Obstetric violence in the United States and other high-income countries: an integrative review

Abstract

Obstetric violence has been documented throughout the world, yet this human rights issue has mostly been investigated in middle- and low-income countries where the intensity and brutality of abuse and mistreatment is more easily recognised as problematic. This integrative review aimed to analyse sources about obstetric violence in high-income countries with the objective of identifying gaps in the research, challenges to the study of obstetric violence, and solutions to framing research that meets those challenges. A systematic search was conducted using the PubMed and CINAHL databases from February to June 2022. Empirical and non-empirical sources, published in English, with no date restrictions, were retrieved. Citation searching was also done. Forty-six sources were included. Identified gaps in the research were: (a) scarce attention to obstetric violence in most high-income countries; (b) most US sources are non-scientific and from outside the healthcare disciplines; (c) inconsistencies in terminology; (d) most studies were conducted with samples of women who had given birth, with scant research about healthcare providers and obstetric violence, and (e) the association between obstetric violence and traumatic birth was under-recognised. Identified challenges to the study of obstetric violence were: (1) factors that enable and perpetuate obstetric violence are multilevel and nonlinear; (2) the phenomenon is contextually complex; and (3) blind spots from routinised harmful practices and normalised mistreatment can prevent healthcare providers and birthing people from recognising obstetric violence. A systems approach and complexity theory are guiding frameworks recommended as solutions to the challenges of studying and correcting obstetric violence.

Résumé

Les violences obstétricales ont été documentées dans le monde entier, mais cette question des droits de l’homme a principalement été étudiée dans les pays à revenu faible et intermédiaire, où l’intensité et la brutalité des abus et des mauvais traitements sont plus facilement acceptées comme problématiques. Cette revue intégrative visait à analyser les sources sur les violences obstétricales dans les pays à revenu élevé afin d’identifier les lacunes de la recherche, les difficultés dans l’étude des violences obstétricales et les solutions pour encadrer une recherche qui réponde à ces difficultés. De février à juin 2022, une recherche systématique a été menée à l’aide des bases de données PubMed et CINAHL. Des sources empiriques et non empiriques, publiées en anglais, sans restriction de date, ont été récupérées. Une recherche de citations a également été effectuée. Quarante-six sources ont été incluses. Les lacunes identifiées dans la recherche étaient les suivantes: (a) le peu d’attention portée aux violences obstétricales dans la majorité des pays à revenu élevé; (b) la plupart des sources des États-Unis ne sont pas scientifiques et ne relèvent pas des disciplines de la santé; (c) des incohérences dans la terminologie; (d) la plupart des études ont été menées auprès de femmes ayant accouché, avec peu de recherches sur les prestataires de soins de santé et les violences obstétricales; et (e) l’association entre violences obstétricales et accouchement traumatique était sous-estimée. Les difficultés identifiées dans l’étude des violences obstétricales étaient les suivantes: (1) les facteurs qui permettent et perpétuent les violences obstétricales se situent à plusieurs niveaux et sont non linéaires; (2) le phénomène est contextuellement complexe; et (3) les angles morts liés aux pratiques néfastes routinières et aux mauvais traitements normalisés peuvent empêcher les prestataires de soins de santé et les personnes qui accouchent de prendre conscience des violences obstétricales. Une approche systémique et une théorie de la complexité guident les cadres de travail recommandés comme solutions aux difficultés rencontrées pour étudier et corriger les violences obstétricales.

Resumen

Aunque la violencia obstétrica se ha documentado a nivel mundial, este problema de derechos humanos se ha investigado principalmente en países de bajos y medianos ingresos donde la intensidad y brutalidad del abuso y maltrato son aceptadas con más facilidad como problemáticas. Esta revisión integrativa buscaba analizar fuentes sobre violencia obstétrica en países de altos ingresos con el objetivo de identificar brechas en las investigaciones, retos al estudio de violencia obstétrica y soluciones a delimitar las investigaciones que abordan esos retos. Entre febrero y junio de 2022, se realizó una búsqueda sistemática utilizando las bases de datos de PubMed y CINAHL. Se obtuvieron fuentes empíricas y no empíricas, publicadas en inglés, sin restricciones de fecha. Además, se realizó una búsqueda de citas. Se incluyeron 46 fuentes. Las brechas identificadas en las investigaciones eran: (a) escasa atención a la violencia obstétrica en la mayoría de los países de altos ingresos; (b) la mayoría de las fuentes de EE. UU. no son científicas y no provienen de disciplinas relacionadas con los servicios de salud; (c) incongruencias en terminología; (d) la mayoría de los estudios se realizaron con mujeres que habían dado a luz, con escasa investigación sobre los prestadores de servicios de salud y la violencia obstétrica, y (e) la asociación entre la violencia obstétrica y el parto traumático fue poco reconocida. Los retos identificados al estudio de la violencia obstétrica son: (1) los factores que permiten y perpetúan la violencia obstétrica ocurren en múltiples niveles y no son lineales; (2) el fenómeno es complejo contextualmente; y (3) los puntos ciegos de las prácticas nocivas rutinarias y el maltrato normalizado pueden impedir que los prestadores de servicios de salud y las personas en proceso de parto reconozcan la violencia obstétrica. Como soluciones a los retos de estudiar y corregir la violencia obstétrica, se recomienda un enfoque sistémico y la teoría de complejidad como marcos rectores.

Keywords:

• complexity theory
• integrative review
• maternity care
• obstetric racism
• obstetric violence
• systems analysis

Plain Language Summary

Obstetric violence is a gender-based form of violence against women that is recognised as a violation of human rights. Evidence of obstetric violence has been documented in every region of the world. Most obstetric violence studies are about pregnancy and birth in middle- and low-income countries where the brutality of the abuse and mistreatment has been more readily recognised as a problem. This review found that the features of obstetric violence are consistent across the range of high-income countries in this sample. Systems thinking and complexity theory are recommended frameworks to address the multidimensional features of obstetric violence that can make the problem challenging to study and correct within different healthcare settings. There is a conflict between the delay in conducting scientific studies about obstetric violence and the non-scientific evidence that the problem is a human rights violation that demands immediate action. Obstetric violence is a complex problem that requires information be shared across all academic, professional, and non-academic community partners for success in dismantling and eliminating it. This integrative review can serve as a summary and starting point for all interested and affected parties who want to stop the problem of obstetric violence in their healthcare systems.

Introduction

Researchers broadly support the view of obstetric violence as a structural form of violence that is a sex-specific, gender-based form of violence against women* and a violation of human rights.^1–4 The harms associated with obstetric violence that have been discussed in US publications are: psychological trauma, avoidable injury and morbidity, unnecessary invasive procedures and caesarean births, disrespect and incivility, disrupted newborn bonding, and future avoidance of the healthcare system.^5–9 Similar findings have been reported worldwide. These studies further demonstrate that obstetric violence is associated with negative effects on the mental health of childbearing women, along with evidence that the problem is structural and modifiable.^10–15 Some of the power imbalances that converge during hospital-based maternity care have been discussed as coming from expected compliance with health facility policies, women being in the biomedical role of the submissive patient, and compounded vulnerabilities for marginalised groups.^3,7,16,17

Arguments have been made in favour of using the term “obstetric violence” as an intentional conceptual choice that makes the routinised abuse and mistreatment of birthing people visible,^2,18,19 This visibility is made possible by using a vocabulary commensurate with the structural source of violence against women, which manifests in maternity care systems that devalue and disembody childbearing people from their own birthing experiences.^2,15,20,21 Godfrey-Isaacs has discussed how the unequal power dynamics and depersonalisation that are routine in hospital-based maternity care can create the insidious belief that it is normal to have “women’s bodies exposed and displayed, their sexual organs uncovered and interventions that cut, penetrate, and hurt them” (p. 6).²² Meanwhile, after 25 years researching obstetric violence in Latin America, one of the leading authors continues to argue that the complexity of the problem cannot be solved without recognising its structural roots in the power of the medical field and its institutions, along with the power imbalance that women are socially and situationally subjected to in control of their reproductive processes.²³

