The Whatness of Obstetric Violence: How reframing violent practices in UK maternity wards helps us to tackle them

By: Frances Hand

Childbirth is often heralded as a joyful occasion.¹ Yet, the 2022 Health Strategy for England report suggests that pregnancy-related care is the second most important sector in need of dramatic change.²The current state of affairs has had devastating consequences. According to the 2022 Kirkup report, 46.9% of NHS cases involving maternal morbidity and mortality could have been prevented through implementing nationally recognised standards of care.³ Equally, around 28,000 women in the UK experience maternal PTSD every year, making this a ‘significant public health concern’.⁴

Yet, such statistics only reveal the tip of an insidious iceberg of behaviours and practices, performed by healthcare professionals, or facilitated through medical structures, which harm women who use publicly funded maternity services.⁵ Informed by victim testimony, I have re-conceptualised the nature of violence committed against women during childbirth. I term this the ‘whatness’ of obstetric violence; which is formulated through experiences of disempowerment, vulnerability and shame. In this article, I will briefly explore the range of experiences of obstetric violence, before explaining how recognition of this treatment as gender-based violence brings attention to these currently invisible harms, as part of international law.

The ’Whatness’ of Obstetric Violence

The primary issue is that there currently exists no global definition for the harms experienced by pregnant women in maternity wards. The term ‘obstetric violence’ has not yet been recognised within UK law or policy. Instead, claims that violence is committed against women in NHS maternity wards are often met with backlash from medical professionals, who consider its use an affront to their professional integrity, and an inaccurate description of the often unintentional maltreatment suffered by women.⁶ However, I argue that the term ‘obstetric violence’ is not only necessary as a disruptive and uncomfortable term, used to highlight previously invisible harms, but it also allows us to explore how structural elements of obstetric practice, such as historic under-funding or unreachable Trust-mandated targets, create an environment that perpetuates violence against women. In such cases, behaviours and practices by medical professionals are merely symptomatic of wider structural problems. My thesis examines three core elements of the harm experienced by women. Disempowerment occurs when a woman has an inability to disable others from exerting influence over her.⁷ Women continue to experience a systemic lack of credibility within the public healthcare system. 84% of women in the 2022 Women’s Health Strategy for England report stated that they were not listened to during their procedures.⁸ As one example, the 2022 Kirkup report highlights how women were given epidurals which failed, yet when they voiced their concerns these were ignored. One woman recounted her experience:

‘they didn’t listen… they carried on…to cut me open. I could feel it all’.⁹

In the context of childbirth, an examination of vulnerability can capture how medical structures increase distress related to childbirth.¹⁰ Currently, maternity practices are chronically understaffed,¹¹ which left one woman in labour for six days after being induced, as they did not have enough staff to move her to the labour ward.¹²

Finally, I explore how shame is used to coerce women to undergo procedures which have long-term health consequences.¹³ This is often fuelled by an idealised notion that motherhood dictates self-sacrifice, even if it results in a minor or non-existent increase in the safety of the foetus.¹⁴ Testimonies describe women being ‘bullied’ and ‘brow-beaten’ into agreeing to courses of conduct.¹⁵ Yet, the social significance of these behaviours is often missed by doctors, who equate coercive tactics with direct threats around medical treatment. One obstetrician argued:  

‘I don’t think [repeated rounds of counselling about risk] ever becomes coercive…if we don’t say no…we don’t coerce them’.¹⁶

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Across this plethora of scenarios I explore how women collectively experience these harms as intense violations of their physical and mental integrity, which often result in long-term health consequences and an inability to form relationships with their baby, support network, and the outside world. This is concurrent with wider trauma literature on the impact of traumatic events.¹⁷ Yet our treatment of pregnant women must be called into question when around one third of women describe their birth as traumatic,¹⁸ and yet legal examination of such cases is sporadic and conducted on an individualistic basis.¹⁹ What testimonies teach us is that regardless of the objective severity of bodily harm suffered, these practices are both widespread and contain all the hallmarks of violence.

Conclusion: Informing human rights responses

Obstetric Violence requires state-level responses in order to truly tackle its structural elements.²⁰ The UK has ratified international law which requires them to take positive steps to protect women from violence.²¹ Current strategies are not enough and women continue to be hurt or die unnecessarily. By expanding our understanding of violence to encompass the experiences highlighted, we can demand that the state take greater action to prevent what is, in reality, a systemic form of gendered violence.

