Obstetric violence is an intersection between institutional violence – condoned, endorsed and/or perpetuated by the state- and violence against women during pregnancy, childbirth and postpartum. It can be manifested in several ways:
• the denial of treatment during childbirth
• forced coerced medical interventions that accelerate the natural process of birth, such as the Kisteller manoeuvre, without a free, informed and expressed consent of the woman,
• disregard of a woman’s needs and pains and/or verbal humiliations before, during and after birth,
• invasive practices,
• physical violence,
• unnecessary use of medication,
• forced unnecessary caesarean section,
• forced unnecessary episiotomy,
• forcing a woman to give birth lying on her back with her feet in stirrups,
• dehumanizing or rude treatment,
• exposing a woman naked in front of many subjects,
• separating a mother from her newborn without medical reason,
• not including a woman in decisions concerning her body and her birth.
In these cases, the woman’s fundamental right to participate actively in the process of pregnancy and childbirth and to decide in a free and conscious way concerning her own body, is limited.
Although, obstetric violence is a serious act of violence with extreme consequences such as degrading and inhumane childbirth, health complications, severe psychological distress, trauma and in some cases death due to neglect, it is often overlooked and normalized. States are responsible for institutional violence when women are denied access to health care, treated inhumanely, forced or coerced into unnecessary medical procedures or when denied the right to choose them. Consequently, governments are obliged to address this problem and to implement the international treaties.
Obstetric violence in Italy
In Italy, this serious form of gender-based violence is widespread yet still ignored. In the last two years, many women have been coming out with their experiences of obstetric violence.
In March 2016, Adriano Zaccagnini of the Democratic Progressive Movement presented the law proposal “Norms for the Protection of the Rights of Women and Newborns in Childbirth and Regulation for the Promotion of Physiological Birth” to promote the recognition of obstetric violence as a criminal offense, since without judicial recognition it is very difficult for women to seek legal redress. Directly connected to the law proposal, the #bastatacere campaign (break the silence) gathered about 3.000 obstetric violence stories through a web questionnaire to get a clear idea of the extent of the phenomenon, to invite women to stand up for their right to be free from any form of violence during and after labour and to draw the public and institutional attention to the phenomenon of obstetric violence. Women responded in such a short time frame that the campaign went viral. The Doxa survey “Women and Childbirth” was conducted on a sample representative of nearly 5 million women in Italy, aged 18-54, with at least one child 0-14 years, analyzing several aspects concerning maternity assistance during labour and birth as the relationship with the health care providers to the type of interventions, the communication by caregivers to informed consent, the role of women in the process of decision making and the respect of personal dignity. The survey revealed that for 4 women out of 10 (41%) the assistance provided at birth in some ways violated their dignity and psychophysical integrity. The most negative experience during birth was the practice of episiotomy by deceit (without informed consent), suffered by over half (54%) of the interviewees. The episiotomy is a surgical intervention in the muscular area between the vagina and the anus made just before delivery to enlarge a vaginal opening. Comparing to the spontaneous tearing that may occur during childbirth, this operation requires a longer recovery time and it carries the risks of infection and hemorrhage. Once considered as helpful for facilitating the expulsion of the newborn, today, the World Health Organization describes it as unnecessary, except on rare occasions.
This data raised awareness that obstetric violence is much wider and more serious than people can imagine. Those who experienced obstetric violence, in particular episiotomy, will have this trauma and scars for the rest of her life. Many women renounced even to have more children. For 15% of women that underwent the procedure, about 400.000 mothers, it was perceived as a genital mutilation, while 13% of mothers, about 350.000, felt deceived by medical personnel. Acts of obstetric violence also involve use of instruments as forceps and movements, such as the Kristeller maneuver, which are risky and can lead to the mortality of the mother and baby. In many cases, the obstrician literally jumped on the top of the woman to accelerate the expulsion of the baby causing vaginal and perianal injuries, uterus rupture, palcenta abruption and broken ribs. In 2016, Alessandra Battisti, an Italian lawyer and activist, together with Elena Skoko, an activist and researcher, co-founded a civil society Obstetric Violence Observatory (OVO) to empower women and lobby healthcare and political institutions to address this issue.
According to the Italian National Health Institute, there are 259 cases of “near misses” every year in Italy, while the maternal mortality rate is underestimated by 60%.
Although an observatory on obstetric violence was implemented, the legislation on criminalizing obstetric violence has not passed. The concept of obstetric violence is far from receiving sufficient critical examination within health care and public policy. There is no willingness among policy makers for making a real change in maternity care provision, improving birth care policies and practices in the respect of the women´s dignity and the right to participate actively, making informed and free decisions.