Evidence of obstetric violence has been documented in every region of the world,²⁴ yet the problem has mostly been investigated in middle- and low-income countries where the brutality and intensity of the abuse and mistreatment is more readily recognised as problematic. The World Health Organization (WHO) statement on the prevention and elimination of disrespect and abuse during facility-based childbirth does not use the term “obstetric violence”, although the globally pervasive problem the statement addresses has been widely referenced as commensurate with obstetric violence as a public health and human rights issue.²⁵ The United Nations Special Rapporteur on violence against women reported on the issue of mistreatment and violence against women in reproductive health services with a focus on childbirth and obstetric violence. The Special Rapporteur used the term “obstetric violence” in her report when referring to violence experienced by women during facility-based childbirth, but because the term was not in use in international human rights law, the Special Rapporteur also used the phrase “violence against women during childbirth” to conform to the existing international framework on the human rights of women.²⁶ This U.N. report further confirmed the framing of obstetric violence as a form of violence against women and a human rights violation that extends beyond clinical issues with poor quality of care.⁴

Attention to obstetric violence in high-income countries is an emerging area in research, with more than half of publications during the time this study was conducted being from 2021 to 2022. The structure and function of obstetric violence in the United States were examined in a concept analysis, and the author determined the defining attributes of obstetric violence as: (a) abuse or mistreatment over the course of the female reproductive continuum; (b) a healthcare provider being the agent of abuse or mistreatment; (c) performance of procedures that lack informed consent, are coerced, or done in violation of refusal; and (d) the presence of the broader problem of violence against women and a violation of human rights.²⁷ The broader, structural factors that enable and perpetuate obstetric violence are embedded in the problem of institutionalised violence against women,^6,7,22,28,29 while the underlying structures of gender-based violence against women perpetuate the problem as a sex-specific violation of human rights that is a consequence of inequalities and discrimination against birthing people. The problem is further compounded by race, socioeconomic status, and any type of marginalised identity that intersects with being female.^4,9,17,30,31

The increasing scientific interest in obstetric violence as a previously overlooked problem in the United States and other high-income countries, combined with the contextual complexity of this structural and interpersonal problem, prompted the following guiding questions for this review: (1) What are the gaps in the research? (2) What are the challenges to the study of obstetric violence? and (3) What solutions are there to meet those challenges?

Methods

An integrative review of the literature on obstetric violence was conducted by this sole investigator from February 2022 through June 2022. Obstetric violence is a complex concept that can benefit from the broadest sample to inform the guiding questions and increase the understanding of the construct and the state of the science. The integrative review method was chosen as the only approach that allows for the inclusion of diverse sources from non-empirical literature.³² The steps for conducting an integrative review described by Whittemore & Knafl³² were followed, and a systematic search was done using the PRISMA flowsheet.³³ The guiding questions for this review were the basis for including reports. In addition, inclusion required the United States or another high-income country to be the setting where obstetric violence was addressed. The World Bank Group for Fiscal Year 2022 results were used to classify income categories.³⁴ The Johns Hopkins Evidence Based Practice Toolkit for Nursing³⁵ was used to assign a level of evidence. No sources were excluded based on level of evidence. This review was done without a prepared protocol and was not registered.

The databases PubMed and CINAHL were used with the search term “obstetric violence” in the title or abstract and no date restrictions. Using “obstetric violence” as the search term, without adding related terms, was a delimiting decision to primarily examine sources that claim obstetric violence as a distinct topic of inquiry or include it as part of the findings. Sources were limited to English.

Reports that do not use the term “obstetric violence” were included from citation searching (n = 4 of 13) because the patterns of mistreatment, disrespect, and abuse that they address during pregnancy and childbirth are representative of obstetric violence and inform the understanding of it. These reports were synthesised into the review and are discussed using the language chosen by the authors.^5,9,36,37 Data were extracted and organised in table format after thorough and reflective readings of the 46 sources included. Iterative rounds of reflective reading were done using a constant comparative approach so that similarities, differences, and research gaps could be identified among the diverse sources. The analytic process and synthesis were guided by the review questions. Three multidisciplinary readers reviewed this current paper with agreement achieved. All readers are doctoral-level academics. One has expertise in English literature and was naïve to the subject of obstetric violence. Another is a midwife from a department of nursing who was familiar with the concept of obstetric violence, and the third is a philosopher from a department of women’s and gender studies who is an international expert on the phenomenon of obstetric violence.

Results

The search results from PubMed (n = 121) and CINAHL (n = 93) had 52 duplicates removed using EndNote. The sole investigator screened 162 records. Citation searching (n = 13) and websites (n = 3) influenced by the familiarity this researcher has with the subject were added to the total sources included. Reports were excluded because they did not inform the aims of this review (n = 40), were not about obstetric violence in the United States or another high-income country (n = 88), or because they could not be found in print (n = 4). A total of 46 sources were included. See Figure 1 for the PRISMA flowsheet.

Figure 1: PRISMA flowsheet

Note: This PRISMA flowsheet is based on the updated guidance from Page et al.³³

The 46 sources included for this integrative review have publication years from 2014 to 2022. Most sources were from 2021 (n = 14) followed by 2020 (n = 7) and 2022 (n = 7). Half of the sources were scientific research with 15 quantitative and 8 qualitative studies. Other sources included papers that were reviews (n = 6), commentary or discussion (n = 5), legal analyses (n = 4), philosophical (n = 3), theory or concept analyses (n = 2), and advocacy web sites (n = 3). There were eight high-income countries (Australia, Chile, Italy, Spain, the United States, Qatar, Sweden, and the United Kingdom) where obstetric violence was examined as a problem with study samples exclusively from their healthcare systems. The details of each source are described in Table 1.

Table 1: Summary of included sources about obstetric violence in high-income countries

