‘Everything is Obstetric Violence Now’: Identifying the Violence in ‘Obstetric Violence’ to Strengthen Socio-legal Reform Efforts

Abstract

1. Introduction

‘Obstetric violence’ names a previously unnamed and widely unrecognised harmful social phenomenon: violence and abuse during childbirth in healthcare facilities.¹ It is rooted in a gender-based violence framework and exposes institutional violence in formal maternity care settings.² The concept names the everydayness of broadly accepted maternity care services as violence, with a particular focus on approaches to maternity services that dehumanise women, trans and non-binary people. ‘Obstetric violence’ is a prized political concept with rich transformative potential³ evidenced in its broader feminist activism across the globe,⁴ in its introduction into legislation on gender-based violence⁵ and in the international recognition of obstetric violence as a particular form of gender-based violence against women.⁶ Broader international recognition introduces very clear human rights obligations on governments to prevent and respond to obstetric violence and the law is identified as a key role player in the context of social reform obligations.⁷

Accepting the law to be an important mechanism for social reform, the analysis presented in this article seeks to support the feminist agenda to ensure effective legal uptake of ‘obstetric violence’, specifically in respect to jurisdictions where socio-legal reform is still needed. Before legislating on obstetric violence, however, socio-legal scholars need to know what counts as ‘obstetric violence’. However, this is a particularly challenging project, and the article seeks to contribute to this foundational concern by considering where the violence lies in obstetric violence.

With the increased acceptance and application of ‘obstetric violence’ by activists and researchers beyond the Latin American context, ‘obstetric violence’ runs the risk of becoming an overgeneralised and nebulous concept.⁸ The finer details of what obstetric violence is (or is not) are missing, its start and end points cannot be identified with a measure of certainty, and it is not clear how obstetric violence links to or overlaps with other forms of violence in reproductive health services. The literature published in the English language rarely interacts with theoretical underpinnings that could help to explain this form of violence and its apparent growing reach.⁹

Arguedas Ramirez emphasises that deep theoretical engagement is necessary to meaningfully understand ‘obstetric violence’ because when that understanding is missing, it opens the door to depoliticisation of the issue and rejection of the concept.¹⁰ That is, rejection of ‘obstetric violence’ allows people to deny the existence of the phenomenon and this translates into denying women’s experiences, rejecting women as authoritative and moral agents, and this, in turn, denies women access to justice.¹¹

This article aims to inject a measure of conceptual certainty with a view to facilitate a theoretically grounded understanding of ‘obstetric violence’ to support social reform through legal reform strategies and productive socio-legal uptake of ‘obstetric violence’. I define the violence in ‘obstetric violence’ with reference to Bufacchi’s framing of violence as a violation of integrity,¹² and this provides a universal thread that explains where the violence lies. I then reflect on how taking a ‘view from everywhere’¹³ can allow us to particularise the universal thread to accommodate intersectional specifics and differences relevant to local communities, and to create the possibility to centre systematically marginalised voices in the process of recognising violence. I recommend introducing conceptual limits to ‘obstetric violence’ and take guidance from the approach adopted in Latin America: for instance, recognising that the violence targets women and birthing bodies, and that it takes place in the specific context of antenatal, intrapartum and postpartum care. While this approach helps to separate obstetric violence from other violence in reproductive healthcare, I position it on the ‘continuum of violence’¹⁴ in reproductive healthcare to highlight the possible links and overlaps with other instances of reproductive violence. This approach recognises that obstetric violence cannot be neatly separated out from other violences in reproductive healthcare.

To start, however, I consider the historical roots of ‘obstetric violence’, then demonstrate how I come to interpret ‘obstetric violence’ as an overgeneralised and nebulous concept, before considering some of the implications of this status in the context of broader efforts to effect on-the-ground change.

2. The Rise of ‘Obstetric Violence’

‘Obstetric violence’ is a concept that developed from the Latin American socio-political context, and it gained regional¹⁵ and international¹⁶ traction when Venezuela formally recognised it as a particular form of violence against women. Article 15 of the Venezuelan Organic Law on the Right of Women to a Life Free from Violence (2007) describes it as

the appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, an abuse of medication, and to convert the natural processes into pathological ones, bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women.¹⁷

The legal recognition of obstetric violence and the attachment of legal consequences to its incidence is the result of successful grassroots feminist activism aimed at promoting and protecting women’s sexual and reproductive rights during childbirth.¹⁸ Childbirth was, and remains, an urgent and necessary focal point of activism because many experience their ‘care’ as violence or abuse, and the dominant position of a biomedical approach to childbirth leaves little to no room for women to give birth according to personal needs, in culturally relevant ways or in more supportive environments.¹⁹

Contemporary concerns about violations during childbirth and the biomedical dominance of childbirth can be traced to the historical masculinisation and monopolisation of healing work, which was spread and enforced through colonisation.²⁰ Deep-rooted sexist, racist and colonial ideologies informed the emergent androcentric understanding of health and privileged healthcare professionals as authoritative agents in the provision of care.²¹ Ultimately, women and other marginalised Indigenous groups were expelled as legitimate healers and sources of relevant knowledge in the fields of health and healing. The specialist field of obstetrics emerged under this paradigm, resulting in a ‘colonization of the womb’,²² and obstetrics came to inform social perceptions of legitimate knowledge in reproductive healthcare and of what counts as ‘normal’ childbirth processes.²³ The determined delegitimisation of other knowledge systems cleared the way for obstetric dominance and control over women and childbirth where women are ‘made passive and silenced within hierarchical and authoritarian structures of a medical specialty—Ob-Gyn—that is deeply patriarchal in its historical origin, medical practice and socio-clinical interactions’.²⁴

A biomedical approach to childbirth treats it as a pathology, and this strips birth of its physiological character and its richly diverse socio-cultural significance.²⁵ Pathologisation supports a highly medicalised and interventionist approach to childbirth, which translates into the medical appropriation of women’s bodies and reproductive processes.²⁶ Broader social knowledge about pregnancy and childbirth is determined according to obstetric knowledge, and childbirth is the object of clinical control and direction, leading to the sustained erasure of women, their embodied knowledge, lived experiences, and individual and communal needs.²⁷

In Latin America, the systemic sidelining of women and their needs was the core focus of the humanisation birth movement, a movement that came to life in Brazil through the Network for the Humanization of Childbirth.²⁸ The movement developed as a response to the hyper-medicalised and dehumanising nature of western-informed facility-based childbirth, and it seeks to overcome the harmful consequences thereof.²⁹ It redefines childbirth as a normal physiological event, emphasising that care must be in line with human rights, centred on the needs of women as authoritative knowers and supported with reference to evidence-based care.³⁰ However, Latin American scholars and activists, drawing from lived experiences of facility-based childbirth, note clear and significant overlap between institutional childbirth and violence against women, giving rise to ‘obstetric violence’.³¹ Thus, obstetric violence concerns a particular form of violence against women within the institutionalised healthcare during childbirth.³²

