of unnecessary and harmful procedures in obstetric care (Tesser et al., 2014).

1. The Right to Information and Decision-making

In the context of antepartum, childbirth, and immediate postpartum care, the observance of these rights is related to women’s access to objective, truthful and unbiased information about their options without the presence of bias on the part of health professionals. Informed consent is not limited to formal (written) acceptance of the procedure to be performed on the patient but also encompasses her understanding of the information being conveyed to her. Thus, service providers have a responsibility to provide clear and thorough information, adopting language and methods that are understandable to the patient (UNESCO, 2005).

However, in practice, most procedures are adopted without the prior consent of the patient, who is not only unaware of the procedures to which she is being subjected      but also of the potential harm. Consequently, any possibility of alternative decision-making at a time of vulnerability, in which the woman should be the protagonist, is denied. All this reflects medical paternalism, which advocates that the woman in labour does not know and should not be in charge of her birth. Many women are unaware of their rights to childbirth care, and because of this, they are reluctant to take control of their physical and mental wellbeing and surrender their bodies to the choices of the health professional (Belli, 2013).

An example of conduct and procedures which constitute a violation of women’s rights to information and decision-making is the adoption of the routine lithotomy position with or without stirrups during childbirth. This position, which consists of leaving the woman in a horizontal position (lying down with her legs elevated by supports) has been considered since 1996, according to      guidelines published      by the WHO^[2], as a harmful or ineffective practice, and that should be eliminated. According to Andrade et al. (2016), the lithotomy position can cause compression of the great vessels and prolongation of labour and the second stage of labour, with negative repercussions on perinatal outcomes. In this way, apart from impairing the dynamics of labour and being uncomfortable for the parturient, it impairs the oxygenation of the newborn (Rede Parto do Principio – Mulheres em Rede pela Maternidade Ativa, 2012).

Bowel cleansing and pubic shaving are routine obstetric procedures that also violate the decision-making rights of women in labour. Health professionals presume that shaving of pubic hair reduces infection and facilitates suturing. However, the WHO stresses that there is no evidence to support this claim and recommends that the decision regarding depilation rests with the woman and not with the health care provider (Agar, 2010).

The same is true of scheduled caesarean sections for medical convenience. Many women undergo caesarean sections without any indication of risk to their health or the health of the baby in a vaginal delivery. It is a matter of the practitioner’s desire to fit the surgical procedure into the best time slot in his or her schedule. Thus, working on weekends and public holidays can be avoided. Thus, apart from being an offence against the right to information and the right to make decisions, terminations scheduled for medical convenience are a violation of the patient’s integrity since they can be considered a physical injury Rede Parto do Principio – Mulheres em Rede pela Maternidade Ativa, 2012).

1. Right to Privacy and Intimacy

When it comes to reproductive health, the Grupo de Información en Reproducción Elegida (GIRE, 2015) states that this right refers to the right of individuals to decide on their reproduction, especially women, based on clear, objective, and truthful information. In this way, the right to privacy and intimacy is violated in health centres when the loss of autonomy of the parturient is configured, who is no longer able to make decisions, subject to undue exposure of her body, mainly her genital organs (Belli, 2013).

The most frequent violation of this right is the subjection of women to unnecessary and painful procedures in advance, subjecting them to risks and complications, solely for didactic purposes. Examples include repeated vaginal touching, routine episiotomy, and the use of forceps.

The violation of this right also includes the prohibition of the presence of a companion during obstetric care, contrary to WHO recommendations (2019). In Brazil, for example, this right is provided for in a specific law (Law 11.108/2005) that safeguards the right of users to have someone of their own free choice, regardless of sex, by their side throughout labour, delivery, and the immediate postpartum period. According to Aguiar (2010), the presence of a companion promotes a safe and welcoming environment for the patient and has been associated with a decrease in surgical interventions, a higher degree of satisfaction among postpartum women about the birth experience, and, mainly, a reduction in institutional violence.

1. Right to personal integrity, not to be subjected to torture or cruel, inhuman, or degrading treatment or punishment

The violation of the right to personal integrity occurs through bodily injury, torture, ill-treatment, and interventions to verify and accelerate childbirth. One of the behaviours frequently adopted in maternity wards, and which constitutes a violation of this right, is       routine episiotomy. Contraindicated as a routine procedure in 1985 by the WHO, episiotomy has been routinely performed since the middle of the 20th century under the justification that it facilitates birth and safeguards the woman’s genital integrity. However, since 1980, there has been scientific evidence in favour of eliminating routine episiotomy. Today, it is only recommended when there is sufficient indication of maternal-foetal distress or to achieve progress in situations where the perineum is responsible for inadequate progress (Diniz & Chacham, 2006).