Author(s)/Year	Sample – Participants/Country	Study design/Level of evidence	Results/Key findings
Annborn & Finnbogadottir^Citation38	n = 12 Swedish women of childbearing age who reported a negative/traumatic birth experience	Qualitative inductive using narrative stories to carry out individual interviews/Level III	Four main thematic categories were identified from investigating the meaning of obstetric violence to women who reported a negative birth experience. The categories were: lack of information and consent, insufficient pain relief, lack of trust and security, and the experience of abuse. Participants experienced psychological and physical abuse during childbirth that could be interpreted as obstetric violence.
Beck^Citation5	n = 23 from NZ, n = 8 from US, n = 6 from AUS, and n = 3 from UK for primary data set of 40 mothers who experienced traumatic births	Secondary data qualitative content analysis/Level III	Six types of disrespectful and abusive treatment were identified using typologies from Bohren et al.^Citation36 Types of mistreatment were listed from most often to least often as: failure to meet professional standards of care, poor rapport between women and providers, verbal abuse, physical abuse, health system conditions/constraints, and stigma/discrimination. Findings confirmed results consistent with studies of mistreatment during childbirth in facilities in low- and middle-income countries.
Birth Monopoly^Citation39	N/a – US creator (Advocate/activist)	Advocacy web site/Level V	Establishes the presence of obstetric violence in the United States and globally with experiences reported by birthing people and birth workers. Provides advocacy, education, and change work against the mistreatment, disrespect, and abuse of birthing people.
Bohren et al.^Citation36	n = 65 studies from 34 countries	Systematic review without meta-analysis/Level III	Synthesised evidence on the mistreatment of women in health facilities globally to develop an evidence-based typology of the phenomenon. Qualitative studies were organised in the domains: (1) physical abuse, (2) sexual abuse, (3) verbal abuse, (4) stigma and discrimination, (5) failure to meet professional standards of care, (6) poor rapport between women and providers, and (7) health systems conditions and constraints. Quantitative studies were too heterogeneous for meta-analysis. The United States was included from findings by Beck.^Citation40
Borges^Citation6	N/a – Author from the U.S. (Attorney)	Legal Note/Level V	Obstetric violence is a subset of gendered violence that is structural and needs to be addressed systemically. The tort system is inadequate for obstetric violence cases because there is no recovery standard for women’s suffering from coerced procedures or an invasion of their rights to refuse. American legal system needs a civil and criminal liability regime to address obstetric violence.
Bowser & Hill^Citation37	n = 150 publications, n = 9 expert informants, and n = 2 participants from the Women Deliver Conference 2010	Landscape analysis with literature review, interviews, and structured group discussion/Level IV	Identified seven categories of disrespect and abuse in childbirth globally: physical abuse, non-consented clinical care, non-confidential care, non-dignified care (including verbal abuse), discrimination based on patient attributes, abandonment of care, and detention in facilities.
Break the Silence^Citation41	N/a – US viral social media campaign	Social media campaign/Level V	Documents experiences of obstetric violence in the United States with viral social media participation from birthing people, their partners, and birth workers.
Cohen Shabot^Citation28	N/a – Author from Israel (Women’s and Gender Studies)	Philosophical analysis/Level V	Obstetric violence is structural, gendered violence directed at women because they are women. It embodies oppression, diminishment of self, and physical and emotional infantilisation. Obstetric violence is sometimes interpreted as rape because the childbirth experience is deeply sexual. Obstetric violence is pervasive in societies where childbirth is highly medicalised, predominantly controlled and managed by medical authorities, and heavily influenced by capitalist and patriarchal values.
Cohen Shabot^Citation42	N/a – Author from Israel (Women’s and Gender Studies)	Phenomenological analysis/Level V	The patriarchal reification of women frames sexual violence as not-violence, which prevents labouring women and healthcare providers from recognising vaginal exams during labour as violence. Obstetric violence is difficult to frame as violence largely because of how violence is usually conceptualised as requiring intention and as an oxymoron in medical spaces that are assumed to be benevolent or involving practices that are in an individual’s best interest.
Cohen Shabot^Citation21	N/a – Author from Israel (Women’s and Gender Studies)	Theoretical/Level V	Childbearing women suffer both systematic and incidental epistemic injustices in the phenomenon of obstetric violence. These dual injustices happen because the healthcare system privileges the medicalised knowledge of providers over the specific, embodied knowledge that birthing people often display. Then childbearing people are doubly dismissed: once because they are female (and females suffer from a systematic devaluation of their epistemic capacities) and second because the specific knowledge many of them bring to the childbirth experience is believed to be irrational and unreliable.
Darilek^Citation43	No literature selection flowsheet or summary provided – Author from U.S. (Nursing)	Literature review/Level V	Obstetric mistreatment was made synonymous with obstetric violence. Concluded that obstetric mistreatment is globally documented with differing aetiologies of the problem based on socio-political differences around the world. Recognised the overlap between birth trauma and obstetric violence.
Davis^Citation16	n = 14 mothers who gave birth in the U.S. with n = 11 who identified as Black	Qualitative oral histories and ethnographic observations/Level III	Obstetric racism is the intersection of obstetric violence and medical racism. Obstetric violence is gender-based violence experienced by people giving birth who are subjected to acts of violence and subordination because they are obstetric patients. Obstetric racism, as both an occurrence and analytic, best captures the particularities of Black women’s reproductive care which is differently choreographed on Black women’s bodies.
Diaz-Tello^Citation7	N/a – Author from U.S. (Attorney)	Legal case studies/Level V	Obstetric violence is gender-based violence, discriminatory, and an infringement on human rights. The US civil justice system is limited in its ability to address obstetric violence. There are few attorneys who will accept obstetric violence cases, no legal definition of the offence in the United States, challenges with statutes of limitations, and lack of clarity about whether it is considered malpractice and/or battery.
Exposing the Silence Project^Citation44	N/a – Co-creators from the U.S. (Birth activists, photographer, doula)	Web based advocacy and activism project/Level V	Online gallery project to make people who have experienced obstetric violence in the United States visible. Recognises the pervasiveness of obstetric violence as a problem that involves disrespect, loss of autonomy, coercion, manipulation, bullying, and sometimes a complete loss of human rights during pregnancy or childbirth.
Fielding-Singh & Dmowska^Citation45	n = 46 women who gave birth in the U.S. (2019-2020) and self-defined birth as traumatic or very difficult	Qualitative in-depth, semi-structured interviews/Level III	Obstetric gaslighting was a key sociological mechanism in experiences of obstetric violence. The four core types of denial to alter and negate mothers’ realities through obstetric gaslighting were denials of: 1) mothers’ humanity, 2) mothers’ knowledge as valid, 3) mothers’ judgments as rational, and 4) mothers’ feelings as legitimate. All four denials worked to transform pregnant, birthing, and postpartum women from agentic subjects into medical objects with the distortion or erasure of their realities.
Garcia^Citation27	N/a – Author from U.S. (Nursing/Midwife)	Concept analysis/Level IV	Synthesised a definition of obstetric violence, determined defining attributes, and identified antecedents and consequences of obstetric violence.
Garcia^Citation17	N/a – Author from U.S. (Nursing/Midwife)	Theory analysis/Level IV	The soundness and usability of the theory of social justice in nursing^Citation46 was recommended for framing obstetric violence research based on nursing practice that is aligned with social justice being antithetical to the occurrence of obstetric violence.
Godfrey-Isaacs^Citation22	N/a – Author from UK (Midwife, Artist, and Birth Activist)	Discussion paper/Level V	The normalised occurrence of obstetric violence is influenced by depictions of women in art, media, culture, and medical frameworks that consistently objectify, sexualise, and violate women’s bodies.
Gray et al.^Citation47	n = 50 obstetricians and n = 167 nursing/midwifery staff from a private maternity hospital in Doha, Qatar	Quantitative: cross-sectional, comparative survey with a dramatised video scenario of obstetric violence by Amnesty International/Level III	Most respondents (63%) had witnessed obstetric violence similar to what was depicted in the video. Most (52%) had previously heard of the term obstetric violence, and 48% understood what the term meant. Obstetricians were significantly less likely to change their perceptions of how a provider team should interact with a patient compared to the nursing/midwifery group (p < 0.001). Each provider group was significantly more critical of the other based on the video scenario.
Gray et al.^Citation48	n = 58 medical students in the UK and n = 62 medical students in India	Quantitative: cross sectional survey responses compared using chi squared/Student’s t-test/Level III	More medical students from India (34%) had heard of obstetric violence than those from the UK (26%). Both cohorts correctly identified obstetric violence at similar rates (32% versus 34%). Medical students from India were significantly less critical (p < 0.001) of all scored behaviours from the obstetric violence scenario video compared to students from the UK. Medical students from the UK were significantly less likely (p < 0.001) to agree that the obstetric violence scenario video changed their perception of how maternity care teams should behave and act in the example.
Jardim & Modena^Citation3	n = 24 publications in English, Spanish, or Portuguese from 2007–2017	Integrative literature review/Level V	Obstetric violence is a violation of human rights and a public health problem. Negligent, abusive, reckless, omissive, disrespectful, and discriminatory acts by health professionals are legitimised by symbolic relations of power that normalise and trivialise the occurrence of obstetric violence. Women who are Black, ethnic minorities, adolescents, poor, with low education levels, drug users, without housing, without prenatal care, and without a companion are more vulnerable to obstetric violence.
Keedle et al.^Citation49	n = 559 Australian women who planned a vaginal birth after cesarean: n = 171 pregnant and currently planning, and n = 388 following birth	Qualitative, open-ended survey/Level III	The category of negative interactions between participants and healthcare providers was identified as “Fighting for my birthing rights.” Intensity varied across the sub-categories: the odds were against me, lack of belief in women birthing, and coercion. Obstetric violence was most clearly present in coercion to accept a repeat cesarean. Examples escalated from verbal coercion, threatening, up to more extreme examples of receiving unconsented procedures and having physical force used against them.
Kukura^Citation29	N/a – Author from U.S. (Attorney)	Legal Article/Level V	Discusses the fluidity of obstetric violence with the potential for different intensities of one or all types of abuse, coercion, or disrespect to be involved when a birthing person experiences obstetric violence. Recognises the social norms, structure, and function of maternity care for factors that enable and normalise the mistreatment of childbearing people with a focus on economic pressures, the over-medicalisation of childbirth, and fears of liability that drive the practice of defensive medicine. Explains the inadequacies of the legal tort system and other areas of law as barriers to recourse for victims of obstetric violence.
Liese et al.^Citation50	n = 62 American childbearers	Qualitative interviews and autoethnographies/Level III	Along the entirety of the unintentional harm to overt disrespect, violence, and abuse spectrum, the performance of unnecessary, non-evidence based procedures—especially unnecessary cesareans—constitutes obstetric violence and iatrogenesis.
Martín-Badia et al.^Citation51	n = 23 midwives from five hospitals of different complexities in Catalonia, Spain	Qualitative phenomenology using focus groups/Level III	Obstetric violence infringes on the main bioethical principles. The four categories identified were: the maleficence of forgetting women’s vulnerability; beneficence requires respect for women’s integrity and dignity; women’s autonomy is being removed from them; and a problem of social justice towards women.