Many of the recognised manifestations of violence and abuse refer to instances of interpersonal violence, such as physical abuse; harmful medical interventions or procedures; verbal abuse; and general lack of respect. However, Castrillo warns that ‘obstetric violence’ is not limited to the obvious and extreme manifestations of abuse that interpersonal violence tends to emphasise.³³ Instead, it exposes and names more ‘subtle’ and invisible forms of violence, such as unnecessary but routine medical interventions camouflaged as science (for instance, requiring women to birth in certain positions, denying women access to food and water, or routine provision of episiotomies). Narrowing our focus to interpersonal issues limits ‘obstetric violence’ to quality-of-care issues, and this suggests that obstetric violence can be addressed by superficial improvements in managerial processes or technical and resources support.³⁴ Castro and Erviti emphasise that constructing the issue as one limited to quality-of-care issues explains the systemic failure in broader awareness campaigns and the ineffectiveness of some of the past responses to violations in childbirth.³⁵ To be better placed to develop effective responses, these researchers adopt and support an expansive understanding of violence by drawing from structural and institutional violence.³⁶

Latin American research underscores the link between individual experiences of violence in childbirth (reflecting the ‘tip of the iceberg’)³⁷ to the broader concern of structural discrimination, which is recognised as a form of structural violence.³⁸ According to Sadler and others,³⁹ ‘obstetric violence’ concerns invisible social structures that are built into the fabric of society (gender, race and other discriminatory sociocultural statuses)⁴⁰ and have a particularly harmful impact on how healthcare professionals and institutions approach ‘care’ during facility-based childbirth.⁴¹ For instance, Mexican midwives recognise that how women are treated in labour and birth reflect how they are treated in society in general: ‘For many midwives, this means that women are set up from the beginning to be treated poorly in public hospitals—because of their status as lower class and/or indigenous.’⁴²

The broader framework of violence against women captures institutional violence as a core feature of ‘obstetric violence’ too.⁴³ Institutional violence refers to those situations where state officials or agents of public institutions impede, obstruct or delay women’s access to public services or the enjoyment of their rights during childbirth.⁴⁴ This form of violence is perpetuated ‘in an organised manner and through the exercise of legitimate power, within hierarchical institutions … where individuals tend to lose their personal autonomy’.⁴⁵ This view requires that we acknowledge the fact that medicine, consisting of a professional field with a particular authoritative ‘habitus’,⁴⁶ is a social and cultural system that responds to and reproduces social discrimination within the way it functions.⁴⁷ Thus, for instance, it reflects as under-resourced healthcare facilities, unequal distribution of resources affecting poor and/or rural regions, systemic failure to comply with evidence-based protocols and guidelines, and systemic and routine dehumanisation of women.⁴⁸

‘Obstetric violence’ is a powerful Latin American feminist epistemic critique of institutionalised childbirth which challenges the legitimacy of biomedicine’s dominant and authoritative role in the provision of care during childbirth. In this way, ‘obstetric violence’ reflects a decolonial agenda—‘a fight to decolonize the womb’. Espinoza-Reyes and Marlene Solís explain:

decolonization of the womb means to imagine, analyze and make visible the forms of agency employed by those who have suffered this occupation, to resist it and reappropriate their bodies and their sexuality, either responding through modern or nonmodern shared knowledges, relations, values and practices.⁴⁹

In line with this understanding, Castro and Frías emphasise that the eradication of obstetric violence involves the reappropriation, by women, of their reproductive processes and the elimination of medical domination over their bodies.⁵⁰

‘Obstetric violence’ goes a long way to operationalise this agenda because it provides the necessary framework to identify membership to a ‘collective of victims’ who are connected by a particularly complex sociocultural phenomenon of multiple, diverse and intersecting violations that occur during institutional childbirth.⁵¹ For Sesia, ‘obstetric violence’ manifests as a ‘powerful tool for legal and political action’⁵² directed towards supporting women’s reproductive rights during childbirth to ultimately pick apart modern medicine’s authority to continue to dictate how to birth. Indeed, the growing legal recognition of obstetric violence across Latin America and the Caribbean reflects this point.⁵³

The Latin American success in ‘breaking the silence’ on obstetric violence and exposing the normalisation of violence in institutional childbirth readied the ground to secure much-needed international attention, for the benefit of women and other birthing people living in countries outside of Latin America.⁵⁴ A very important gain in this respect is the international recognition of obstetric violence as a form of gender-based violence against women,⁵⁵ trans and non-binary people.⁵⁶ Recently, the Committee on the Elimination of Discrimination against Women has recommended that Spain adopt a broad range of legal and policy measures to address obstetric violence.⁵⁷ This highlights that obstetric violence falls within the remit of the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) and that governments that have ratified the Convention are under a human rights obligation to tackle this form of violence. In her thematic report on violence and abuse in childbirth, the United Nations Special Rapporteur on violence against women and girls, its causes and consequences takes the same approach.⁵⁸ She emphasises that governments are under a human rights obligation to prosecute perpetrators and provide adequate remedies to victims/survivors in the form of restitution, compensation, satisfaction or guarantees of non-repetition. The Special Rapporteur recommends further that states should conduct investigations into allegations of obstetric violence and use those findings to revise laws, policies and national action plans and to raise awareness of the issue among lawyers, judges and the public to ensure effective use of remedies. Similar responsibilities were set out by the Council of Europe Parliamentary Assembly, calling on states to ‘propose specific and accessible reporting and complaint mechanisms for victims of gynaecological and obstetrical violence, within and outside hospitals, including with ombudspersons’.⁵⁹

To meaningfully translate these gains into concrete benefits for those living in jurisdictions where obstetric violence is not the focus of legal reform efforts, it is necessary to establish what counts as ‘obstetric violence’.

3. The Shifting and Porous Boundaries of ‘Obstetric Violence’

While different activist and academics tend to favour the Venezuelan statutory definition of ‘obstetric violence’, it is important to recognise that it serves no more than a starting point because the ‘obstetric violence’ conceptual landscape is far more complicated than the legislative definition presents.⁶⁰ The literature on ‘violence’ is vast, with contributions from a range of disciplines and theoretical perspectives which all attempt to provide authoritative claims about the meaning of ‘violence’. Thus, it is understood differently by different researchers depending on their context, the stakeholders involved and their aims and objectives.⁶¹ Ultimately, the fluidity of ‘violence’ renders it a slippery and contested concept, with disputes about who is best place to define it.⁶² Against this backdrop, we should expect to be confronted with a range of issues when drawing from ‘violence’ while navigating literature and lived experiences of violations in childbirth, and within the ‘obstetric violence’ literature specifically.

Two discernible approaches to defining ‘violence’ can be identified: some researchers adopt a narrow approach to ‘violence’ (approach A,) while others take a less restrictive approach (approach B). A less restrictive understanding of violence manifests in two ways: some treat ‘obstetric violence’ as synonymous with ‘mistreatment in childbirth’ and/or ‘disrespect and abuse during childbirth’, which are other labels used to capture violations in childbirth (approach B(1)); and some use ‘obstetric violence’ as a distinct, but all-inclusive, concept for a wide range of violations during reproductive healthcare (approach B(2)). These diverging approaches highlight that, as with ‘violence’, ‘obstetric violence’ is a contested concept, with tensions between a narrow and broad approach, and that its current usages under the broad approach render ‘obstetric violence’ particularly nebulous in nature.

