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

Figures & data

Figure 1: PRISMA flowsheet

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

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.

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.

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