Martínez-Galiano et al.^Citation52	n = 899 women who gave birth in Spain in the last 12 months	Quantitative: cross-sectional survey study/Level III	Obstetric violence was reported by 67.4% (n = 606) of participants. The types of obstetric violence reported were: verbal violence, 25.1% (n = 226); physical violence, 54.5%, (n = 490), and psycho-affective violence, 36.7%, (n = 330). Feeling respected, skin-to-skin contact with the newborn, and having a respected birth plan were protective factors against obstetric violence.
Martinez-Vázquez et al.^Citation11	n = 899 women who gave birth in Spain in the last 12 months with at least one month elapsed since birth	Quantitative: cross-sectional survey study/Level III	Risk factors associated with perinatal posttraumatic stress disorder (PTSD) included verbal obstetric violence (aOR: 5.07, 95% CI 2.98-8.63) and psycho-affective obstetric violence (aOR: 2.61, 95% CI 1.45-4.67). There were 12.7% of women who had scores high risk for PTSD. Women who responded yes to forms of obstetric violence had increased risk for PTSD (verbal violence 32.3%, physical violence 17.6%, and psycho-affective violence 27.0%).
Martinez-Vázquez et al.^Citation12	n = 1301 women who had given birth in Spain between 12 and 36 months after childbirth	Quantitative: cross-sectional survey study/Level III	The prevalence of long-term postpartum post-traumatic stress disorder (PTSD) in this sample was 13.1% (n = 171). Factors associated with a higher risk of long-term postpartum PTSD were experiences of: not having a birth plan respected (aOR: 1.89, 95% CI 1.21-2.94), newborn formula feeding at discharge (aOR: 2.50, 95% CI 1.20-5.17), postpartum surgical intervention (aOR: 2.23, 95% CI 1.02-4.85), maternal hospital readmission (aOR: 3.45, 95% CI 1.21-9.84), verbal obstetric violence (aOR: 3.73, 95% CI 2.52-5.53), and psycho-affective obstetric violence (aOR 3.98, 95% CI 2.48-6.39).
Martinez-Vázquez et al.^Citation53	n = 782 women who gave birth in Spain in the last 12 months	Quantitative: cross-sectional survey study/Level III	A higher prevalence of postpartum depression risk was found among women who were multiparous (aOR: 1.62, 95% CI: 1.10-2.39), had their baby admitted to NICU (aOR: 1.93, 95% CI: 1.06-3.51), reported experiencing verbal obstetric violence (aOR: 2.02, 95% CI: 1.35-3.02), and reported experiencing psycho-affective obstetric violence (aOR: 2.65, 95% CI: 1.79-3.93). The perception of support during pregnancy, birth, and postpartum was found to be a protective factor that was positively associated with perceived level of support received.
Mena-Tudela et al.^Citation13	n = 17,541 women who gave birth or had a miscarriage in a Spanish hospital from 2009 to 2018	Quantitative: descriptive, retrospective, cross-sectional survey/Level III	Nationwide, 38.3% of respondents perceived having suffered obstetric violence during pregnancy, birth, or postpartum. 44.4% of respondents perceived they had undergone unnecessary and/or painful procedures. Of these, 83.4% indicated that they were not requested to provide informed consent. The mean satisfaction score for maternity care received was 8.31 points for women who did not report experiencing obstetric violence and 4.85 points for women who responded they were victims of obstetric violence. Obstetric violence was reported to occur mainly in the private health care context (p = 0.023).
Mena-Tudela et al.^Citation54	n = 17,541 women who gave birth or had a miscarriage in a Spanish hospital from 2009 to 2018	Quantitative: descriptive, retrospective, cross-sectional survey/Level III	Childbirth in Spain seems to be highly medicalised with reported interventions and procedures that exceed recommended rates and do not conform to evidence-based practices. Satisfaction scores and perceived obstetric violence were significantly different in public, private, and mixed healthcare settings. Of all the women who reported they experienced unnecessary and/or painful procedures (44.4%), 74.3% of those also reported experiencing obstetric violence.
Mena-Tudela et al.^Citation55	n = 153 nursing, midwifery, and medical students from Spain	Quantitative: measurement study for the design and validation of the Perception of Obstetric Violence in Students (PercOV-S) tool/Level III	The PercOV-S instrument was validated. Factor analysis explained 54.7% of the variance in two factors called protocolised, visible obstetric violence and non-protocolised-invisible obstetric violence. All items had factor loads greater than 0.4, except one, which was retained for the type of care it represented. Overall reliability of the questionnaire (α = 0.936) and the domains were reported as excellent (domain 1, α = 0.802; domain 2, α = 0.952).
Mena-Tudela et al.^Citation56	n = 107 questionnaires completed by nursing and medical students from Spain	Quantitative: longitudinal, pre-post quasi-experimental study using an educational intervention on obstetric violence/Level II	26 of the 33 analyses of the Perception of Obstetric Violence in Students scale by paired data with Student’s t-test showed statistically significant differences (p < 0.05; CI 95%) between the pre- and post-intervention measures. Only 24.4% (n = 8) of the 33 items on the obstetric violence perception scale had no relationship with the sample’s sociodemographic and control variables. The normalisation of obstetric violence was observed with the progression of student training and from personal experience with pregnancy and birth.
Mena-Tudela et al.^Citation57	n = 17,541 women who gave birth or had a miscarriage in a Spanish hospital from 2009 to 2018	Quantitative: descriptive, retrospective, cross-sectional survey/Level III	Women reported obstetric violence was most often experienced during the time of birth. Hospitals were the place identified with the most obstetric violence reported. Gynecologists and midwives were most often identified as the agents of harm for obstetric violence. The two most common types of obstetric violence reported were verbal violence (87.6%)—most often being criticised for behaviour with ironic and discrediting remarks (34.5%) and being called by nicknames or childish diminuitives (31.4%)—and lack of information and informed consent (74.2%).
Mena-Tudela et al.^Citation58	n = 540 health sciences students in Spain between October 2019 and November 2020	Quantitative: descriptive and comparative, cross-sectional, survey study/Level III	Results showed statistically significant differences in the overall Perception of Obstetric Violence in Students (PercOV-S) score, its dimensions, and most items according to the degree programme of students. Students in nursing and midwifery reported a higher perception of obstetric violence for almost all PercOV-S items, the dimensions, and overall scores than medical and psychology students. In addition, nursing and midwifery students perceived more obstetric violence with advancing academic year, while medical students showed the opposite. There were no significant differences in psychology students’ perceptions of obstetric violence by academic year.
Nagle & Samari^Citation59	n = 987,187 term, singleton, vertex, first births to women ages 15–49 years recorded with complete data in the U.S. in 2018	Quantitative: cross-sectional, descriptive and correlational/Level III	Structural sexism had a significant positive relationship with cesarean birth (OR = 1.19, p < 0.001), controlling for age, race and ethnicity, education level, and payment type. Every one-point increase in a state’s structural sexism score was associated with a 19% increase in the likelihood of a low-risk woman having a cesarean, controlling for confounders. This study examined a macro driver for low-risk cesarean rates by state with results that connected structural sexism to the overuse of cesareans as a form of obstetric violence.
O’Brien & Rich^Citation60	N/a – Authors from U.S. (History of Medicine)	Perspectives/Level V	The scope of the under-recognised history of obstetric violence across time and place illustrates the embeddedness of the problem within historical structures and social inequities.
Perrotte et al.^Citation24	n = 22 publications of qualitative and quantitative studies in English or French from 2015–2020	Integrative literature review/Level V	Obstetric violence is rooted in a patriarchal understanding of gender stereotypes and is exacerbated by power dynamics between health professionals and patients, especially for minorities. Obstetric violence is intrinsically related to institutional violence against women, has a lasting impact on women’s lives, and can lead to avoidance of healthcare services in the future. Evidence of obstetric violence was found in every region of the world.
Pope^Citation61	N/a – Author from U.S. (Attorney)	Legal Briefing/Level V	Legal review of cases involving coerced and forced cesareans calls for better training and institutional policies, and new statutory legal theories to protect women from obstetric violence.
Sadler et al.^Citation62	N/a – Interdisciplinary, multinational authors	Discussion/Level V	Recommends the concept of obstetric violence as a useful tool for addressing structural violence within the multiple forms of disrespect and abuse in maternity care. Argues for the harmful power structures that are normalised and reproduced in biomedicine to be made visible. Recommends a multidimensional, interdisciplinary approach to dismantle obstetric violence.
Salter et al.^Citation19	N/a – Authors from U.S. (School of Medicine)	Commentary/Level V	Naming obstetric violence is essential to describe the violent experiences reported by patients and clinicians and for addressing the structures and contexts that produce and perpetuate such violence. Naming and confronting obstetric violence as a form of structural violence challenges the ongoing normalisation of it and offers a path to recognise the full humanity of patients and clinicians.
Scandurra et al.^Citation14	n = 282 women who gave birth in Italy at least once and were 18 years or older	Quantitative: cross-sectional survey/Level III	More than three-quarters of the sample (78.4%) reported experiencing at least one type of obstetric violence (55.5% non-consented care and 66.4% abuse and violence). Both forms of obstetric violence were positively correlated with psychological distress and post-traumatic stress. Abuse and violence was the form of obstetric violence with a greater association to negative effects on the mental health of childbearing women.
Searcy & Castañeda^Citation63	n = 515 doulas in 23 countries from March and April 2020. Follow up survey in July 2020 with n = 52 doulas in 7 countries	Qualitative, thematic analysis of surveys with closed and open-ended questions/Level III	Doulas raised concerns during the time of COVID-19 restrictions that centred around the theme of “increasing obstetric violence without a birth partner to bear witness.” Doulas were most concerned about increases in obstetric violence due to their restricted access from attending births. This theme was consistent across the 23 countries represented despite variation in international public health strategies for COVID-19. Doulas gave examples of lack of consent, fear mongering used to coerce cesareans, and harsher treatment of birthing people.
Silva et al.^Citation64	n = 70 documents published in Chile from 2000 to 2019	Scoping review/Level III	Challenges for improvements related to the problem of obstetric violence were identified as the historical, sociocultural, and economic construction of the dominant biomedical model for pregnancy and birth. The scientific community and other stakeholders agreed on recognising the benefits of humanised birth and the need to overcome institutional obstacles in the Chilean healthcare system. The current system that does not function with the well-being of women as the primary driver was identified as a social determinant of health that acts as a barrier to intended outcomes.
Vedam et al.^Citation9	n = 2138 women who experienced at least one pregnancy in the U.S. from 2010 to 2016	Quantitative: cross-sectional online survey using a community-based participatory research process/Level III	Used the term mistreatment in pregnancy and childbirth. One in six women experienced one or more types of mistreatment. Context of care mattered with differences for place of birth correlated with increased reports of mistreatment: 5.1% for home births versus 28% for hospital births. Addressed intersectionality and found rates of mistreatment for women of color were consistently higher. For example, 27.2% of women of color with low socioeconomic status reported mistreatment versus 18.7% of white women with low socioeconomic status.
Williams & Meier^Citation4	N/a – Authors from U.S. (Global Public Health & Global Health Policy)	Commentary/Level V	Obstetric violence is gender-based mistreatment in childbirth, a form of violence against women, and a human rights violation addressed by the United Nations. Obstetric violence involves multiple concurrent and intersecting human rights violations. Importance of a rights-based approach to obstetric violence that empowers individuals to seek redress and legal accountability for violations.

