Written by Amruta Bavadekar, M. Sivakami
As the global community celebrates the 30th anniversary of the Beijing Declaration and Platform for Action (1995), which marked a pivotal moment in advancing women’s rights worldwide, the annual 16 Days of Activism Against Gender-Based Violence (GBV) ( November 25 – December 10) serves as a reminder of the persistent challenges women face in achieving of equality and justice. The 2024 theme, #NoExcuse, calls for a firm stand against all forms of violence and accountability for perpetrators (UN Women, 2024). However, obstetric violence (OBV) a form of maltreatment during childbirth remains largely invisible in these discussions. This gap reflects systemic failures to address violations of women’s autonomy and dignity in health care. Obstetric violence includes verbal abuse, coercion, non-consensual medical interventions, neglect and denial of care (Bowser & Hill, 2010). It perpetuates gender inequality and undermines public health efforts to improve maternal outcomes.
Rose Revolution Day, celebrated annually on November 25, highlights OBV during childbirth. Started in 2011 by women in Spain, the movement protests mistreatment such as non-consensual medical procedures and forced sterilizations (Sadler et al., 2016). Women place pink or red roses outside facilities where abuse occurred, sharing personal stories to break the silence and reveal hidden trauma. However, this issue remains underrepresented in global activism. Recognizing OBV as a critical aspect of GBV is necessary to achieve broader gender equality and to ensure that health care systems are held accountable for upholding women’s rights.
Cultural Roots of Obstetrical Violence
OBV is deeply embedded in the cultural fabric of health care systems, reflecting paternalistic attitudes and systemic disregard for women’s autonomy. Health care providers (HCPs) often justify coercive or non-consensual actions in terms of patients’ “best interests,” which reinforces their power and perpetuates harm (Freedman et al., 2014). This paternalism, combined with social norms that glorify medical authority, normalizes maltreatment during childbirth.
Freedman et al. (2014) argue that the perception of HCP as benevolent actors often shields them from scrutiny, allowing systemic abuses to continue. Women are often expected to comply with medical decisions without question, and their experiences of coercion or abuse are often dismissed as necessary to ensure safe childbirth. This dynamic disproportionately affects marginalized women, who face intersecting forms of discrimination based on class, caste or ethnicity.
Public Health Dimensions of Obstetrical Violence
The push for institutional births in India, led by programs such as the Janani Suraksha Yojana (2005), has significantly increased facility births, with 88% of women giving birth in institutions according to NFHS-5 (2019-21) . While this change has improved maternal and newborn survival rates, it has also exposed women to systematic abuse. Reports from states such as Bihar and Madhya Pradesh reveal widespread cases of verbal abuse, neglect and coercion during childbirth (Sinha et al., 2020).
Programs such as LaQshya (Workplace Quality Improvement Initiative, 2017) and SUMAN (Surakshit Matritva Aashwasan, 2019) focus on improving infrastructure and clinical care, but fall short in addressing interpersonal aspects of care. This divide perpetuates a culture where women’s dignity and autonomy are routinely compromised, reinforcing OBV as a public health issue.
OBV is not limited to public hospitals only. Evidence shows that private healthcare institutions also engage in coercive and neglectful practices, challenging the assumption that higher costs guarantee respectful care (Sivakami & Shrivastava, 2020). These systemic failures underscore the need to address obstetric violence as a critical public health issue that requires urgent attention.
Measurement challenges and opportunities
A lack of standardized measurement tools hampers efforts to address OBV. Current methods, such as clinical audits and patient surveys, often miss psychological abuse, coercion and neglect (Bohren et al., 2015). Drawing on the development of WHO domestic violence (IPV) measurement tools (WHO, 2005), later adapted to India’s National Family Health Survey (NFHS) to capture domestic violence and its health impacts (IIPS, 2021) , similar frameworks for OBV are needed to evaluate both clinical and interpersonal care.
While standardization is key, qualitative research is essential to capture women’s subjective experiences. Sen (2018) emphasizes that interviews and narratives reveal emotional and psychological harm, often overlooked in clinical data. Combining quantitative and qualitative methods can provide a more complete understanding of obstetric violence.
Actionable strategies
Addressing obstetric violence requires systemic reforms that prioritize respectful maternity care (RMC) and hold health care systems accountable for violations:
Integrate RMC into national policies:
Maternal health policies must explicitly include RMC as a fundamental right. Clear guidelines should mandate informed consent, patient-centered care, and protection of women’s dignity during childbirth.
Strengthening accountability mechanisms:
Health care institutions must establish complaint resolution systems that allow women to report mistreatment without fear of retaliation. Regular audits should assess compliance with RMC standards alongside clinical outcomes, with transparent procedures for dealing with breaches.
Mandatory training for healthcare providers:
Comprehensive training on gender sensitivity and RMC should be mandatory for all health professionals. This education must address the cultural roots of obstetric violence, emphasizing women’s autonomy and informed decision-making.
Community Education and Advocacy:
Empower women to demand respectful care through community-based awareness campaigns. Advocacy efforts should also target families and communities to challenge norms that normalize maltreatment during childbirth.
Developing robust measurement frameworks:
Standardized tools for measuring obstetric violence need to be developed and incorporated into national surveys such as the NFHS. Qualitative methods such as interviews and focus groups should complement these tools to capture the full scope of harm.
Integrating solutions into practice
The successful implementation of these strategies requires sustained political will and multi-sectoral cooperation. Governments must allocate resources to enforce RMC guidelines, train health care workers, and establish accountability systems. Civil society organizations can play a critical role in advocacy and capacity-building efforts, and researchers must continue to document and analyze women’s experiences to inform policy and practice.
By addressing the systemic and cultural dimensions of obstetric violence, we can ensure that all women receive respectful, dignified care during childbirth. This change will not only improve maternal health outcomes, but also affirm women’s rights to autonomy and dignity – key principles of gender equality.
References
Bohren, MA, Vogel, JP, Hunter, EC, Lutsiv, O., Makh, SK, Souza, JP, … & Gülmezoglu, AM (2015). Maltreatment of women during childbirth in health facilities worldwide: A mixed methods systematic review. PLoS Medicine, 12(6), e1001847.
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Freedman, LP, Ramsey, K., Abuya, T., Bellows, B., Ndwiga, C., Warren, CE, & Kruk, ME (2014). Defining abuse and abuse of women in childbirth: A research, policy and rights agenda. Bulletin of the World Health Organization, 92(12), 915–917.
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Sinha, K., Bhatia, P., & Verma, R. (2020). Assessing maltreatment and abuse during childbirth: Evidence from Bihar and Madhya Pradesh. Reproductive Health Issues, 17(1), 57–65.
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