Naming Silence and Inadequate Obstetric Care as Obstetric Violence is a Necessary Step for Change

Exploring Definitions of Violence

The authors present the 2019 World Health Organization definition of violence, noting intentionality as a core factor. Their emphasis on intentionality can be contrasted with Shapiro’s (2018) interpretation of WHO guidance that focuses on the impact of chosen behaviors and actions rather than intent. Furthermore, it is useful to inform this definition of violence with additional elements described in the WHO definition of IPV, which is primarily experienced by women and which includes emotional and psychological abuse, such as intimidation, belittling, and insults, as well as controlling behaviors, such as isolating women and controlling their access to information, services, or resources (World Health Organization, 2012). This conceptualization of violence does not dwell on intentionality.

In addition, as the authors note, a broad literature describes the harmful impact obstetrical care can have on patients in a wide variety of care settings, and the WHO devotes particular attention to mistreatment and abuse in maternity care. Indeed “poor rapport between women and providers,” including ineffective communication and lack of supportive care, is one of seven categories of mistreatment of women in maternity care facilities described in a 2015 systematic review of 65 studies from 34 counties (Bohren et al., 2015). This and other research describes inequities in maternity care treatment that patients experience related to racism, low socioeconomic status, and education level—in both high-resource and low-resource settings around the world. Recent research in the United States and Canada, for example, found that women of color and of low socioeconomic status report receiving substandard care (Davis, 2019; McLemore et al., 2018; Salm Ward et al., 2013; Vedam et al., 2019). In addition, inequities in treatment and care provision affect not only the patient’s reported experiences of maternity care but also the physical and mental health outcomes for both mother and infant (Bohren et al., 2015; Chadwick et al., 2014; Jewkes & Penn-Kekana, 2015; Kruger & Schoombee, 2010; Wabiri et al., 2013).

Despite this evidence, Lappeman and Swartz, while noting differences in language and ethnicity between clinicians and patients in their examination of “silent ward milieu,” remain silent on the potential role these differences—and the historical racial inequities related to them—might play in care and in the “silent ward milieu” itself (Ford & Airhihenbuwa, 2010b). Furthermore, they fail to interrogate their own positionality within the health care system (Charmaz, 2014) or in relation to these inequities (Ford & Airhihenbuwa, 2010b). Given the engrained racism common through history in many countries such as the United States and South Africa, and prior studies demonstrating use of physical aggression and other controlling behaviors in South African maternity settings, this seems a glaring omission (Bohren et al., 2015; Chadwick et al., 2014; Jewkes et al., 1998; Kruger & Schoombee, 2010).

Expanding on Concepts of Disempowerment to Explore Agency and Intersectionality

In discussing violence and agency, the authors express concern that naming the silent ward milieu as violence will cast patients as victims and take away their agency. They present the fact that women do not choose to have birth companions as evidence of women’s agency to contradict medical advice, which while accurate, fails to take into consideration the fluidity and situational nature of agency and the intersectional axes along which power (necessary for agency) operates (Ford & Airhihenbuwa, 2010a). For example, in the United States studies have shown that the prolonged exposure of black women to racism and their heightened sensitivity to discriminatory practices and bias have negatively impacted their health care-seeking behavior, and their expectations of and attitudes toward health care services and workers. (Aronson et al., 2013; Benkert et al., 2006; Byrd & Clayton, 2001; Dovidio et al., 2008; Penner et al., 2013; Prather et al., 2016). In South Africa, Chadwick (2017), in her interviews with 35 marginalized South African women giving birth at public hospitals, uses a decentered view of agency, which she describes as “ambiguous” and “never total or separate from wider relations of power” (p. 494).

Assumptions that naming violence takes away agency, however, are not unprecedented and have been explored in the literature on IPV as well. Crenshaw (1991) described how U.S. women of color experiencing IPV also often experienced poverty, class oppression, and lack of economic possibilities, and emphasized that experiences of violence must be considered within the context of women’s lives. As described by Mahoney (2009):

. . . the abuse of women and its consequences must be explained “without defining the woman herself by the experience of abuse” [emphasis added]; second the woman’s perceptions and the context of her life must be explained . . . in a way that locates her experience within patterns of system power and oppression. (p. 59)

Describing structural “violence” against patients in the maternity care system does not take away patient agency but rather has the potential to illuminate and interrogate the power dynamics inherent, implicit, and in some cases, explicit, within the health care system. In particular, naming structural violence throws into relief the whole system, and moves away from blaming individual perpetrators to building accountability for the violence embedded within systems, hierarchies, and institutionalized practices (Scott et al., 2019).