Gaps in research on obstetric violence

This integrative review identified the following gaps in the research on obstetric violence: (a) scarce attention to obstetric violence in most high-income countries, (b) most US sources are non-scientific and from outside the healthcare disciplines, (c) inconsistencies in terminology, (d) most studies were conducted with samples of women who had given birth, with scant research about healthcare providers and obstetric violence, and (e) the under-recognised association between obstetric violence and traumatic birth.

Scarce attention to obstetric violence in most high-income countries

Overall, a total of only 19 of the 80 countries classified as high-income addressed the problem of obstetric violence in their own country, or were represented in studies that used multinational samples (Canada, Denmark, Finland, Germany, Hungary, Ireland, Israel, Japan, New Zealand, Portugal, and Taiwan). Research teams from Spain are the leaders in empirical studies on the problem of obstetric violence in their country. Research efforts in Spain have produced: (a) prevalence and descriptive studies on obstetric violence,^13,52,54,57 (b) Perception of Obstetric Violence in Students (PercOV-S) scale development and measurement studies,^55,56,58 (c) relationship studies between obstetric violence and postpartum depression, perinatal post-traumatic stress disorder, and long-term post-traumatic stress disorder,^11,12,53 and (d) an examination of how obstetric violence infringes on bioethical principles.⁵¹

Researchers from Italy have also analysed the prevalence of obstetric violence and its association with poor mental health. An Italian research team found that 78.4% of their national sample reported experiencing obstetric violence, and both types of obstetric violence addressed (non-consented care and abuse and violence) were positively correlated with psychological distress and post-traumatic stress.¹⁴ In Australia, researchers explored the continuum from coercion to respectful care for women who planned to have a vaginal birth after caesarean. Examples of obstetric violence were most clearly present in negative interactions as verbal coercion to have a repeat caesarean, threatening, and overt examples of unconsented procedures and having physical force used against the birthing person.⁴⁹ Co-researchers from Sweden found that interview participants had experienced psychological and physical abuse during childbirth that was considered obstetric violence. Results included accounts of higher-intensity experiences of obstetric violence that were compared to rape.³⁸

The scoping review by Silva et al⁶⁴ about stakeholders’ perceptions of humanised birth practices and obstetric violence only included sources about Chile. A useful structural conclusion was that the predominant hyper-medicalised model of childbirth care in Chile – in which routinised practices that do not conform with recommended standards of care persist – is a social determinant of health that acts as a barrier to intended outcomes. Philosophical and theoretical papers by a researcher from Israel support the conclusion that obstetric violence is pervasive in societies where childbirth is highly medicalised, almost exclusively controlled and managed by medical authorities, and heavily influenced by capitalist and patriarchal values.²⁸ These sociocultural and politico-economic features have also been discussed as factors that contribute to framing normalised forms of obstetric violence in medical spaces as not-violence.⁴² In addition, obstetric violence has been further discussed as a form of testimonial injustice in which women suffer both systematic and incidental epistemic injustices.²¹

Most US sources are non-scientific and from outside the healthcare disciplines

The second gap identified from the conduct of this review is that most US sources about obstetric violence are non-scientific and come from authors outside the healthcare disciplines. Empirical publications about obstetric violence in the United States, though low overall, are second in total number to Spain. There were 11 empirical studies focused on the problem in Spain and six that addressed the problem in the United States. Three of the six empirical studies about obstetric violence in the US context are focused explicitly on the concept. One is a qualitative interview study that examined how obstetric gaslighting worked to deny and destabilise mothers’ realities about their negative birth experiences and showed how obstetric gaslighting works as an under-recognised mechanism of obstetric violence.⁴⁵ The second study, by Liese and colleagues,⁵⁰ determined that the performance of unnecessary, non-evidence-based procedures – especially unnecessary caesareans – constitutes obstetric violence and iatrogenesis. The third study examined the association between state-level structural sexism and low-risk caesareans across the United States and found that women living in states with higher structural sexism scores were more likely to have a caesarean.⁵⁹ This is notable as the first known study to demonstrate quantitatively and conceptually that a macro-level driver affects obstetric violence through the overmedicalisation of birth.

The other three empirical studies about obstetric violence in the United States are described in other sections below. The central problem for analysis and discussion by Davis¹⁶ is obstetric racism, hence that paper is addressed in a subsection on intersectionality, obstetric racism, and obstetric violence. The other two papers about obstetric violence are discussed in findings for inconsistencies in terminology because the research teams for each of those studies used the term “mistreatment during pregnancy and childbirth”.^5,9

This review includes a concept analysis of obstetric violence in the United States²⁷ and a theory analysis of social justice in nursing⁴⁶ with arguments for using the theory as an emancipatory framework to guide obstetric violence research.¹⁷ Three of the five discussion-level sources in this review are by US authors from different disciplines in medicine, global public health, and public policy.^4,19,60 Each of those papers was organised with a different approach to discussing the need to better understand, confront, and eliminate obstetric violence. Yet all three papers agree on the attributes of obstetric violence as:

• a contextually complex, structural problem that is embedded within historical structures and social inequities,

• a phenomenon that manifests across the childbearing continuum as a gender-based form of violence against women, and

• a harmful occurrence with negative effects on the full humanity of birthing people and the clinicians who provide their care.^4,19,60

In addition to being non-empirical, most sources about obstetric violence in the United States come from outside the healthcare disciplines. This gap in research highlights a lack of attention to the problem from the disciplines responsible for providing most maternity care services (i.e. nurses, midwives, and physicians). Legal scholars in the United States have made arguments that a recognised obstetric violence framework centred on lack of informed consent, coerced, or forced procedures can provide a pathway for accountability and restitution when bodily autonomy, consent, and a woman’s legal right to a life free from violence are violated.^6,7,29,61 Tort law and other areas of the law in the United States have been discussed as inadequate to successfully handle obstetric violence claims. These legal and regulatory challenges are compounded by difficulties in accessing an attorney who will accept an obstetric violence case and navigating a legal system that largely favours perceived fetal rights over the rights of a woman.^6,7,29 A final non-empirical source is the naturally occurring data about obstetric violence in US maternity care that can be seen online from advocacy groups, birth rights groups, and social media campaigns.^39,41,44

