Commentary on the Article “How Gentle Must Violence Against Women Be in Order to Not Be Violent? Rethinking the Word ‘Violence’ in Obstetric Settings,” Reframed Within a Critical Discourse Orientation

Introduction

Violence against women is a known scourge on our society that affects far too many women worldwide. Primarily, when we speak about violence against women, we are referring to the physical, psychological, an sexual manifestations of this violence (World Health Organization [WHO], 2014). Its effects create significant health issues for women, families, and our society. Citing the WHO’s widely used definition of violence, it is understood as “. . . the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation” (WHO, 2019, para. 2).

The Swartz and Lappeman article titled, “How Gentle Must Violence Against Women Be in Order to Not Be Violent? Rethinking the Word ‘Violence’ in Obstetric Settings,” asks us to “rethink the word violence” and its use of the term as one that could potentially and inadvertently “disempower the women that it is meant to empower (p. 2).”

Behind this is the assertion that more recently the term “obstetrical violence” has been used to describe “an array of issues” surrounding women’s disempowering childbirth experiences (p. 2). More specifically, the authors help us to understand that this form of violence refers to various form of mistreatment experienced by birthing women that range from forced and unconsented procedures to the obvious more familiar acts of violence. Importantly, the authors center the root cause of these dehumanizing acts as a result of power, patriarchy, and societal norms. Yet, the authors posit that the use of the term obstetrical violence broadens the foundational use of the word “violence” as it has traditionally been understood. This “broadening” and reconceptualization of violence is believed to be most evident in the use of the term structural violence. Differentiation ensues by the authors in recognizing that structural violence extends violence through its unintentionality versus being intentional, and through its perpetrator—that being organization versus an individual. Furthermore, the authors ethically ponder causing unintended harm by labeling women as victims of violence, and institutions and their providers as perpetrators of such.

Background

Building on the authors’ point of departure for us to begin to rethink violence in obstetrical settings is the foundation of structural violence. For all intents and purposes, structural violence is violence that is insidious, socially/structurally sanctioned, causes oppressive injury to the individual’s sense of autonomy, and is damaging morally, psychologically, and emotionally. According to Galtung (1969), it exists at the organizational level and interferes with one’s ability to achieve their full potential. Unlike other forms of violence, structural violence can be more mystifying in pinpointing its origins; however, in my opinion, the authors correctly use it as a critical launching platform for coalescing the reimaging of the definition of violence. Less appreciated is the use of the term “slow” violence and “gentle” violence as additional ways of understanding the broadened applicability of the term violence. The authors discuss both “slow” and “gentle” violence as options for consideration within the obstetrical violence narrative, yet these terms seem to simplify violence. Those terms reduce the definition of violence to (a) occur within the constraints of timing, that is, slow versus fast, and (b) be subject to intensity, that is, gentle versus harsh. Doing so dilutes the severity of the impact of violence on its victims and implies being less harmful. Use of those terms conveys a subtlety of impact and onset, which are distinct and important delineations that can be more confusing than intended. However, in trying to understand the launching point from which to examine and unpack ways in which obstetrical care is delivered that may cause harm physically and psychologically, the authors lean toward an ecological orientation. They reference Freedman et al.’s (2014) typology to articulate the various levels that affect childbirth experiences: the individual, the structural, and the policy. From there, the authors introduce the feminist ethics of care paradigm which “require theorists not to label individual actors as good or bad, but rather to interrogate networks of power in which those relationships are embedded” (p. 7). It takes on the task of deepening our knowledge of the care ethics approach which builds on the notion of relations. Hence, the combined impact of using an ecological feminist informed lens accomplishes critical linkages to understanding and defining violence. First, it introduces context. When you have contextual considerations, you no longer have the experience occurring in isolation nor being shaped in siloes. It recognizes that the individual is situated and embedded within a family, community, and society and that the combination of these influences outcomes. Second, there is an acknowledgment of the relational aspect between and within these various contexts, particularly with issues of power and oppression, which although spatially perceived at the outer rungs deeply consequences the inner circles which include the individual. According to Jardim and Modina (2018), obstetrical violence is a feminist question because it is “the result of patriarchal oppression that leads to the undervaluation, oppression and objectification of the female body limiting the power and ways of expression of the women” (p. 8). Their discussion about this aspect is a beginning to what could have been further unpacked to underscore the interconnected networks of power that are highly relevant to deepening our examination of the phenomena of violence, its terminology uses, and how it becomes reified through these networks.

Commentary

With this in mind, the authors’ study setting is a community hospital labor ward located in a region of South Africa, a country with decades of exposure to various forms of violence at all levels and trauma. They used a multimethod ethnographic approach to gather information that ranged from observations, interviews, and document review. There is no explicit study purpose provided nor is there a rationale as to why the focus on stillbirth was central to the study population. This would be important to know to help better inform their position, their approach to analysis, and their conclusions.