A. Approach A: A Narrow Approach to ‘Violence’

One approach to defining ‘violence’ in childbirth is to limit it to positive, interpersonal actions that intend to cause harm during childbirth. Global health researchers⁶³ adopt this approach because, for them, ‘violence’ implies ‘intentionality of the act to cause harm’.⁶⁴ Their approach is aligned with what Coady frames as ‘the ordinary understanding of “violence”’.⁶⁵ It is ‘ordinary’ in the sense that this is how ‘violence’ is defined in dictionaries and it tends to take the form of a physical interaction which can be readily identifiable and understandable as violence. Further, Galtung explains that this narrow approach to ‘violence’ is legitimised in law because it complements our long-standing Judaeo-Christian-Roman tradition that someone cannot be found guilty of something in cases where intention is lacking.⁶⁶

‘Violence’ defined in this way offers certainty regarding what counts as ‘violence’ in ‘obstetric violence’ because its boundaries are clearly defined.⁶⁷ However, this approach it not widely supported in the literature that reports on or draws from lived experiences of violations in childbirth, as demonstrated below. A victim/survivor perspective reveals the inadequacies of a narrow approach to defining ‘violence’ in childbirth. It leaves out too much that ought to be included, all of which becomes clear if we expand our view to include a consideration of the impact of behaviours, structures and/or institutional functioning on the victims/survivors.⁶⁸ As within the broader violence literature, there is a clear divide in the way that ‘violence’ is used by researchers working on issues relevant to violations in childbirth.

B. Approach B(1): ‘Obstetric Violence’ Synonymous with ‘Mistreatment in Childbirth’ and ‘Disrespect and Abuse’

Contrary to the ‘ordinary’ or narrow approach to ‘violence’, some researchers adopt a broader approach. This approach is seen in a branch of the literature that treats ‘obstetric violence’ as synonymous with ‘disrespect and abuse’ and ‘mistreatment during childbirth’.⁶⁹ This approach introduces several challenges because it is not entirely clear what is meant by ‘disrespect and abuse’ and ‘mistreatment’, and therefore it is not clear what is meant by ‘obstetric violence’.

Initially, ‘disrespect and abuse’ was determined in relation to typologies of abuse in childbirth: physical abuse; non-consented care; non-confidential care; non-dignified care; discrimination; abandonment; and detention in facilities.⁷⁰ However, there has since been an attempt by some researchers to provide definitions of ‘abuse in childbirth’,⁷¹ but these have not been universally adopted by other researchers or widely applied in practice. For instance, the World Health Organization’s researchers reject ‘disrespect and abuse’ as an inadequate articulation of the phenomenon, and opt for a ‘mistreatment’ discourse, which is now the World Health Organization’s preferred label.⁷² However, ‘mistreatment’ remains undefined, and is currently limited to first-, second- and third-order typologies.⁷³ The third-order themes are broader than ‘disrespect and abuse’: physical abuse; sexual abuse; verbal abuse; stigma and discrimination; failure to meet a professional standard of care; poor rapport between women and providers; and health system conditions.

Adopting a typology-based approach presents some challenges in the context of ‘obstetric violence’. Typologies are not definitions;⁷⁴ they do not explain what criteria must be met for an interaction or condition to qualify and be counted as ‘mistreatment’ or ‘disrespect and abuse’. Consequently, when used interchangeably with ‘obstetric violence’, the ‘obstetric violence’ label inherits this uncertainty. Further, ‘mistreatment’ and ‘disrespect and abuse’ cast a very wide net. Viewing the different concepts as synonymous with ‘violence’ inspires scepticism because it is questionable whether all of what is included therein constitutes ‘obstetric violence’, being a particular form of violence. This broad approach does very little to inform us about what is or is not ‘obstetric violence’. Importantly, Castro and Frías explain that limiting our focus to individual typologies hides the fact that the origins of violence in childbirth rest in violent nature of the western medical model of care during childbirth.⁷⁵

C. Approach B(2): ‘Obstetric Violence’ as an All-Inclusive Concept

Casting the net too wide features as an issue in the literature that is specifically centred on the concept of ‘obstetric violence’ or that uses ‘obstetric violence’ as its primary analytical framework. As with approach B(1), this branch of literature stretches our everyday understanding of violence insofar as it introduces behaviours or interactions not typically understood to be ‘violence’. In addition to physical abuse, the conceptual net is cast wide enough to include subtle manipulation and oppressive use of ‘silence’;⁷⁶ humiliation and verbal abuse;⁷⁷ discrimination;⁷⁸ neglect and omissions;⁷⁹ extortion;⁸⁰ forced, coerced or unconsented procedures⁸¹ and administration of medications, including long-term contraceptives;⁸² and routinisation of biomedical interventions that are not evidence-based or women-centred.⁸³ Given that this is not a systematic literature review, this list serves as a mere glimpse into some of the issues being classed as ‘obstetric violence’; the full list is undoubtedly longer.

One branch of the obstetric violence literature expands this form of violence to include issues of broader reproductive health injustices. For instance, Garcia argues that ‘obstetric violence’ should be defined as the

abuse or mistreatment by a health care provider of a female who is engaged in fertility treatment, pre-conception care, pregnant, birthing or postpartum, or the performance of any invasive or surgical procedure during the full span of the childbearing continuum without informed consent, or in violation of refusal.⁸⁴

Mena-Tudela and others apply ‘obstetric violence’ to those instances in which ‘women cannot obtain sufficiently long maternity leave to attend to their babies’ physical and emotional needs, and to be able to offer their offspring, if they so wish, exclusive breastfeeding in the first six months of life’.⁸⁵ ‘Obstetric violence’ has been used to describe inappropriate behaviour in the context of neonatal intensive care;⁸⁶ abortion and post-abortion services;⁸⁷ and coercive and oppressive involvement of welfare services to remove children from their parents soon after birth.⁸⁸ From an activism perspective, this ever-expanding use of ‘obstetric violence’ might be essential for purposes of naming conditions and experiences that are made to be unnameable in the current context of institutional childbirth, awareness raising and coalition building. However, for purposes of approaching ‘obstetric violence’ with a view to supporting law reform, the ever-expanding use of ‘obstetric violence’ feeds the sense that it is an overgeneralised or especially vague concept because its possible boundaries are not easily discernible from the available literature.