Inconsistencies in terminology

The third gap identified from this review is that the literature about obstetric violence is not consistent in the use of terminology. Researchers from the United States published the most recent literature review on obstetric violence.²⁴ The authors addressed obstetric violence or disrespect and abuse in childbirth and used the terms interchangeably. Their use of “disrespect and abuse” as a search term included a prominent source about mistreatment during pregnancy and childbirth in the United States,⁹ and all their review findings were collectively discussed as forms of obstetric violence. Another literature review on obstetric mistreatment by a US author asserts that obstetric mistreatment and obstetric violence are synonymous.⁴³ In addition, “obstetric iatrogenesis” is a new term that has emerged in obstetric violence research. The term combines the classic understanding of iatrogenesis as injury or harm caused by the clinician in the course of providing medical care together with the specificity of the problem in obstetric care, where obstetric iatrogenesis was examined along a spectrum ranging from unintentional harm to overt disrespect, violence, and abuse.⁵⁰

An overarching reason for gaps in the research on obstetric violence is that publications that use alternative terminology do not claim the concept of obstetric violence as a distinct topic of inquiry or a related finding. For example, The Giving Voice to Mothers – US Study is important for advancing the understanding of obstetric violence and inequity in US maternity care because the mistreatment examined is representative of obstetric violence. This study has been disseminated into the evidence base for obstetric violence despite there being no use of the term in the paper. Vedam et al.⁹ quantified the prevalence of mistreatment during pregnancy and childbirth in the United States along with examining intersectional relationships with race and other maternal variables. Overall results showed that one in six women across all settings reported one or more types of mistreatment during pregnancy or childbirth. Results by context of care showed that place of birth mattered, with the highest rate of mistreatment reported in hospital settings (28.1%) compared to rates for freestanding birth centres (7.0%) and home births (5.1%). Results also showed that rates of mistreatment for women of colour were significantly higher, and regardless of the race of the birthing person, having a partner who was Black increased reported mistreatment.⁹

Beck⁵ also used the term “mistreatment during childbirth” when conducting a secondary analysis of a qualitative data set on women’s experiences of traumatic birth. The mistreatment examined is representative of obstetric violence, but the terminology chosen for the study was based on the seven typologies of mistreatment described by Bohren et al.³⁶ Results showed that six types of disrespectful and abusive treatment during childbirth were reported by participants. Sexual abuse was the only type of mistreatment not reported. Overall, findings confirmed that women from the four high-income countries represented in the study sample experienced mistreatment during childbirth in facilities that was consistent with findings from middle- and low-income countries.⁵

The landscape analysis of evidence for disrespect and abuse in facility-based childbirth³⁷ precedes the mixed-methods systematic review of the mistreatment of women during childbirth in health facilities.³⁶ These global examinations of mistreatment and disrespect and abuse of childbearing people, although not named as obstetric violence, are used as examples of the problem worldwide. A later integrative review on obstetric violence also used a table of typologies to organise results on the routinisation and characteristics of the phenomenon.³ The typologies the authors derived to organise what exemplifies obstetric violence in the more recent review are similar to previous findings. See Table 2 for a summary of the typologies that categorised obstetric violence from these global reviews.^3,36,37

Table 2: Typology summaries from global review sources that categorised obstetric violence

Authors/Year	Jardim & Modena^Citation3^a	Bohren et al.^Citation36^b	Bowser & Hill^Citation37^c
Typologies of obstetric violence	Physical violence	Physical abuse	Physical abuse
	Sexual violence	Sexual abuse	(No equivalent category)
	Verbal violence	Verbal abuse	Non-dignified care
	Social discrimination	Stigma and discrimination	Discrimination based on specific patient attributes
	Inappropriate use of procedures and technologies	Failure to meet professional standards of care	Non-consented care Non-confidential care
	Psychological violence	Poor rapport between women and providers	Detention in facilities
	Neglect of care	Health system constraints and conditions	Abandonment of care

^a Obstetric violence in the daily routine of care and its characteristics³

^b The mistreatment of women during childbirth in health facilities globally: A mixed-methods systematic review³⁶

^c Exploring evidence for disrespect and abuse in facility-based childbirth: Report of a landscape analysis³⁷

Note: The seven typologies of obstetric violence determined by each of these sources were arranged in rows to match this author’s interpretation of how they align as most similar to one another.

Most studies only used samples of women who had given birth

A fourth gap identified from this review is that there were only seven studies that examined obstetric violence using samples that were not based on women who had given birth. While the prevalence and experience of obstetric violence must be understood by those who are directly harmed by it, the goal of eliminating obstetric violence cannot be achieved without understanding the phenomenon from the full range of interested and affected groups. This needs to include healthcare providers who are the actors when obstetric violence occurs, as well as being an essential part of the solution to prevent and eliminate obstetric violence.

There are measurement studies on perceptions of obstetric violence that used samples of nursing, midwifery, medical, and psychology students in Spain.^55,56,58 There is also a phenomenological study that explored obstetric violence as an infringement of bioethical principles using focus groups with midwives from Spain.⁵¹ Another study used a sample of multinational nurses, midwives, and obstetricians working in Qatar to determine perceptions of obstetric violence from a video of simulated practice.⁴⁷ An additional example is a survey study by Gray et al.⁴⁸ that compared obstetric violence awareness, understanding, and perceptions between medical students from the United Kingdom and India. A final example is a qualitative study with a multinational sample of doulas during the first wave of COVID-19. Results showed that the greatest concern was expressed about COVID restrictions and the theme: “increasing obstetric violence without a birth partner to bear witness” (p. 2).⁶³

Under-recognised association between obstetric violence and traumatic birth

A final gap in the research identified from this review is the largely unexamined association between obstetric violence and traumatic birth. A descriptive phenomenology study by Beck⁴⁰ – with the objective of discovering the meaning of women’s birth trauma – was identified from the results in a systematic review.³⁶ That primary study was linked during this review to the secondary study by Beck⁵ that revisited the data on traumatic birth by asking the new question about types and frequency of mistreatment of women during childbirth in high-income countries. Several participants from the primary study shared that they felt raped during their births. One respondent stated, “I am amazed that 3 ½ hours in the labor and delivery room could cause such utter destruction in my life. It truly was like being the victim of a violent crime or rape” (p. 32).⁴⁰

In addition, a mixed methods study of secondary traumatic stress in labour and delivery nurses⁶⁵ was found from citation searching for this review. That study did not address obstetric violence, yet the issue was present in the results. A distinct situation that magnified exposure to traumatic births was when nurses perceived the birth as abusive by the physician. Nurses frequently used the following phrases to describe these situations: “the physician violated her,” “a perfect delivery turned violent”, “unnecessary roughness with her perineum”, and “felt like an accomplice to a crime” (p. 754).⁶⁵ One nurse described her experience with a traumatic birth as, “The doctor treated her like a piece of dirt … . I felt like I was watching a rape” (p. 754).⁶⁵

These examples of evidence of obstetric violence being present in research results about traumatic birth make it important to recognise that not all traumatic births involve obstetric violence. A woman can receive the best of compassionate, respectful care and still have a traumatic experience. The two phenomena are connected when obstetric violence is the reason for a traumatic birth. The distinction can be understood more clearly from examples of reported traumatic births most often involving infant/fetal demise, maternal death, and shoulder dystocia with no connection to obstetric violence solely by their clinical occurrence.⁶⁵

Challenges to studying obstetric violence

The challenges to studying obstetric violence that were identified from this review are:

1. The factors that enable and perpetuate obstetric violence are multilevel and nonlinear.

2. The phenomenon is contextually complex.

3. There are epistemic blind spots that prevent healthcare providers and birthing people from perceiving and recognising obstetric violence.

Multilevel, nonlinear factors that enable and perpetuate obstetric violence

The risk factors associated with biases that contribute to health disparities and further marginalise women during the vulnerable time of childbearing have been described as a multilevel, interrelated web of factors. This multidirectional web is made up of culturally embedded and institutionally enforced factors that enable and perpetuate obstetric violence.^3,6,17,28 In addition, these intersectional vulnerabilities place marginalised groups at increased risk for harm and inequitable outcomes. This juncture highlights one of the places where obstetric racism needs to be introduced as a related concept and as an example of the intersectionality that is a feature of obstetric violence.

