Written by Jenna Murray de López, Programme Director of HCRI’s MA in Humanitarianism and Conflict Response. 
jenna.murray@manchester.ac.uk

Measuring the quality of maternal health outcomes is not isolated to the moment of birth. As Dr. Princess Nothemba Simelela (WHO Assistant Director-General for Family, Women, Children and Adolescents) recently stated: A good birth goes beyond have a healthy baby. A new WHO guideline released in February 2018 demonstrates that global health governance is finally coming to terms with the idea that quality and equity in maternal health is more than just a mortality numbers game. Something that midwives and medical anthropologists have been arguing for decades.

An emerging challenge to our understanding of why women die as a consequence of childbearing is a phenomenon referred to as part of the obstetric transition – moving from the natural history of pregnancy and childbirth towards institutionalization of maternity care, increasing rates of obstetric intervention and eventual over-medicalization. Whilst increasing access to hospitals in low to middle income countries (LMICs) is improving maternal mortality in the core stages of labour, the growth in obstetric intervention is paradoxically causing an increase in late maternal mortality (deaths that occur more than 42 days but less than one year after the termination of pregnancy). In short, it is now recognised that the obstetric transition does not equate to better quality in care and improvements in mortality. This recognition is to be celebrated; however, in the rush for evidence-based medicine fans to pat themselves on the back, we are in danger of losing sight of non-mortality implications of obstetric transition, that impact on women’s health throughout the life-course.

Abuse and Mistreatment in Childbearing

In 2014 the WHO declared the mistreatment of women during childbirth and associated human rights violations a ‘global problem’. The issue was further highlighted in 2015, as UN and regional human rights experts issued a joint statement explicitly calling on states to address ‘acts of obstetric and institutional violence’. Despite this, international and regional standards on abuse and mistreatment of women during birth remain in the early stages of development. Moreover, the testimonies of women who are subject to violence remain on the periphery of knowledge and drivers of change.

Naming Obstetric Violence

Ideas, arguments and debates about mistreatment and abuse during childbirth have been most developed in Latin America, where the term Obstetric Violence grew out of activist movements in Venezuela, Argentina and, more recently, Mexico. Though the terminology has been contested by global health institutions, obstetric violence is a term well suited to the Latin American context. Recognised as a form of gender-based violence (GBV), it has been incorporated into national legislation aimed at women’s rights to live a life free from violence. As a collection of acts and consequences obstetric violence is now clearly defined, yet it remains little understood in terms of the direct impact on women, and the inherent muddiness between emergency medical treatment and systemic misuse of intervention. At least by naming the abuse as violence, broader links can be made to societal influence outside of the institution.

My own research in Mexico argues that it is a form of GBV precisely because it is done to women because of who they are (biological reproducers) and what they represent (moral subjects). Obstetric violence violates women’s reproductive health rights, and results in physical or psychological harm during pregnancy, birth and postpartum. The measurable signs of a violent and dysfunctional system in Mexico include a 50% caesarean section rate in the public sector, with estimates of up to 85% in the private hospitals; and episiotomy as routine practice.  Perpetrators of obstetric violence can be lead clinicians, though they can also be nurses, student doctors and other support staff – regardless of gender. Obstetric violence earned its name because it happens within the space of obstetric logic, it happens as a direct consequence of the obstetric transition.

Obstetric violence is both direct and structural and this means it is complicated. Large public facilities in LMICs (and beyond) are understaffed and understocked, providing a stressful environment where professionals are unable to ensure levels of care that are kind and respectful. Unlike other forms of violence, treating perpetrators of obstetric violence as criminals detracts from the problem that is inherently structural. Imposing criminal sanctions on health personnel who commit acts owing to serious weaknesses in the health system leaves the causes at the heart of the phenomenon unresolved, resulting in inefficient measures to resolve incidents of violence. All the whilst the pressure to improve maternal mortality rates and meet global development goals mean that women in LMICs are left with little choice but to be treated in an environment that will no doubt scar them in some way for life.

The right to live or die, receive respectful medical care and have autonomy throughout pregnancy, birth and puerperium are heavily loaded concepts when so much is at stake politically and professionally. The stitches from unnecessary interventions may only take weeks to heal but as is evident in the wealth of testimonies coming out of Mexico the trauma of abuse will last throughout the life-course.

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