In many countries, episiotomy is accompanied by ‘husband stitches’, a further tightening of the vulva supposedly to restore the woman to her virginal condition. This tighter stitch has the sole purpose of making the woman fit to provide male pleasure. Therefore, the routine adoption of episiotomy has been understood as a form of genital mutilation, as well as an expression of gender-based violence perpetrated by health professionals (Amorin & Katz, 2008; Diniz & Chacham, 2006; Diniz, 2001).

The Kristeller manoeuvre, for example, is another behaviour that constitutes obstetric violence of a physical and psychological nature. This procedure has been developed without scientific evidence and is performed by pressing the woman’s belly with the hands or forearm to accelerate the delivery of the baby (Rede Parto do Principio – Mulheres em Rede pela Maternidade Ativa, 2012). This behaviour generates serious consequences such as trauma to the abdominal viscera, the thorax, and dislocation of the placenta. Despite this, Kristeller’s manoeuvre is still invisible, it is often performed without the woman’s consent and information, and it is not usually recorded in the woman’s medical records due to lack of awareness or even to avoid possible legal sanctions (El Parto es Nuestro, 2014).

ACTIONS TAKEN AT THE INTERNATIONAL AND NATIONAL LEVEL

Venezuela (2007) was the first country to treat this type of violence as a matter of law, demonstrating a certain degree of maturity of their legislative, executive, and judiciary powers, in fulfilling their obligation as a State. After that, Argentina (2009), Panama (2013), Mexico (2014), Suriname (2014) have passed laws criminalising obstetric violence.

According to GIRE (2015), the criminalisation of obstetric violence is an easy way to try to solve the problem but does not bring about real change. The occurrence of this type of violence is closely related to a context full of issues that go beyond the mission of criminal law. For the author, converting harmful attitudes and routines into crimes       which are part of the dynamics of the faculties that train and educate health professionals may end up adding new problems instead of protecting women. It is inappropriate to resort to criminal law when the State has other, less damaging instruments that can address the problem in a more effective way. The solution to the problem is not in filling the penal codes with new offences, but in solving the problem by considering its root causes, starting with public policies in the health area, reinforcing the protection of human rights in obstetric care (GIRE, 2015).

On 11 July 2019, the Special Rapporteur on violence against women, its causes and consequences, Dubravka Šimonović, presented to the United Nations General Assembly a report which for the first time refers to what women experience in reproductive health services as violence that offends human rights and the Declaration on the Elimination of Violence against Women. The report “A human rights-based approach to mistreatment and violence against women in reproductive health services with a focus on childbirth and obstetric violence^[3]” reaffirms respect for women’s human rights, which include their right to be treated with dignity and respect in health centres      and hospitals and obstetric care without being subjected to discrimination or violence, sexism or any other form of psychological violence, inhuman or degrading treatment, torture or coercion. In addition to stating that:

“States should address the current problem of mistreatment and violence against women in reproductive services and childbirth from a human rights perspective and use it to conduct an independent investigation into women’s allegations of mistreatment and gender-based violence in health-care facilities, which should include structural and systematic causes, including stereotypes on the role of women role in society, and should publish the results and recommendations, which should be used to revise laws, policies and national action plans on reproductive health.” (United Nations General Assembly, 2019, p.21)

CONCLUSIONS

Obstetric violence is a violation of human rights, and violates  several rights outlined in international conventions and treaties. Unfortunately, its constant occurrence in maternity hospitals around the world constitutes disrespect for the right to life, to live free of violence, to autonomy, and the personal integrity of women during the assistance labour, delivery, and immediate postpartum. Discussing this issue is important, mainly because the number of victims may be even higher than what the researchers are showing      for the simple fact that many women do not recognise themselves as victims      because they are unaware of their rights at the time of hospital care.

This is because many women do not recognise some behaviours and procedures as violations of their rights, and if they do, they are afraid to report them because they see themselves as vulnerable to the health professional. In the different forms of violence discussed in this article, it is possible to identify that discrimination against the condition of women contributes to the maintenance of this situation so that often the violence is not recognised by those who practice it, nor by those who suffer it.

Given this, all subjects involved in this process must be aware of the need to rethink the paradigm of interventionist childbirth care. The experiences women go through during pregnancy and childbirth represent unique moments in their lives and, as such, should be seen as natural, biological, and human. In this way, seeing the woman as a subject in the professional-patient relationship is to respect and understand her individuality, valuing the attention to her needs and well-being. It is to give her the tools to claim and protect her rights. Because obstetric violence is a routine, it is more than necessary to discuss this issue and provide the women themselves with mechanisms to be aware of it, denounce it, stop it, and change this reality.