Intersectionality, obstetric racism, and obstetric violence

Intersectionality is an exemplar of the multilevel, nonlinear factors that differentially enable and perpetuate obstetric violence. In addition, the concept of intersectionality serves as a theoretical vehicle for understanding how marginalised groups are at increased risk for obstetric violence and associated harms.^3,4,9,24,60 The term intersectionality was first introduced by Crenshaw^66,67 to address the failures of antidiscrimination law, feminist theory, and antiracist politics to inclusively represent Black women and women of colour whose identities and vulnerabilities are not singular. An intersectional view of obstetric violence is aligned with the explication that when addressing the problem of violence against women “the other multilayered and routinised forms of domination that often converge in these women’s lives” must also be confronted (p. 1245).⁶⁷ These examples of discriminatory marginalisation go beyond sex and race to include class, sexuality, immigration status, and social capital¹⁷ with an emphasis on the idea that a person’s whole identity cannot be adequately represented with single-issue analyses.^66,68

While intersectionality is a broad concept, obstetric racism is a specific example in pregnancy and childbirth. Davis¹⁶ situates obstetric racism as both an occurrence and an analytic for Black women’s reproductive experiences where racism is the violence that increases risks and harms and obstetric racism is what “lies at the intersection of obstetric violence and medical racism” (p. 561).¹⁶ This reality can be seen in the ongoing failure of the US maternity system to improve inequitable outcomes, where Black women continue to suffer a national maternal mortality rate more than three times that of white women even when socioeconomic and educational attainment are controlled for.^16,69,70

O’Brien and Rich⁶⁰ delved into history to discuss the intersections of religion, colonisation, and obstetric violence. Contemporary global reviews consistently find “social discrimination”,³ “stigma and discrimination”,³⁶ and “discrimination based on specific patient attributes”³⁷ as categories for a typology of obstetric violence. The consistency of these findings demonstrates the strength of the evidence for multiple marginalised identities that can inequitably intersect with being a birthing person. It is notable that the identities for otherness that are summarised in each review are not the same over time. Jardim and Modena³ are the only authors who identified “sexual choice” as an example of social discrimination, while Bowser & Hill³⁷ are the only authors who included “traditional beliefs and preferences”. These differences raise questions for obstetric violence research going forward as the recognition of more diversity in the identities of birthing people increases, and different religious, political, legislative, and sociocultural influences differentially help or harm marginalised groups.

Contextual complexity of obstetric violence

A second feature of obstetric violence that poses a challenge to research is the contextual complexity of the phenomenon, whereby obstetric violence is perpetuated and manifests differently depending on the unique contextual factors that converge to determine the realities of birthing people around the world.^24,36,37 For example, in a high-income country like the United States obstetric violence is often an unintended consequence of the normalisation of a depersonalised, hyper-medicalised, technocratic model of care.^{28,45,50,60,62} Explicit violence in the maternity care systems of most high-income countries is less common compared to obstetric violence in middle- and low-income countries where obstetric violence can be seen more overtly in the forms of hitting, pinching, cursing, profound humiliation, and sometimes avoidable death.^30,36

The defining attributes of obstetric violence do not change, but the particularities of how it is produced, perceived, and experienced can vary across different settings and with different clinicians. Researchers from Spain have provided a foundation for demonstrating that there are statistically significant differences in the perception of obstetric violence among different types of healthcare students. Differences varied beyond the academic discipline of students to include gender, experience in maternity care training, ethnic group, type of obstetric violence, and academic year.⁵⁸ In addition, Gray and colleagues have demonstrated differences in the knowledge and attitudes about obstetric violence between multinational nursing/midwifery staff and obstetricians in a private hospital in Qatar⁴⁷ along with demonstrating differences in the perception of obstetric violence between medical students in India and in the United Kingdom.⁴⁸ Continuing to advance the understanding of obstetric violence across the contextual differences of groups, settings, healthcare systems, and sociocultural beliefs is essential to effectively dismantle and eliminate it.

While the contextual complexity of obstetric violence can be challenging to study, this review of the literature showed that obstetric violence is conceptually consistent across the range of sources reviewed. This degree of consistency across diverse, international settings shows that the patterns of meaning for obstetric violence do not deviate in the contexts where the problem has been shown to occur. Scholars from around the world have established an evidence base for obstetric violence that is conceptually and theoretically consistent. Two of the five discussion-level papers about obstetric violence in this review represent work by an interdisciplinary, multinational collection of authors.^22,62 These authors wrote their papers with different perspectives and purposes, and they all agree on the structural normalisation of violence against women as a conceptual attribute of obstetric violence. The authors of both these publications effectively describe how it is within the harmful power structures and discriminatory messaging about women’s bodies and female reproduction that the different forms of obstetric violence can be seen.^22,62

Obstetric violence as an epistemic blind spot

The need to consider the contextual factors that produce obstetric violence is joined by the need to also consider epistemological questions about the differing origins of knowledge about obstetric violence. It has been argued that the biomedical model of care is wrongly privileged in institutionalised childbirth, and the abundance of authority granted to physicians erases women as the locus of power and source of embodied knowing in their own birth experiences.²¹ The prevailing biomedical paradigm contributes to the epistemic challenge that makes it so birthing people and healthcare providers may not perceive obstetric violence when the problem occurs. Chadwick¹⁸ discussed this challenge and concluded that “of all forms of gendered violence, abuse during birth remains one of the most unrecognised and invisible iterations of such violence” (p. 5).¹⁸ This epistemic blind spot highlights the need to name and claim obstetric violence in research so that the science and solutions can be advanced as to how such a pervasive and globally recognised problem can also remain unseen.

The lack of recognition, or invisibility, of normalised structural violence is problematic. When considering obstetric violence, this leaves birthing people at increased risk for continued harm from the unequal power relations that disbelieve and dehumanise them while minimising and erasing their suffering.^21,42. Examples of this paradox can be seen in the literature where obstetric violence was phenomenologically perceived and described but not epistemically recognised or named.^42,71 Framing the expansiveness of the problem of obstetric violence as a complex, structural, and interpersonal issue would work towards developing research that advances the understanding of how providers and patients may not recognise obstetric violence in normalised, routine practices.

Discussion

Guiding frameworks that meet the challenges of studying obstetric violence

The occurrence of obstetric violence is a prime example of a systems problem, wherein maternity care systems do not reliably produce the desired outcome of a positive birth experience. In particular, women in the United States reported the least positive healthcare experiences compared to women in 10 other high-income countries.⁷² The persistent failure to meet standards for maternity care are usually looked at in isolation as areas of concern where quality of care measures are not being met, but a shift in thinking to a systems view creates space to see how these issues can be connected by the common problem of obstetric violence.^17,23,73,74

Using a systems approach to view the nonlinear, multidimensional issue of obstetric violence offers a solution for addressing the complexity of the phenomenon. Systems thinking provides a wide-angle view to see the full scope of complex problems while also elevating research questions beyond the level of the individual. This expanded field of vision is important for situating obstetric violence as a gendered form of sexual violence that is “rooted in social relations of (patriarchal, racist, medical, and colonial) power” where “the enemy is not individual persons but unjust structures, repressive hierarchies, and unequal relations of power” (p. 6).¹⁸ In addition, the systemic approach to research has been embraced across disciplines to avoid micro-reductionism and macro-reductionism.⁷⁵ The utility of a multilevel schema can also prevent a myopic focus on lower-level mechanisms that can bring in causally irrelevant considerations and risk missing the true source of explanation that may not reside at the micro level.⁷⁶ These considerations are important for the study of obstetric violence because even when the level of analysis is defined in research, multilevel factors continue to exert effects.

A second solution to studying structural problems that was identified from this review is the use of complexity theory as a guiding framework. The expansiveness of what has been described to enable and perpetuate obstetric violence requires conjunctive theorising that was developed to account for problems embedded in organisational complexity.⁷⁷ Complexity theory can provide a framework for the connections that need to be made among concepts that have previously remained compartmentalised, so that the multiple dimensions of a structural issue like obstetric violence can be more effectively addressed. For example, the overuse of caesarean births, unnecessary episiotomies, coerced or forced procedures, and routinised interventions that are not aligned with evidence-based practice, provide examples of problems that are linked when they are broadly viewed as having a common cause in the structural mechanism of obstetric violence.