Part of this expanded understanding of ‘obstetric violence’ can be explained with reference to the notions of structural and institutional violence. As noted earlier in the article, Latin American scholars recognised that there is more to obstetric violence than interpersonal violence, and limiting our understanding of violence to interpersonal violence reflects a flawed account of the issue that will undermine efforts to address and prevent obstetric violence. Indeed, working from the foundations of the Latin American scholarship, much of the expanded versions of ‘obstetric violence’ under approach B(2) is institutional violence that emerges from and is maintained by structural discrimination on intersecting grounds against particular women, especially those marginalised in their countries or communities. For instance, coercive and oppressive involvement of Canadian welfare services to remove children from their parents soon after birth is a particular institutional practice that specifically targets Indigenous women and families from rural and remote communities or who live in poor urban neighbourhoods.⁸⁹ Silencing practices⁹⁰ reflect ‘invisible relations of dominance’ woven into the mechanics of institutionalised childbirth and is used against black and typically low-income women in publicly funded healthcare facilities in South Africa.⁹¹

While these forms of violence help to explain the expanding conceptual reach of ‘obstetric violence’, as with violence literature more generally, there is minimal uniformity in how structural and institutional violence are considered in the literature on obstetric violence. On the one hand, there is a determined focus on structural dimensions of obstetric violence. Dixon takes the position that ‘obstetric violence’ has a ‘dual definition’ because it includes both individual and structural violence.⁹² However, it is not clear what features transform ‘general’ structural violences into obstetric structural violence. On the other hand, van der Waal and others emphasise that obstetric violence should be understood as institutionalised violence.⁹³ Some of the literature’s limited focus on institutional violence could be an indication that some may perceive structural violence to include institutional violence. For instance, in the broader literature on violence, structural violence is sometimes treated as synonymous with institutional violence,⁹⁴ and this was my own understanding until very recently. Additionally, or in the alternative, the uncertain navigation of these violence frameworks may be a consequence of what Vorobej refers to as a gap in ‘violence literacy’.⁹⁵ Whatever the explanation might be, there is a measure of uncertainty present that impacts the construction of ‘obstetric violence’ in the literature.

It is noteworthy that the ambiguous construction of violence in childbirth is also reflected in some of the legal conceptualisations of obstetric violence, resulting in a notable lack of uniformity across different jurisdictions in Latin America.⁹⁶ As noted earlier, several jurisdictions across Latin America and the Caribbean recognise obstetric violence as a form of gender-based violence in various legal codes, but the laws focus on individual provider actions rather than institutional or structural issues.⁹⁷

Article 51 of the Venezuelan Organic Law on the Right of Women to a Life Free from Violence (2007) attached criminal liability to only five manifestations of obstetric violence: failing to respond to obstetric emergencies; forcing women to give birth in the supine position; preventing mother–baby bonding; altering the physiological process of labour and birth without clinical justification and informed consent; and performing a caesarean section without clinical justification or need and consent.

Many states in Mexico built from Venezuela’s model. For instance, the state of Veracruz follows the Venezuelan approach but also includes undue psychological pressure or harassment and forcing women to give birth in a position which is contrary to her mores and traditions.⁹⁸ In Chihuahua, ‘obstetric violence’ includes any negligent or intentional act or omission by healthcare personnel that injures or denigrates women during pregnancy, labour and the puerperium periods.⁹⁹ According to article 3 of the Tamaulipas Law for Gender Equality (2015), obstetric violence includes negligent care caused by inhumane treatment; pathologisation of the childbirth process, which includes failing to respond adequately to obstetric emergencies; performing caesarean section procedures without clinical indication; performing sterilisations or using other contraceptive methods without women’s voluntary and informed consent; and hampering mother–baby bonding after childbirth. San Luis Potosi includes forced sterilisations and involuntary administration of contraceptives within its list of recognised manifestations of obstetric violence too.¹⁰⁰

While there is formal recognition of ‘obstetric violence’ in legal codes, it has fluid boundaries, which renders it a difficult concept to pin down in legal terms. This is because it appears to be a concept that can be stretched in different directions or even limited without explicit observance of core features that act to bind the concept to defined boundaries. For example, it is not clear how negligence evolves into violence in some jurisdictions but not others,¹⁰¹ or how ‘obstetric violence’ can simultaneously include and exclude involuntary sterilisations or forced contraceptives.¹⁰²

Differences in the constructions of obstetric violence may reflect an evolution of the understanding of violence and abuse in childbirth over time, the local political landscape and the general willingness of governments to respond to calls for social and legal reform as presented in the research available.¹⁰³ Further, differences might emerge because violence against women, trans and non-binary people manifests differently in different geopolitical contexts, with the nature and the extent of violence correlating with different people’s social status, race and sexual orientation/identity within those particular contexts, thus justifying a focusing on different behaviours.¹⁰⁴ It could be argued, then, that the different conceptualisations and legislative approaches are relative to the contexts from which they emerge.

The literature presented here makes it clear that ‘obstetric violence’ is a particularly difficult concept to pin down. It has inherited some of the contestations found in the broader literature on violence as seen in the tension between narrow and wider approaches to ‘violence’ and in the different approaches towards structural and institutional violence. While ‘violence’ should always be subject to regular and rigorous challenges to gain insights into the nature of our social reality,¹⁰⁵ this issue cements my interpretation of ‘obstetric violence’ as being problematically vague because the available information does not fully explain what frameworks support or justify how the concept is used by different researchers. In those instances where a wide approach to ‘violence’ is relied on, the dividing line between that which is or is not obstetric violence becomes difficult to establish because ‘obstetric violence’ is now being used to capture any or all violations in reproductive healthcare. While this inclusive approach captures various lived experiences, the start and end points of ‘obstetric violence’ are significantly blurred.

4. The Challenges of Working with a Nebulous Concept

Framing something as violence raises the social and political profile of disturbing behaviours and harmful social structures. ‘Violence’ helps to distinguish between that which we consider acceptable and that which we reject as unacceptable. When we label behaviour or social phenomena as violence, we separate out this issue and declare it an issue that needs focused attention, a response, justifications and explanations, and as something that needs to be stopped.¹⁰⁶ In many respects, a nebulous concept such as ‘obstetric violence’ facilitates these aims because it creates the space for critical debate and thus creative knowledge development. Fluidity allows excluded experiences to be included in discussions by challenging what we ‘know’ about obstetric violence.

Nevertheless, when the everyday use of a concept fails to communicate a clear narrative shaped by discernible frameworks, it can be easily disregarded as unhelpful in capturing our reality.¹⁰⁷ It creates the space for the concept to be perceived as a wild and thus unsupported representation of the issue, as presented in the quotes from healthcare professionals: ‘Today anything you do with the patient can be viewed as obstetric violence. If you have a normal birth, it is violence, if you have a cesarean, it is violence.’¹⁰⁸ And:

Everything is obstetric violence now: if the patient cannot eat, is left in bed, gets an episiotomy, has a uterine cavity revision without anaesthesia, if we leave them there too long, if we give then Pitocin, if we ask them about birth control too much … it is all considered obstetric violence.¹⁰⁹

A general lack of coherence provides a basis for outright rejection, rather than creating an opportunity for reflection on what makes institutional childbirth a site of violence.

Accurate legal formulation of ‘obstetric violence’ can be diluted if the concept manifests as significantly blurred; its productivity in contributing to concrete social reform efforts can be undermined. This is of particular concern to Farías Rodríguez and Magnone Alemán in relation to the Uruguayan experience, noting that poorly defined concepts make it difficult to establish what acts count as obstetric violence and how to respond to it, and this undermines effective integration into broader legal practice.¹¹⁰ Other Latin American countries have similar concerns.

