Ending the abuse: the human rights implications of obstetric violence and the promise of rights-based policy to realise respectful maternity care

In September 2019, Dubravka Šimonovic, the United Nations (UN) Special Rapporteur on violence against women (VAW), submitted her report to the UN General Assembly on “mistreatment and VAW during reproductive health services with a focus on childbirth and obstetric violence”. This report solidified obstetric violence as a form of VAW – a human rights violation to be addressed by the UN, rather than solely a matter of quality of care for maternal health professionals. The positioning opens new channels for interdisciplinary advocacy to be translated into multisectoral policy. However, the risk is that rights-based approaches remain siloed within the human rights community, rather than serving as a foundation for broad-based policy reforms.

Effectively addressing obstetric violence will require collaborative multisectoral efforts, at the nexus of global health and human rights, to respect, protect, and fulfil the intersecting rights violated when health providers disrespect, abuse, or mistreat women seeking sexual and reproductive health (SRH) care. The sexual and reproductive health and rights (SRHR) community has a crucial role in ensuring that efforts to eliminate obstetric violence are grounded in a rich contextual understanding of the underlying factors that contribute to mistreatment. This opens the opportunity to work with a broad set of health and human rights actors, so that appropriate norms and metrics are developed and implemented for accountability.

Building from the report of the Special Rapporteur, this commentary outlines the interdisciplinary scholarship and advocacy around obstetric violence, examines mistreatment in SRH services as an intersectional human rights violation, and provides policy recommendations for strengthening multisectoral efforts to ensure respectful maternity care for all.

Elevating obstetric violence on the global health governance agenda

In the 1980s and 1990s, advocates in Latin America began organising against non-evidence-based medicalisation of birth, calling for a “humanised” approach to care. In 2000, Latin American feminist collectives, women’s rights advocates, and public health professionals at the First International Conference on the Humanization of Birth developed the first shared understanding of mistreatment of women in childbirth as a form of gender-based violence, dubbing this harm “obstetric violence”.¹

In 2015, the World Health Organization (WHO) synthesised existing research, establishing an evidence-based typology of forms of mistreatment.² Bridging maternal health and human rights, in 2016, WHO delineated the human rights standards and international laws violated by various types of mistreatment.³ These two publications elevated obstetric violence on the global health governance agenda.

In 2018, the Reproductive Health Matters themed issue on “disrespect and abuse in maternal care” centred on improving empirical research on obstetric violence and enriching understanding of related structural factors.⁴ Such scholarly work is generating robust public health evidence around obstetric violence, laying the groundwork to move from describing the problem to developing rights-based policy for alleviation.

Obstetric violence and the human rights obligations of states

Human rights provide a means to operationalise international norms through national policy. When mistreatment in sexual and reproductive health care, including childbirth, is seen as a violation of human rights, the “rights-based approach” empowers individuals to seek redress for rights violations rather than serve as passive recipients of government benevolence, shifting the policy debate from political aspiration to legal accountability.⁵ As a foundation for rights-based accountability, conceptualising obstetric violence at the nexus of multiple human rights violations can provide a framework across human rights to address this intersectional reproductive health harm.

Sexual and reproductive health is central to human rights, reflecting the need for dignity, substantive equality, and autonomy in reproductive decision-making. Protections against discrimination have long supported women’s rights under international law, beginning with language barring sex-based discrimination in the 1948 Universal Declaration of Human Rights and codified seminally in the 1979 Convention on the Elimination of all Forms of Discrimination Against Women. Yet intersectional sexual and reproductive rights were not explicitly declared internationally until the 1990s.⁶ The 1994 International Conference on Population and Development Programme of Action unequivocally declared that reproductive rights are human rights and paved the way for jurisprudence that recognised mistreatment in SRH care at the intersection of multiple concurrent human rights violations.⁷

In line with subsequent jurisprudence on sexual and reproductive rights, as well as international law regarding VAW, obstetric violence is understood to simultaneously violate an encompassing set of human rights, which include the rights to health, privacy, freedom from discrimination, freedom from violence, and freedom from torture and other ill-treatment, among others.³

Governments bear obligations to respect, protect, and fulfil rights. This means that governments must ensure that the human rights implicated by obstetric violence are respected within public sector health facilities, but also that women are protected from abuse when they seek care in the private sector. Governments must take positive action to fulfil rights obligations, for example by ensuring that survivors of obstetric violence can access effective remedies. The Special Rapporteur’s report highlights these obligations and provides specific recommendations for States to meet them. Yet developing and implementing a comprehensive human rights approach will necessitate broad interdisciplinary collaboration in framing State obligations and designing multisectoral policies to redress obstetric mistreatment.

The promise of rights-based policy

Developing rights-based policy that addresses obstetric violence is contingent on building broad-based support for the elimination of disrespect and abuse in SRH care settings. The work of WHO and the Special Rapporteur on VAW has begun to create a shared interdisciplinary understanding of obstetric violence as a health and human rights violation. Additional UN special rapporteurs across related thematic areas, including Special Rapporteurs on the rights of persons with disabilities, the rights of indigenous peoples, the human rights of migrants, and the right to health, can bring complementary human rights to bear, supporting the development of a truly intersectional rights-based policy approach to respectful maternity care. Beyond these thematic human rights officials and complementing the treaty-specific interpretations of human rights treaty bodies, is the role of SRHR practitioners.

As experts on the underlying drivers of obstetric violence, the SRHR community has a powerful role in the continuing evolution of human rights to promote public health. A nuanced understanding of the structural determinants that underpin obstetric violence¹ can and should inform the analysis of which human rights are violated and, building from the Special Rapporteur’s report, how public policies can respect, protect, and fulfil rights. Expanding partnerships with the human rights system can help to strengthen this work of SRH professionals, catalysing international and national advocacy that is grounded simultaneously in public health evidence and human rights law.

The development of interconnected health and human rights norms can help set standards that influence policymakers. WHO has begun the process in global health governance but these efforts must be integrated across the sectors devoted to SRHR, establishing inter-organisational partnerships with both UNFPA and the Office of the UN High Commissioner for Human Rights.⁸ To facilitate accountability, common metrics are needed to monitor the extent of the problem and to review progress toward its elimination. For example, key indicators of obstetric mistreatment could be incorporated into the health data reviewed by human rights treaty bodies, Sustainable Development Goal targets, and the Universal Periodic Review. These metrics can also be assessed by civil society organisations, national human rights institutions, and gender-based violence agencies to facilitate accountability at the national level.

Conclusion

Beginning in the 1980s, work to name and eliminate mistreatment and abuse in SRH services has spanned multiple disciplines and sectors. This is fitting, as obstetric violence raises multiple concurrent and intersecting human rights violations. Developing adequate responses, then, requires multisectoral collaboration. The SRHR community has much to offer and much to gain. Advancing partnerships across the human rights community can yield shared norms and metrics that reflect both public health evidence and human rights standards. Such norms and metrics can subsequently be used to monitor the progressive realisation of rights as a means to facilitate accountability. Policy reforms to strengthen protections against obstetric violence can be extended to enhance protections for other sexual and reproductive rights, particularly those that reflect intersections across multiple human rights. Expanding the community of practice around ensuring safe and respectful maternity care for all can help to accelerate progress to end obstetric violence.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Caitlin R. Williams http://orcid.org/0000-0002-4925-869X