Applying a Reproductive Justice Framework and Using a Systems Thinking Perspective to Examine Unintended Consequences

Finally, the authors express concern that naming the “silent ward milieu” as “violence,” even “gentle violence,” will produce unintended consequences, specifically low morale among clinicians who might resist efforts to change violent behavior, as well as a community-level perception of the maternity hospital as a place of violence. We advocate a systems thinking perspective that assumes and prepares for unintended consequences as well as a reproductive justice framework that considers reproductive health care a human right that must be available to all people. The ward silence itself is an unintended consequence of the current maternal care structure and the power dynamics of institutionalized racism and sexism.

The authors remind readers that clinicians are overworked and untrained for cultural engagement, which is consistent with the emerging literature on obstetric violence. For example, a review of 25 publications describing obstetric violence around the world noted:

Another explanation commonly given by professionals in the attempt to justify the violent scenario of obstetric care is based on elements such as work overload, scarce human resources, physical and mental exhaustion of professionals, precariousness of the conditions for care provision, and lack of adequate infrastructure in institutions. (Barbosa Jardim & Modena, 2018)

These stressful conditions in inadequate care environments result in providers themselves feeling violated by working conditions (Barbosa Jardim & Modena, 2018; Sadler et al., 2016).

The authors apply the feminist ethics of care paradigm, which focuses on the relational context of actions rather than right/wrong binaries, moving away from conceptualizations of “perpetrators” and “victims” and resisting the tendency to label actors as “good” or “bad”—or to blame patients. From our perspective, applying this paradigm argues in favor of naming the structural violence, as does black feminist theory, because both patients and clinicians are potentially harmed by the silent yet harried environment on the ward (Crenshaw, 1991; Scott et al., 2019). Thus, clinicians also experience the negative effects of structural violence within maternity care systems, and they too can benefit from adequate naming and examination of that violence. Chadwick (2017), for example, describes South African nurses in her research: “Rather than problematic individual perpetrators responsible for ‘causing’ violence, nurses are themselves intersectional subjects positioned in multiple ways in the birth assemblage” (p. 505). Helping practitioners to see both their behavior toward patients as well as their own unsatisfactory and overwhelmed experiences of the health care system within the context of structural violence clears a path forward for change.

It is true; some clinicians will feel attacked. But prioritizing clinicians’ comfort in the current system over the need for addressing violence against women inherent in the system is itself oppressive, and in the long run, unproductive. Naming obstetric violence fits within the reproductive justice framework, which has conceptual building blocks of intersectionality, reproductive oppression, and human rights (Ross & Solinger, 2017).

The jarring nature of the word “violence” can serve as a leverage point for driving change. As Shapiro (2018) describes it:

One reason for calling unintended harms a kind of “violence” is to overcome the relative ease with which such events are ignored, dismissed or trivialized. Employing the word violence is a conscious way of highlighting a continuum of violence that we could prefer to ignore. (p. 2)

In the United States, for example, naming racism has allowed for the exploration of its impact on health outcomes and investigation into the effects health care workers’ biases can have on racial disparities in health outcomes, including maternal outcomes. Despite some clinicians’ negative response, naming and identifying racism, including working with providers to reflect and identify how racism and other forms of oppression show up in their thinking and actions, was a first step to addressing the problem. This naming has also led to the development and implementation of anti-racism frameworks in medical training and health care institutions (Hardeman et al., 2018; Liaison Committee on Medical Education, 2019). The potential and positive impact of these changes on improving patient–clinician communication and patient-centered care and reducing clinician bias, emphasize the importance of naming an issue to allow for accountability and to spur change. A 2016 review concludes that the term obstetric violence is a “useful tool for addressing structural violence in maternity care” and for recognizing that obstetric violence is a form of violence against women (Sadler et al., 2016, p. 47).

In conclusion, naming obstetric violence is critical for describing the experiences of those experiencing such violence, and addressing the structures and contexts that create and fuel such violence, not for judgment but for accountability and change. Naming allows for study, for redress, and for growth. Obstetric violence itself often begins as a consequence of complex health care systems that in many cases are not centered on the pregnant people entering those systems and that violence has been institutionalized as normal. Naming and acknowledging structural violence can begin to challenge the normalization of obstetric violence, interrogate systems to allow for nuanced discussion of power dynamics, realistic care limitations, and recognition of full humanity of both patients and clinicians.