According to the Mexican feminist organisation Grupo de Información en Reproducción Elegida, some legislators introduced the definition of ‘obstetric violence’ to raise awareness, but many of the laws are noted for their confused representation of the issue.¹¹¹ Range Flores and others highlight that some Mexican women are unable to identify their experiences of violence and abuse in childbirth as ‘obstetric violence’ because that which they identify as problematic is not captured by the legal construction of ‘obstetric violence’.¹¹² Dixon explains that healthcare professionals in Mexico are unclear about the legislative scope of ‘obstetric violence’ and that women struggle to identify their experiences in terms of its legislative construction.¹¹³ In respect of the Organic Law on the Right of Women to a Life Free of Violence (2007), Terán and others report that women are confused by its provisions in that only 27% of the women who participated in their study knew of the term ‘obstetric violence’.¹¹⁴ Faneite, Feo and Toro Merlo share similar findings.¹¹⁵ Of the 500 healthcare professionals who took part in their study, 89% of the participants knew of the term ‘obstetric violence’, but they did not know how the law defined it and there was a clear misunderstanding regarding what acts constitute this form of violence.

More recent arguments to develop or implement laws¹¹⁶ will be frustrated because it is not clear what the law should be responding to, especially if ‘obstetric violence’ is accepted to be such a broad, all-inclusive concept. If use of the law can be justified, some clarification is needed to establish the extent to which the law can interject for purposes of social reform.

‘Obstetric violence’ clearly inherits some of contestations about the meaning of ‘violence’, but, ultimately, we miss important ways to improve our reality. A wide construction of ‘obstetric violence’ may be justified because it takes the perspective of the victim/survivor,¹¹⁷ but this approach makes it difficult to establish all that ‘obstetric violence’ captures. It may well be that everything materialises as obstetric violence during facility-based childbirth,¹¹⁸ but we cannot fully engage with this possibility without a theoretical framework that would provide an explanation. Vorobej warns

we can’t effectively control violence … if we can’t discuss violence … in some reasonably coherent fashion. In order to tackle the problem, we need to know what the problem is. We need to know what we are talking about.¹¹⁹

Consequently, it is necessary to consider whether there is a framework of ‘violence’ with which to approach the obstetric violence material that can help to organise and connect what appears to be a confused conceptual landscape. Bufacchi’s violence as a violation of integrity offers a promising start given his victim/survivor-orientated approach.¹²⁰

5. Violence as a Violation of Integrity: A Universal Thread

Bufacchi offers a compelling meeting in the middle, between the narrow and comprehensive approaches to defining ‘violence’,¹²¹ and he defines it as a violation of integrity. ‘Integrity’ refers to a state of wholeness or intactness, as something that is not broken or that has not lost its form; it ‘points to the notion of “unity”, or to the quality of being complete or undivided … Thus, an act of violence is fundamentally a violation of integrity, to the extent that it damages or destroys a pre-existing unity.’¹²² Bufacchi notes that integrity should be understood to be a process, but, rather than an endpoint,

we may never be fully intact, or whole, with full integrity, but at any moment in the trajectory, we are as whole or as intact as we can be, with all the imperfections that are the trademark of the human species.¹²³

Violence as a violation of integrity moves beyond violence as physical harm or injury and works to capture all the ways integrity might be violated at a physical or psychological level. According to Bufacchi,

when a person becomes a victim of an act of violence, it is one’s integrity as a person that is being infringed, since in the process of being violated one is reduced to a lesser being, in physical and/or psychological terms.¹²⁴

A victim-orientated approach creates the opportunity to see violence where it tends to be hidden when a narrow approach is adopted or when we are confined to existing categories or regulations (legal or otherwise). Bufacchi argues that ‘The experience of injury, suffering or harm is a consequence or symptom of having one’s integrity violated’.¹²⁵ Thus, this approach to defining violence is rooted in phenomenology,¹²⁶ being an approach that raises questions about how an interaction or an intersection of social circumstances invades the field of experience.¹²⁷ To demonstrate the scope of what he intends to capture by ‘integrity’, he draws from Brison’s personal narrative of sexual assault and attempted murder.¹²⁸ While rape and physical attack against Brison caused injuries to her body in its material form, the essence of the violence lies in the violation of her integrity based on ‘a metaphysical concept of the self as something violable, which is related to but at the same time distinct from a person’s body’.¹²⁹ In this respect, the violence undoes the self insofar as it undermined her fundamental assumptions about the world, and severed the connections she experienced between her self and the rest of humanity.¹³⁰

A victim-orientated approach also challenges the notion that something will count as ‘violence’ only if it takes the form of an intentional and positive act (doing something). Indeed, Bufacchi uses a victim-orientated approach to accommodate omissions within his definition of ‘violence’. An omission refers to a failure to act or ‘not doing something’ to help to avoid harms, and Bufacchi uses extreme cases of neglect as an example.¹³¹ However, an omission will only count as violence if two conditions are met: the harmful consequences of the omission to act must be foreseeable; and there must be a viable possibility of an alternative action.¹³²

On the issue of intention, Bufacchi recognises intention to be an important consideration because it helps to distinguish between benevolent and malevolent acts and accidents. This distinction is worth noting because these hold different moral weight in society, and he recognises that intention to cause harm is relevant to questions about how to approach responsibility.¹³³ However, the perpetrator’s intention tells only part of the story because violence involves more than just the perpetrator—it includes victims and has an impact on them. A victim-orientated approach justifies extending the definition of violence to include both intentional violence and unintentional violence.¹³⁴ Unintentional violence includes acts or omissions that cause foreseeable and avoidable suffering or injury and excludes mere accidents. Distinguishing between unintentional violence and accidents can be challenging, but Bufacchi emphasises that the foreseeability of the avoidable consequences (injury or suffering) of one’s actions makes it possible for us to navigate hard cases.¹³⁵

There is significant overlap between Bufacchi’s violence framework and that which is articulated in the obstetric violence literature, where the self is a core feature. For instance, Salinero Rates references descriptions of experiences of obstetric violence as an ‘earthquake’.¹³⁶ This comparison conveys the feeling of having one’s foundations being so significantly disturbed that a process of self-rebuilding becomes necessary.¹³⁷ Thus, obstetric violence alters how women conceive of themselves and their relationships, and challenges their way of life. For Wolf, the violation that occurs in medicalised childbirth ‘affects who or what one is; it is a violence aimed at the very being of its victim’.¹³⁸ This violence manifests as

erasure of the being’s self or identity-constituting aspects, denying that the being is a self or a legitimate entity with moral standing in the universe, preventing someone from doing what is needed to be a self or making it impossible for one to develop into oneself, or an obfuscation of key aspects of oneself (or things needed in order to connect to oneself or identify it).¹³⁹

Like Brison’s experience of being subjected to sexual assault, Wolf¹⁴⁰ and Salinero Rates¹⁴¹ recognise that, in addition to physical injuries, violence in childbirth undermines a person’s ability to feel at home in the world and makes it difficult to act according to a person’s own volition. Childbirth in these contexts reduces women to objects, and their unique selves are erased and replaced with a generic person—‘the patient’, who is externally constructed by attending healthcare professionals and medical systems and protocols.¹⁴² Cohen Shabot’s feminist phenomenological approach supports this analysis.¹⁴³