In addition, using complexity theory to guide obstetric violence research can show how normalised clinical routines in maternity care are an area with profound potential for change. A unique feature of maternity care is that most patients are healthy individuals experiencing the normal physiological events of pregnancy and birth. This space is where there is a wide range of potential for change in organisational routines and the actions of individual providers who exercise their discretion in how they deliver care to birthing people. For example, the functional organisation of most labour and delivery units provides the context for non-deliberate actions by clinicians that keep routines within the desired requirements for hospital processes and provider convenience. This creates a contradictory situation where many organisational routines that satisfy what the system wants are in direct conflict with what serves the preferences and desired experiences for birthing people.^6,7,29,61 Providing a theoretical space to see structuring as a process through the actions of providers, who either disrupt or maintain the currently entrenched system, rather than structure as an immovable thing,⁷⁸ opens up an important area of inquiry. Process change is achievable, and it provides a perspective for designing studies that seek to understand how healthcare providers see the issue of obstetric violence in relation to their own interactions and in relation to the organisation of the environments where they provide care.

Implications for research, education, practice, and policy

The collective efforts from all interested and affected parties who are working to dismantle and eliminate obstetric violence can reach a tipping point. Continuing to push past that point is where a paradigm shift can make obstetric violence recognisable, understood, and unacceptable across the fields of research, education, practice, and policy. The contextual complexity that has been described as a feature of obstetric violence will remain. In addition, the challenging multilevel and nonlinear features of obstetric violence are why the discussion from this review recommends the use of systems thinking and complexity theory as guiding frameworks that are expansive enough to meet the challenges of studying obstetric violence. The transformative principles of these suggested solutions can also advance the science in ways that can be implemented across disciplines and action areas that include non-academic community partners.

There is an outline for achieving paradigm shifts with complex, structural problems like obstetric violence and obstetric racism.

• Keep pointing at the anomalies and failures in the old paradigm.

• Keep speaking and acting, loudly and with assurance, from the new one.

• Insert people with the new paradigm in places of public visibility and power.

• Avoid losing time with reactionaries.

• Work with active change agents and with the vast middle ground of people who are open-minded (p. 164).⁷⁴

Evidence and support to accomplish change of the magnitude it will take to dismantle and eliminate obstetric violence is gaining strength from transdisciplinary efforts inside and outside of academia. “Respectful maternity care” is a term used as both a description of a basic human right for women and an optimal strategy to ensure that all childbearing people receive equitable maternity care free from mistreatment, disrespect, and abuse.⁷⁹ Respectful maternity care is antithetical to obstetric violence, and the concept is increasingly being advanced as a solution to the problem of obstetric violence. Respectful maternity care can be applied as a theoretical framework and a guideline for recommended practices in maternity care. The term “respectful maternity care” has evolved as both a description of a basic human right and a multilevel, systemic strategy to ensure that all birthing people receive equitable care free from mistreatment, abuse, unconsented, or undignified care – by all providers, at all times, in all settings.^25,79,80,81

The implications for research from this review are broad because obstetric violence is still emerging in empirical research, particularly in high-income countries. In addition, some of the areas open for research about obstetric violence are related to ongoing changes in political, legal, and sociocultural shifts. For example, there are no known studies that examine abortion in the scope of obstetric violence research. Another area open for inquiry is how obstetric violence may be associated with the gender shift in some countries where the majority of Obstetrics and Gynecology residents and physicians are now female. The Association of American Medical Colleges’ report on the number and percentage of active Obstetrics and Gynecology residents who identified as women for the year 2021–2022 was 86.4% compared to 13.6% men.⁸² This relatively new gender bias among Obstetrics and Gynecology residents and physicians raises many questions about gender-concordant care and a lack of diversity in the specialty.⁸³ In particular, this shift provides an opportunity to examine the interpersonal and structural complexity of obstetric violence, considering possible differences between male and female physician interactions within healthcare systems that are known to be rooted in structural norms and routines that enable and perpetuate obstetric violence.^{3,17,23,28,62}

Several areas of inquiry about obstetric violence in different contexts could benefit from the development or adaptation of validated measurement tools. There are obstetric violence measurement tools that have been used in research from low-, middle- and high-income countries.^{1,10,14,55,84} The increased use of validated measurement tools for obstetric violence can provide better insight into prevalence in different locations and settings, and inform concerns about obstetric violence being under-reported. Finally, research into the association between obstetric violence and negative mental health outcomes for birthing people could be extended to investigate associations with poor physical health.

Limitations

The focus of this integrative review on obstetric violence in the United States and other high-income countries could be considered a limitation. Instead, I argue that the attention paid to more high-intensity forms of obstetric violence in middle- and low-income countries, that are more easily recognised, creates a false bias of superiority that has delayed examining the problem in high-resource settings. The scarcity of research on obstetric violence in most high-income countries may also contribute to the false belief that it is not a problem in those nations. Another limitation of the search strategy for this review is under-reporting of sources due to an unknown number of publications that are about obstetric violence, but use alternative terminology and do not link findings to the problem of obstetric violence. In addition, analysing and synthesising sources with various methodologies combined with non-empirical sources introduces challenges to the rigour of integrative reviews.³² The ability to include only sources in English is also a limitation. In particular, this excludes sources in Spanish or Portuguese from countries where the term “obstetric violence” originated, active research and advocacy work are ongoing, and obstetric violence has been codified into law.^85–87 Another limitation is that this integrative review was done by a solo investigator. The potential bias and weaknesses in rigour from this were addressed by using multidisciplinary, international readers to achieve agreement on the review.

Conclusion

The conduct and synthesis of this integrative review found the emerging knowledge about obstetric violence to be increasing substantially following each previous review. I believe the field is ready for a systematic review on obstetric violence to increase the level of evidence beyond what an integrative review can offer. Recent publications from the last three years continue to explore philosophical questions, conceptual and theoretical work, and there are a growing number of studies that have operationalised obstetric violence and used empirical methods. In particular, the evidence base on obstetric violence now has an increasing number of researchers from high-income countries who are studying the problem in their own maternity care contexts. The universal understanding of obstetric violence as a sex-specific, gender-based form of structural violence against childbearing people is well established, although the contextual complexities remain for how it may be differently experienced, perceived, and recognised. The mixing of terminology is not desirable for consistency and clarity in advancing research, though the recent use of the terms mistreatment, disrespect, and abuse, as synonymous or interchangeable with the obstetric violence they represent, demonstrates an increasing acceptance of obstetric violence into the research lexicon. The defining attributes of obstetric violence were conceptually consistent across the range of literature reviewed despite the variation in terms used.

It is time for obstetric violence research to move forward from categorising what it is and on to a more utilitarian understanding of how to effectively recognise and eliminate it from maternity care systems. The gaps in research identified from this review highlight areas for study where the science on obstetric violence is lacking. Future studies are needed to examine the association between traumatic birth and obstetric violence and to continue to advance the examination of obstetric violence as a problem in high-income settings. As the focus on understanding the experiences of obstetric violence among birthing people continues to be strengthened, there is an additional need to understand the problem from the perspectives of the full spectrum of maternity care providers. In particular, I call out the need for health sciences researchers in the United States to become engaged in conducting empirical studies on obstetric violence in the context of the US maternity care system. Finally, the use of systems-level thinking and complexity theory are recommended as guiding frameworks to design research on obstetric violence in ways that can meet the challenges to advancing the science on the problem.

The conclusion from analysing the literature reviewed is that the understanding of obstetric violence in the United States and most other high-income countries needs a more solid foundation of research before the explication of higher-level theory that has more direct practice, policy, and legislative implications can be accomplished. I believe this research-based conclusion represents a conflict between the delay while building a strong empirical foundation to direct change and the non-empirical evidence that obstetric violence is a human rights violation that demands immediate action. This integrative review can serve as a current summation and starting point for researchers, and all interested and affected parties, who want to address the problem of obstetric violence in the context of their settings.

Acknowledgements

I would like to thank the reviewers for the time and consideration they gave to this paper from their diverse areas of expertise and points of view at different phases in its development. Thank you Darryl Ellison, Brie Thumm, and Sara Cohen Shabot. I would also like to thank the reviewers for publication who contributed to the final manuscript through their insightful, constructive, and thought-provoking feedback.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

* The terms childbearing person and birthing person are used throughout this work for language that is inclusive of those who do not identify as heteronormative, cisgender, binary, or mothers. The language chosen by original authors is used when referring to other publications and sources. The language for women and mothers is also used throughout this work because the construct of woman is essential to the attribute of obstetric violence that makes it a gendered, sex-specific form of violence against women. Gender-neutralising a problem that is a form of violence against women obfuscates a problem that is already challenged by its cultural, sociopolitical, and contextual complexities that are specific to female reproduction.