1. Jenny Patterson, Caroline Hollins Martin and Thanos Karatzias, Disempowered midwives and traumatised women: exploring the parallel processes of care provider interaction that contribute to women developing Post Traumatic Stress Disorder (PTSD) post childbirth, Midwifery 76 (2019) 21, 24; Ndola Prata, Paula Tavrow and Ushma Upadhyay, ‘Women’s Empowerment Related to Pregnancy and Childbirth: Introduction to Special Issue’ (2017) 17 BMC Pregnancy and Childbirth 352. ↩︎
2. Department of Health and Social Care, ‘Women’s Health Strategy for England’ Report (30 August 2022) < https://www.gov.uk/government/publications/womens-health-strategy-for-england/womens-health-strategy-for-england#ministerial-foreword> accessed 27 February 2023, section 12. ↩︎
3. Bill Kirkup, Maternity and neonatal services in East Kent: ‘Reading the signals’ report (2022). ↩︎
4. ‘Maternal PTSD could affect up to 28,000 women in the UK each year, says new review’ (City, University of London, 20 February 2017) <https://www.city.ac.uk/news-and-events/news/2017/02/maternal-ptsd-could-affect-up-to-28000-women-in-the-uk-each-year-says-new-review#:~:text=says%20new%20review-,Maternal%20PTSD%20could%20affect%20up%20to%2028%2C000%20women%20in%20the,warrants%20routine%20screening%20and%20treatment> accessed 16 November 2023;  Ayers et al, ‘Traumatic birth and childbirth-related post-traumatic stress disorder: International expert consensus recommendations for practice, policy, and research’ (2023) Women and Birth (in press). ↩︎
5. Frances Hand, ‘Ockenden and Beyond: The Potential for a Human Rights Approach to Tackling Obstetric Violence’ (Oxford Human Rights Hub, 2 November 2022) <https://ohrh.law.ox.ac.uk/ockenden-and-beyond-the-potential-for-a-human-rights-approach-to-tackling-obstetric-violence/> accessed 7 December 2022 ↩︎
6. Giovanni Scambia et al, ‘“Obstetric Violence”: Between Misunderstanding and Mystification’ (2018) 228 European Journal of Obstetrics & Gynecology and Reproductive Biology 331; Chuck Dinerstein MD ‘Obstetric Violence: New Legal Phrase that hurts more than it helps (American Council on Science and Health 2018); Shapiro, J. (2018). “Violence” in medicine: Necessary and unnecessary, intentional and unintentional. Philosophy, Ethics, and Humanities in Medicine, 13(7), 1. ↩︎
7. To form this definition I have taken inspiration from Alfred Archer et al, ‘Celebrity, Democracy, and Epistemic Power’ (2020) 18 Perspectives on Politics 27, 29. ↩︎
8. Of almost 100,000 interviews: ‘Women’s Health Strategy for England’ Report (n 2), Ministerial foreword. ↩︎
9. “Reading the Signals” Report (n 3) [1.32]. ↩︎
10. [1] Martha Fineman ‘The vulnerable subject: Anchoring equality in the human condition’. (2008) 20 Yale Journal of Law and Feminism 1vulnerability is a ‘ universal, inevitable, enduring aspect of the human condition; Martha Fineman, ‘Feminism, Masculinities and Multiple Identities’, (2013) 13 Nevada Law Review 101, 119 “[W]e are born, live, and die within a fragile materiality that renders all of us constantly susceptible to destructive external forces and internal disintegration”. ↩︎
11. Royal College of Midwives, ‘RCM warns of worsening maternity crisis as senior midwife survey shows services at boiling point’ (RCM, 26 January 2023) https://www.rcm.org.uk/media-releases/2023/january/rcm-warns-of-worsening-maternity-crisis-as-senior-midwife-survey-shows-services-at-boiling-point/#:~:text=Chronic%20understaffing%20is%20hitting%20the,a%20matter%20of%20real%20urgency. accessed 26 November 2023. ↩︎
12. Healthwatch, Left unchecked – why maternal mental health matters (2023),10. ↩︎
13. Sara Cohen Shabot  and Keshet Korem, ‘Domesticating Bodies: The Role of Shame in Obstetric Violence’ (2020) 33 Hypatia 384; Hannah Kaplenko, Jennifer Loveland and Chitra Raghavan, ‘Relationships Between Shame, Restrictiveness, Authoritativeness, and Coercive Control in Men Mandated to a Domestic Violence Offenders Program’ (2018) 33 Violence and Victims 296; Anne Drapkin Lyerly, ‘Shame, Gender, Birth’ (2020) 21 Hypatia 101. ↩︎
14. Camilla Pickles and Jonathan Herring, Childbirth, Vulnerability and Law: Exploring Issues of Violence and Control (Routledge 2019), 220; 251. ↩︎
15. Birthrights, Holding It All Together: Understanding how far the human rights of women facing disadvantage are respected during pregnancy, birth and postnatal care (2019), 35. ↩︎
16. Bec Jenkinson, Sue Kruske and Sue Kildea, ‘The experiences of women, midwives and obstetricians when women decline recommended maternity care: A feminist thematic analysis’ (2017) 52 Midwifery 1. ↩︎
17. Michael Weinberg and others, ‘Marital satisfaction and trauma-related symptoms among injured survivors of terror attacks and their spouses’ (2017) 35 Journal of Social and Personal Relationships 395; Susan Brison, Aftermath: Violence and the Remaking of a Self (Princeton University Press 2002); J. Brison Susan, ‘Justice and Gender-Based Violence’ (2013) n° 265 Revue internationale de philosophie 259. ↩︎
18. Pauline Slade, Andrea Murphy and Emma Hayden, ‘Identifying post-traumatic stress disorder after childbirth’ (2022) 377 British Medical Journal e067659; Rachel Reed et al, ‘Women’s descriptions of childbirth trauma relating to care provider actions and interactions’ (2017) 17 BMC Pregnancy Childbirth 1; Elizabeth Sutton and others, Women’s Expectations About Birth, Requests for Pain Relief in Labor and the Subsequent Development of Birth Dissonance and Trauma (Research Square, unpublished 2022); Liz Kelly, Surviving Sexual Violence (Polity 1988). ↩︎
19. See e.g. Operation Lincoln, an active police investigation into 600, individualised cases of medical negligence: Sajid Javid, ‘Ockenden Report: Statement by the Secretary of State for Health and Social Care’ (Sajid Javid MP, 30 March 2022) <https://www.sajidjavid.com/news/ockenden-report-statement-secretary-state-health-and-social-care> accessed 17 October 2022. ↩︎
20. See e.g. Committee on Economic Social and Cultural Rights, General Comment No 3: The Nature of States Parties’ Obligations. ↩︎
21. The United Kingdom is a signatory state to two Conventions which focus on protecting women from violence: Convention on the Elimination of all forms of Discrimination Against Women; The Council of Europe Convention on Preventing and Combating Violence against Women and Domestic Abuse (Istanbul Convention). ↩︎