Concerns around objectification, leading to dehumanisation, has remained a long-standing focal point in the context of facility-based childbirth. As highlighted earlier, ‘obstetric violence’ emerged from the Latin American movement on the humanisation of childbirth movement.¹⁴⁴ Ladeira and Borges explain that

the constant medicalization and pathologization of pregnancy and childbirth end up removing the vital process from the feminine body and placing it at the hands of institutions, transforming them [pregnancy and childbirth] into a medical event, not belonging to the feminine body … what is seen in the stories on obstetric violence is exactly the woman’s feeling of not-belonging to her own body and its inherent phenomena. With this intervention, the woman feels objectified, manipulated in a production line, whose final product is the birth of the baby.¹⁴⁵

The self’s inward and outward (situated and interdependent) manifestations come undone when women, trans or non-binary people are subjected to obstetric violence. Many accounts of childbirth experiences where ‘obstetric violence’ is not explicitly used offer comparisons with other forms of violence, particularly sexual violence, to communicate their experience.¹⁴⁶ Alternatively, if women do not identify their experience as sexual violence, they may experience the aftermath of their childbirth in ways like victims of sexual violence and abuse.¹⁴⁷

Victims/survivors who compare their childbirth experiences to sexual violence are engaging in a process of redefinition. In her research on sexual violence, Kelly highlights this process in the context of redefining ‘sexual interactions’ as ‘sexual abuse’, ‘rape’ or ‘incest’.¹⁴⁸ Here, women focused on unsettled feelings generated by their violations to motivate the renaming of those experiences, defying epistemic limitations created by overly narrow definitions, stereotypes and perceptions of others.¹⁴⁹ In the context of facility-based childbirth, where violence and abuse are normalised, comparisons become necessary because access to adequate or context-specific epistemic resources and names are out of reach. In this process of redefinition, women apprehend a violation despite the oppressive constructions of ‘normal’¹⁵⁰ in childbirth and appear to draw on already existing frameworks of violence and abuse as aids to communicate their experiences for purposes of recognition.

While deeper feminist theorising is ongoing about what is at the heart of the violation in obstetric violence, violation in the context of sexual violence has been the subject of extensive historical and contemporary feminist theorisation. This broader theorisation provides important scaffolding for purposes of understanding where the violence lies in obstetric violence, particularly because victims/survivors’ lived experiences of obstetric violence connect these two violences through objectification and/or dehumanisation.

Nussbaum offers helpful insights here, for instance.¹⁵¹ She positions objectification at the heart of sexual violence and frames it as the ‘what of sexual harm’.¹⁵² Nussbaum explains:

Objectification means converting into a thing, treating as a thing what really is not a thing at all, but a human being. Objectification thus involves a refusal to see the humanity that is there, or, even more often, active denial of that full humanity.¹⁵³

She frames objectification as a ‘cluster concept’ because there are several ways in which humanity can be denied, though not all of the listed features need be present for objectification to be present:¹⁵⁴instrumentality, treating a person as a mere tool; denial of autonomy, treating a person as lacking autonomy and self-determination; inertness, treating a person as lacking agency; fungibility, treating a person as interchangeable with other objects of the same or other types; violability, treating a person as lacking boundary integrity, thus making it permissible to break, smash or break into; ownership, treating a person as something that can be owned, bought or sold; denial of subjectivity, treating a person as something whose experiences and feelings do not count; and silencing, treating a person as unable to speak or not worthy of being listened to.

Bufacchi’s construction of violence as a violation of integrity helps to identify the invisible thread that connects the different manifestations of obstetric violence that researchers and activists record in the broader obstetric violence literature: violation of integrity, which includes a rupturing of the self. Much of what is captured in the obstetric violence literature reveals concerns around objectification through various dehumanisation strategies, whether intentional or not, whether it manifests through actions or omissions, but which violate a person’s physical or psychological integrity. This offers only a partial account of the violence framework though, and it is necessary to position the violation of integrity within its epistemic and social context.

6. ‘A View from Everywhere’: Particularising the Universal Thread

Bufacchi supports an understanding of violence as a trilateral relationship between the victim, the perpetrator and the spectator.¹⁵⁵ The spectator fills the role of evaluating claims of violence to distinguish between ‘legitimate’ and ‘less-legitimate’ claims of victimhood and to assess the reliability of the victim’s and perpetrator’s perspectives by applying standards of truth that may be external to those perspectives.¹⁵⁶ Further, Bufacchi explains that a spectator could prove especially helpful in the context of structural violence because the spectator

may alert us to problems of violence even when we do not hear the voice of the victims. That is because violence can occur when the Perpetrator and/or the Victim are not aware of the violence, or when the awareness is supressed, or even when the violence is not unwanted.¹⁵⁷

While Bufacchi emphasises the integral role of the victim/survivor’s experiences in understanding violence, ultimately, it is the spectator who defines whether actions, interactions or circumstances are violence. Bufacchi argues that this is an important feature of his construction of violence because it ensures objectivity. To achieve objectivity, the spectator takes an ‘impartial standpoint from which to assess violence from beyond subjectivity’.¹⁵⁸ The impartial standpoint is a hypothetical perspective that operates from the ideal position and adopts the ‘view-from-nowhere’.¹⁵⁹ For Bufacchi, ‘the Spectator can be anyone who is able to form a judgement as to the propriety or impropriety of the conduct observed, whether they are directly involved (or even present) in the act in question or not’.¹⁶⁰ Given that Bufacchi defines violence as the violation of integrity, the spectator would be required to determine whether integrity has been violated.

There is significant appeal in Bufacchi’s approach to defining violence. However, the strength of the initial appeal to his framework is diluted because of what the spectator represents in the tripartite relationship. I want to challenge Bufacchi’s reliance on objectivity as presented in his work and suggest a revision to this relationship. A revised relationship is essential for this framework of ‘violence’ to reflect the decolonial foundations of ‘obstetric violence’ and offer a productive way forward.

Bufacchi’s reliance on the ‘view from nowhere’ is essential to his overarching aim to develop an objective definition of violence that will have universal application despite diverging cultures and subjectivities.¹⁶¹ Suggesting that an objective and universal definition is achievable echoes a Eurocentric position founded in western philosophy, and it continues to be privileged in Eurocentric knowledge production and dissemination through the functioning of coloniality.¹⁶² Objectivity in this form reflects a falsity or a myth because it claims that there is only one epistemic tradition that can achieve truth and universality.¹⁶³ Indeed, for those working in the realms of violence against women, and other communities marginalised by patriarchal, heteronormative and racist constructions of ‘acceptable’ definitions, it is essential to challenge the objectivity proposed by Bufacchi.