REFERENCES

AGUIAR. (2010). Violência institucional em maternidades públicas: hostilidade ao invés de acolhimento como uma questão de gênero (PhD Thesis). Retrieved on 10 March, from     : <https://teses.usp.br/teses/disponiveis/5/5137/tde-21062010-175305/publico/JanainaMAguiar.pdf>

AMORIN & KATZ (2008). O papel da episiotomia na obstetrícia moderna. Feminina, 26(1), 47,54. Retrieved on 10 March, from     : <https://pesquisa.bvsalud.org/portal/resource/pt/lil-493990?lang=es>

BELLI (2013). La violencia obstétrica: otra forma de violación a los derechos humanos. Revista red Bioética, 2(8), 25-34. Retrieved on 09 March, from     : <https://ri.conicet.gov.ar/handle/11336/12868>

CESCR. Comité de Derechos Económicos, Sociales y Culturales. (2000). Cuestiones Sustantivas Que Se Plantean En La Aplicación Del Pacto Internacional De Derechos Económicos, Sociales Y Culturales “Observación general No 14 – El derecho al disfrute del más alto nivel posible de salud”. Retrieved on 10 March, from     : <https://www.acnur.org/fileadmin/Documentos/BDL/2001/1451.pdf>

DINIZ & CHACHAM (2006). O “corte por cima” e o “corte por baixo”: o abuso de cesáreas e episiotomias em São Paulo. Questães de Saúde Reprodutiva: Sexualidade e reprodução: ações e serviços de saúde, Rio de Janeiro, 1(1), 80-9 Retrieved on 12 March, from     : <http://www.grupocurumim.org.br/site/revista/qsr1.pdf>

DINIZ, Carmen (2001). Entre a técnica e os direitos humanos: possibilidades e limites da humanização da assistência ao parto (PhD Thesis). Retrieved on 12 March, from     : <http://mulheres.org.br/parto/doutorado.>

DIP (2013). Na hora de fazer não gritou. Retrieved on 12 March, from     : <http://apublica.org/2013/03/na-hora-de-fazer-nao-gritou/>.

El Parto es Nuestro. (2012). Informe de la campa a StopKristeller: cuestión de gravedad. https://www.elpartoesnuestro.es. Retrieved on 08 March, from     : <https://www.elpartoesnuestro.es/sites/default/files/public/blog/20140626KristellerFINAL/informe_stopkristeller.pdf>

GIRE. Grupo de Información en Reproducción Elegida. (2015). Violencia obstétrica: un enfoque de derechos humanos. Retrieved on 08 March, from     : https://gire.org.mx/wp-content/uploads/2016/07/informeviolenciaobstetrica2015.pdf

NAGAHAMA; SANTIAGO (2005). A institucionalização médica do parto no Brasil. Ciência & Saúde Coletiva, Rio de Janeiro, v. 10, n. 3, p.651-657, jul./set. 2005. Retrieved on 10 March, from     :

<http://www.scielo.br/pdf/csc/v10n3/a21v10n3>.

PONTES et al. (2014) Parto nosso de cada dia: um olhar sobre as transformações e perspectivas da assistência. Revista Ciência da Saúde Nova Esperança, João Pessoa, v. 12, n. 1, p.69-78, jun. 2014. Retrieved on 12 March, from     : <http://www.facene.com.br/wp-content/uploads/2010/11/Parto-nosso-de-cadadia.pdf>.

Rede Parto do Princípio – Mulheres em Rede pela Maternidade Ativa. (2012). Dossiê da Violência Obstétrica: “Parirás com dor”. Retrieved on 08 March, from     : <https://www.senado.gov.br/comissoes/documentos/SSCEPI/DOC%20VCM%20367.pdf>

RODRIGUES et al. (2015). A peregrinação no período reprodutivo: uma violência no campo obstétrico. Esc Anna Nery, 19(4), 614-620. Retrieved on 10 March, from     : <https://www.scielo.br/pdf/ean/v19n4/1414-8145-ean-19-04-0614.pdf>

TESSER et al. (2014). Violência obstétrica e prevenção quaternária: o que é e o que fazer. Revista Brasileira de Medicina de Família e Comunidade, 10(35), 1-12. Retrieved on 10 March, from:  <https://www.rbmfc.org.br/rbmfc/article/view/1013>