Women´s sexual and reproductive rights are human rights
As stated by the World Health Organization (WHO) and by the United Nations High Commissioner for Human Rights (UNHCHR), the abuse, the negligence and the lack of respect during childbirth represent a violation of basic human rights of the woman and the child, putting their lives and their security at risk. Consequently, obstetric violence is a grave violation of human rights, as the right to equality, freedom from discrimination, information, integrity, health, and reproductive autonomy.
In 2014, the WHO addressed this issue by stating that “every woman has the right to the highest attainable standard of health, which includes the right to dignified, respectful health care throughout pregnancy and childbirth”. Therefeore, it is important to prevent and eliminate disrespect and abuse during facility-based childbirth, since “such treatment not only violates the rights of women to respectful care, but can also threaten their rights to life, health, bodily integrity, and freedom from discrimination”. The ill-treatment and abuse of women in labour manifests itself in the fact that women are often coerced to accept certain medical procedures that they would have preferred to avoid otherwise, as well as in the denial of services. Moreover, according to WHO, caesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates. Rather the contrary, it is stressed how caesarean sections can cause significant complications, disability or death. The denial of access to good quality medical care, sexual and reproductive health services and rights and inhumane treatment has consequences such as severe psychological distress, trauma and in some cases death due to neglect.
Under international human rights law, states have rigorous and absolute obligations to protect women’s sexual and reproductive lives. Human rights mechanisms have repeatedly recognised that women face particular forms of ill-treatment in health care settings, concerning their sexuality, reproductive capacities and decisions. These violations can cause tremendous and lasting physical and emotional suffering, with grave consequences for women’s personal and bodily integrity, their physical and mental health, and their emotional well-being.
Right to life – The right to life is enshrined in Article 2 of the European Convention on Human Rights and Article 6 of the International Covenant on Civil and Political Rights (ICCPR). Obligations to guarantee women’s equal enjoyment of the right to life also derive from Articles 1 and 2 of CEDAW. The right to life protects women from arbitrary and preventable loss of life and is engaged when states fail to take effective measures to address sexual and reproductive health and rights deficits that expose women to life-threatening risks. For example, guaranteeing women’s right to life requires states to take effective action to prevent maternal mortality, by ensuring women’s access to acceptable, affordable and good quality maternal health services such as emergency obstetric care and skilled birth attendants.
Right to health– Right to health is enshrined in article 12 of the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) according to which every woman has the right to access to high quality health care during childbirth. States have the obligation to take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure equal access to health care services. States have to ensure to women appropriate services in connection with pregnancy, confinement and the post-natal period. The right to health, namely the right to enjoyment of the highest attainable standard of physical and mental health, is enshrined also in article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR), article 24 of the United Nations Convention on the Rights of the Child, article 25 of the Convention on the Rights of Persons with Disabilities and article 12 of the Revised European Social Charter. Women’s right to sexual and reproductive health is an essential part of their right to health. Indeed, the Committee on Economic, Social and Cultural Rights (CESCR) stated in its General Comment on the right to sexual and reproductive health that the right to sexual and reproductive health “entails a set of freedoms and entitlements. The freedoms include the right to make free and responsible decisions and choices, free of violence, coercion and discrimination, regarding matters concerning one’s body and sexual and reproductive health. The entitlements include unhindered access to a whole range of health facilities, goods, services and information, which ensure all people full enjoyment of the right to sexual and reproductive health” (GR No.22/2016).
The right to freedom from torture and ill-treatment – The right to freedom from torture and ill-treatment is enshrined in Article 3 of the European Convention Human Rights, Article 7 of the International Covenant on Civil and Political Rights (ICCPR), and Article 16 of the United Nations Convention against Torture (UNCAT). The right to freedom from torture and ill-treatment requires states to refrain from such treatment and, consequently, states have to implement laws, policies and practices concerning sexual and reproductive health to prevent torture and ill-treatment, eliminating those that might expose women to intense physical or mental suffering or feelings of humiliation. As a result, states have the obligation to eliminate coercive sexual and reproductive health care practices that are carried out in the course of childbirth without women’s informed consent and give rise to various forms of physical and psychological suffering. States have also to eradicate serious forms of verbal abuse and discriminatory treatment in sexual and reproductive health care settings which can cause women intense feelings of humiliation or other forms of psychological suffering.
Women’s rights to freedom from torture and ill-treatment must always be given precedence on social considerations and political, economic or public health concerns and there can never be attempts to “balance” those rights with other rights or state interests. Therefore, ensuring women’s access to quality maternal health care throughout pregnancy, including access to ante-natal and post-natal care and obstetric services, is a crucial component of states’ human rights obligations.
Italy ratified the aforementioned treaties. Consequently, Italy has to address obstetric violence as human rights violation by ensuring respectful and humane treatment, improving the quality of maternal care, protecting women and children´s rights before, during and after childbirth, defining what constitutes mistreatment during childbirth and developing effective interventions and policies to address this mistreatment in all its forms.
By Chiara Paganelli , WAVE Intern