Cohen Shabot and Landry remind us that people are enculturated.¹⁶⁴ Lajoie explains that ‘prior to any theoretical or moral engagement with the world, certain sets of norms already play a role at an embodied, pre-reflexive level and account for our ability to orientate ourselves in the intersubjective lifeworld’.¹⁶⁵ Thus, the spectator can never claim to take a neutral position. Going further, Grosfoguel refers to ‘body-politics of knowledge’ to emphasise that as enculturated people, we always speak from a particular position within power structures: ‘Nobody escapes the class, sexual, gender, spiritual, linguistic, geographical, and racial hierarchies of the “modern/colonial capitalist/patriarchal world-system”.’¹⁶⁶ The ‘view from nowhere’ creates ‘delusions of objectivity’;¹⁶⁷ it is a view that is disembodied and unsituated.¹⁶⁸

Phenomenology provides a helpful critique of the ‘view from nowhere’.¹⁶⁹ Critical phenomenologists recognise ‘that certain ways of experiencing the world are privileged, naturalised, and normalised along structural lines and that, conversely, certain ways of being-in-the-world are rendered invisible’.¹⁷⁰ It is therefore essential that we challenge the definition of ‘normal’ to include invisiblised experiences and rethink and rewrite ‘normal experience’ that is inclusive of women and marginalised people’s lived realities.¹⁷¹ This calls for an emphasis on intersubjectivity in our quest to discover truth(s) and ensures openness to see power structures that condition those truths.¹⁷²

Against that backdrop, feminist and other critical phenomenological approaches do not exclude the spectator. Feminist aims of challenging exclusionary and oppressive constructions of ‘normal’ and broader feminist commitments to embodiment, situatedness, diversity and the intrinsic sociality of subjectivity require the inclusion of the spectator. However, the spectator’s view needs to change from a ‘view from nowhere’ to a ‘view from everywhere’.

Under critical phenomenology, objectivity is ‘the product of a view from everywhere; practically only possible through the continuous intersubjective sharing of subjective perception and experience’.¹⁷³ Daly explains as follows:

Our communications are meaningful whether in agreement or dispute; I can consider anything from your perspective and in fact all potential perspectives and we can negotiate our understandings through lan1guage and expression … it is through these generalities of communication and expression that we know we live in a shared world.¹⁷⁴

While I support Bufacchi’s definition of violence insofar as it reflects an intentional or unintentional act or omission that causes a violation of integrity which captures and undoes the self, and while I fully embrace Bufacchi’s framing of violence as a multi-party relationship, I diverge from his position on the spectator by framing the spectator as the collector of multiple views with the aim to develop a ‘view from everywhere’, thus serving as a focal point to communicate and validate subjective experiences.

Twemlow, Turner and Swaine explain that the

experience of validation does not rest on the ability to infer the perception of the other through direct access to an analogous perception of our own. The validation of our shared world occurs precisely because we know that the other does not occupy the same vantage point as ourselves. It is our very difference, and the multiplicity of perspectives that our differences generate, which allows us to co-create an objective view from everywhere.¹⁷⁵

Further, objectivity generated from adopting the ‘view from everywhere’ is the ‘intersubjective appreciation of the reasonableness of experience of the other given their particularities in our shared world’.¹⁷⁶ This is where we find the space for transparency to see whose views are being considered and counted, whose views are missing and why, and how much further we need to go to push the frontiers of ‘normal’ as suggested by Cohen Shabot and Landry,¹⁷⁷ and to explore whether the violation of integrity is present.

This approach to defining ‘violence’ opens up the opportunity to sharpen our sense of reality and creates conditions for socially legitimate declarations of what may or may not be violence in certain contexts because it is open to diverse critique. While this framework may not provide concrete parameters regarding whether we are confronted with violence or not, it creates the opportunity to develop localised (ground-up) constructions of ‘violence’, particularising the universal thread (violation of integrity) to ensure relevance to local people and different communities. The specificities of social and epistemic contexts help to explain how medicalised childbirths can be violence in some contexts but not others, or how birthing facilities void of certain local traditions and cultural specifications are violence in some contexts but not others.

Understanding violence as a violation of integrity provides a universal thread that helps to organise the existing obstetric violence literature. The ‘view from everywhere’, at the very least, creates the possibility for localised understanding of violence, thus explaining why violence materialises differently in different contexts. Importantly, adopting a ‘view from everywhere’ ensures that this construction of violence is aligned with the decolonial agenda of ‘obstetric violence’. This framework certainly aids in developing a coherent narrative, but it merely goes as far as identifying violence more broadly and not obstetric violence specifically. Just because something may count as violence does not mean that we are concerned with obstetric violence. To this end, it is necessary to consider what makes violence obstetric violence.

7. ‘Obstetric Violence’ and the Continuum of Violence in Reproductive Healthcare

The more recent ever-expanding use of obstetric violence to capture any or all harms very loosely related to childbirth or reproduction makes it quite difficult to distinguish between obstetric violence and other forms of violence. To demonstrate this concern, it is worth returning to Garcia’s definition of ‘obstetric violence’¹⁷⁸ and Chadwick’s responses thereto.

Chadwick commends Garcia’s definition for being ‘expansive and inclusive of reproductive violations beyond the sphere of birth/labour’.¹⁷⁹ This expansive view is deemed necessary because dehumanised, coercive, violent and disrespectful treatment is present in other areas of reproductive healthcare and an expansive approach ultimately helps to build collaborations across different modes of reproductive injustice.¹⁸⁰

Arguably, it appears that, just as processes of comparisons with sexual violence help to communicate violence and abuse in childbirth (discussed above), those more familiar with ‘obstetric violence’ use it as an epistemic base to communicate other violences that might occur in reproductive healthcare more generally, such as inadequate provision of maternity leave,¹⁸¹ violence and abuse during abortion services,¹⁸² and neonatal intensive care.¹⁸³ ‘Obstetric violence’ provides an important resource to help name experiences that may not have an appropriate name for violence and abuse in other areas of reproductive healthcare, but this process causes many violences to be subsumed under ‘obstetric violence’.

Chadwick provides compelling reasons to take a broad approach to obstetric violence, especially given its powerful epistemic disruptive character.¹⁸⁴ However, this approach overlooks some of the historical roots of ‘obstetric violence’ that point to some helpful conceptual boundaries. It is noteworthy that ‘obstetric violence’ emerged from the humanisation of childbirth movement, which was specifically focused on hospital-based care during childbirth (and, by implication, biomedically informed approaches to antenatal and postnatal care), exposing the unnecessary, hyper-medicalised nature of how we approach ‘care’ and the harmful consequences thereof.¹⁸⁵ The movement aimed to reclaim pregnancy and childbirth from the harmful grip of western imposed constructions of ‘normal’ childbirth, which continues to undermine women as authoritative knowers and strips childbirth of its cultural and spiritual values.¹⁸⁶ In general, focus remains on how care during pregnancy and childbirth materialises in the oppressive space of western-informed healthcare systems, processes and training.

In addition to facility-based childbirth being a core organising theme, researchers have highlighted those features about obstetric violence that distinguish it from other forms of violence, with a focus on structural drivers relevant to violence and abuse in childbirth.¹⁸⁷ For instance, Cohen Shabot claims that obstetric violence is different from other medical violence because obstetric violence is a gendered issue: women are disproportionately affected by it.¹⁸⁸ More recent research now recognises and includes the experiences of trans and non-binary people in this context.¹⁸⁹ Cohen Shabot notes how broader gender norms and oppressive stereotypes about women shape expectations and behaviours, with the target of medical focus being on ‘labouring bodies’, which are often active, strong, loud, healthy and not generally in need of curing or medical remedy.¹⁹⁰ ‘Obstetric violence’ therefore provides a name for the reproduction of gender inequalities and racial and socio-economic discrimination as these manifest in relation to women and their bodies while labouring and birthing in health institutions, or receiving antenatal or postnatal care.¹⁹¹ Further, as opposed to other medical procedures, gestation and childbirth are deeply sexual,¹⁹² and imbued with significant and complex cultural meaning. While there is scope to explore further distinguishing features of obstetric violence as our understanding of the phenomenon evolves, the ever-expanding application of ‘obstetric violence’ dissolves its distinctive features.

Distinguishing obstetric violence from other forms of violence is helpful because it recognises that when violence and abuse take place in a hospital labour ward or birthroom, it ‘does not merely locate the place of mistreatment, but identifies a set of norms, hierarchies, and conventions through which acts of abuse and disrespect are rationalized, even normalized’.¹⁹³ This has implications on how we understand obstetric violence as a particular manifestation of violence against women, trans and non-binary people, how broader social reform strategies could be developed and where resources should be deployed. Additionally, the distinguishing features help to inform how we should tailor law reform to ensure new or revised law speaks more directly to the particularities of the context, different relationships and systems involved. For instance, while integrity may be violated during fertility treatments, specific interventions to tackle those may not work very well in the context of violations during childbirth or during postpartum care. For these reasons, conceptual boundaries are important even if the boundaries are subject to constant debate and revision to accommodate improved understanding of the phenomenon.

Further, distinguishing obstetric violence from other manifestations of violence helps expose the range of violences that may simultaneously occur in the birthroom, and this will go a long way to preventing claims of victimhood being brought into competition with each other. This is a particular concern in the context of violence in childbirth, where women’s claims of being subjected to violence are diminished or explained away with reference to broader concerns about facility resources and working conditions for staff.¹⁹⁴ Inadequate resources create different violences for different people: facility staff are subjected to abusive employment practices and conditions, and birthing women, trans and non-binary people are subjected to obstetric violence. Recognising employment violence does not distract from the recognition of obstetric violence. Each violence requires full recognition and tailored responses; neither visibility nor formal recognition should be reduced merely because they exist simultaneously. In this way, we develop a full sense of the extent of violence and abuse in maternity care services.

Finally, Chadwick raises an important point about the need for collaborations across different modes of reproductive injustices. While I support distinguishing obstetric violence from other manifestations of violence, I acknowledge that a perfectly bounded concept is unproductive and impossible given its phenomenological roots. Nevertheless, I propose that these sought-after collaborations can be achieved without including broader reproductive health violences under ‘obstetric violence’. Kelly’s ‘continuum of violence’¹⁹⁵ in the context of sexual violence is especially helpful here. Noting the complexity of women’s experiences of typical and aberrant behaviours, and the deeply inadequate reflection of these issues in the media, laws and existing violence categories, Kelly turns to ‘continuum’ thinking to describe the extent and range of women’s experiences. She assigns two meanings to ‘continuum’. The first refers to ‘a basic common character that underlies many different events’.¹⁹⁶ This meaning of ‘continuum’ opens the space for women to talk about sexual violence in its generic sense. The second meaning refers to ‘a continuous series of elements or events that pass into one another and which cannot be readily distinguished’.¹⁹⁷ The second meaning documents and names a range of abuses while acknowledging that there are no defined analytic categories into which men’s behaviour can be positioned.¹⁹⁸ Kelly uses the continuum of violence to document the range of sexual violence as a whole and within each form, and she recognises that the categories that emerged from women’s experiences are not mutually exclusive but are connected and can overlap.

Another important feature of Kelly’s ‘continuum of violence’ relates to its capacity to capture ‘the everyday, routine intimate intrusions’ or the ‘everydayness of violence’¹⁹⁹ because it draws from lived experiences and thus functions beyond inadequately devised laws or formal categories. Centred on revealing connection, thinking in terms of a continuum links the everydayness of violence not captured by laws or the media to the more extreme versions that do get captured more readily. It is a very powerful resource that reveals the extent of violence and would prove especially helpful in the context of violence during reproductive healthcare generally and obstetric violence specifically. The continuum captures how facility-based birth, with its socially sanctioned ‘gentle violence’,²⁰⁰ shades into and out of exaggerated forms of patriarchal gender, racist and classist norms reflected in coercive or involuntary sterilisations during childbirth of women living with HIV²⁰¹ and outright denial of care leading to death.²⁰²

Bufacchi’s integrity framework helps to identify violence in reproductive healthcare generally, and Kelly’s ‘continuum of violence’ provides the resource to envision the range of violence in reproductive healthcare and within each form. The ‘continuum of violence’ nevertheless maintains a connection between different experiences that inform the range of violence in this context. Arguably, those manifestations of violence that would not fall under ‘obstetric violence’ because it occurs outside of childbirth would still constitute violence against women, trans and non-binary people in reproductive healthcare. However, these different forms of violence are not entirely separate because they share a common character: the violation of physical or psychological integrity.

8. Conclusion

‘Obstetric violence’ is a nebulous concept, with its reach and scope growing. The term ‘obstetric violence’ is increasingly used to capture any or all violations during reproductive healthcare more generally, with few conceptual limits. It may be that indeterminable boundaries enable debate and disrupt accepted norms, creating the space to explore and know something differently. In this respect, ‘obstetric violence’ has proved highly effective in renaming routine childbirth practices and oppressive health systems as a particular form of violence and its political strength is evident in its broader uptake by legislatures and international human rights bodies. This possibly explains why ‘obstetric violence’ is being use in an ever-expansive way. However, its nebulous character makes it increasingly difficult to operationalise ‘obstetric violence’ into law and other formal social reform processes which are clearly needed to support transformation of ‘care’ during childbirth.

With a view to contribute to the broader political agenda of bringing an end to obstetric violence, this paper suggests that ‘obstetric violence’ needs to be clarified in terms of understanding what is meant by ‘violence’ in ‘obstetric violence’ and to consider recognising conceptual boundaries. First, I propose that ‘violence’ in ‘obstetric violence’ be understood as the violation of physical and/or psychological integrity, locally qualified with the ‘view from everywhere’. This is aligned with lived experiences captured as the obvious outwardly disruption to physical unity but also dehumanisation through objectification, which undermines the unity of the self and the self’s broader connections in and with the world. Second, I propose that in order for this violence to qualify as ‘obstetric violence’, the violation of integrity should occur in the context of labour and/or childbirth, and the subject of the violence is the birthing woman, trans or non-binary person. This approach allows for focused reform efforts, and thinking in terms of a continuum of violence in reproductive healthcare ensures that there is always space to recognise different forms of obstetric violence and envisage its connections and overlaps with other reproductive injustices.

Given that the arguments and definitions put forward in this article are founded on lived experiences of victims/survivors and considered from a position that adopts a ‘view from everywhere’, ‘obstetric violence’ is a concept that remains open for creative and inclusive development. Therefore, the point is not that this is an approach set in stone; rather, it is open to change, and in adopting a ‘view from everywhere’ it ensures that all manifestations of obstetric violence in different geopolitical and cultural contexts can be seen, named and included in socio-legal responses to obstetric violence. However, conceptual coherence is required in order to support social reform efforts, including development of the law.

Footnotes