Interestingly, the mothers in the labor ward refused to have birthing partners, which was viewed by the authors as evidence of the woman’s agency. Had the hospital been the refuser or prohibitor of birthing partners, according to the authors, this would have been viewed as “gentle violence” (p. 12). They posit that based on Freedman et al.’s (2014) typology, violence at the individual level is not evident. They ask the reader, “In this context what are the implications of using the term ‘gentle violence’ to describe what they observed?” (Swartz and Lappeman, p. 13). Following this question are a series of discussion points that ask the reader to consider three key ideals. First, their study participants were not educated on the use of the term violence which, they assert, tends to be understood in that region as overt acts and therefore positions women as victims without agency. The second consideration raised is that using the label of “violence” might have harmful effects on health care systems and providers given that they are mostly altruistic in their intentions to do good and not cause harm. Finally, the authors feel that health care systems should be designed to use approaches that improve care and not be subject to the perception of being inherently violent which can inhibit their ability to do so.

In response to the first question posed to the reader, the observation made by the researchers about the use of the term “gentle” violence to describe women not choosing to have a birthing partner in the delivery room is, in my view, limiting. What would be more aligned with the use of the term “violence” would be its use minus the precursor of “gentle” with a renewed focus beyond the individual. This refocusing would include the broader context of understanding women’s experiences, which more accurately grounds the feminist leanings that the authors purport as essential to this exploration. The act of childbirth is gendered and occurs within the broader society of patriarchy, social norms, cultural practices, and issues of women’s rights. Therefore, a more comprehensive application of the term violence is warranted. The conclusions shared in this study based solely on observation and individual perspectives are less likely to illuminate that which is insidious and shapes what are perceived as “choices” that women are making in this situation. Simply, it does not mean that because overt violent was not observed or explicitly named that it does not exist. Nor can we, for these very same reasons, “entertain the possibility of using a different kind of vocabulary to engage with structures and people in direct caregiving professions” (p. 17).

Overt violence cannot be the predicating factor for allowing the use of the term violence in situations where it might not be overt but still occurring. If that were the case, then acts that affect psychological safety and well-being would fall outside of this very narrow view of what violence is. Moreover, at what point is validation that violence occurred evidence that it has? Does this then mean that violence only occurs if it is perceived as such? The authors argue that the women do not perceive themselves to be victims; therefore, to label them as such is an assault on their agency. Before we discuss the implications based on the discourse on abused women’s identity and that of institutional identity, it is important to note that information is powerful. Many times in this field, women are given information about what abuse looks like. This is not to take away from their autonomy; in fact, it is to empower them by increasing their understanding, knowledge, and awareness. Countless women who have been in abusive relationships are seemingly unaware until they are introduced to the Duluth Model (n.d.) power and control wheel. The wheel is a tool to assist the abused in their understanding and recognition of violence in its various manifestations within intimate partner relationships. In these circumstances, we do not hold the same argument that their perception of not being exposed to violence is one which should be sustained to avoid labels. In essence, this disallows women the autonomy of “choosing” to live violence-free or not, and to what label if any they are most amenable. Choice cannot be introduced in the absence of knowledge and awareness. Furthermore, it would still create space for women to embrace or reject a victimization narrative and to choose their own identity.

Critically Bringing “Discourse” Into the Analysis

Beyond obstetrical violence, the issue surrounding the labeling of women exposed to the other forms of violence as victims persists. Leisenring’s (2006) study unpacked this discourse around the identity work of abused women and found that the label of victim can be enabling and constraining. Critically, the Leisenring (2006) study emphasized the importance of letting the individual decide how they want to construct an identity based on the complexities and the intersectionality of their lives. It was clear that we do not make that determination one way or the other.

The authors of this study assert that the “labelling of health care systems and practitioners as violent has far-reaching consequences on their emotional health and the system of people required to maintain health care professions and services” (p. 14). Any labeling of individuals as violent would indeed be harmful; however, naming the behavior is not. Intentionality is used as the precursor for determining the difference if the action should or should not be deemed violent. This is out of step with the ever-evolving understanding of the spectrum of violence: that regardless of the individual intent, the outcome or the impact is still what it is—violence. An additional assertion offered by the authors relates specifically to health care organizations and the need for them to be designed to provide better care and endear more considerate approaches to patient care (p. 14). Agreeably, this is essential. To do so, you have to be informed as to what better care approaches should entail and that includes not revictimizing and reifying violence and injustice within its structures–i.e., its policies, practices, and procedures.

The assertions laid out by the authors stem from conclusions drawn from the observation of silence in the maternity ward as an indicator of violence. As an isolated observation, yes, this clearly would be a stretch in the use of the term violence. Considering the typology and the paradigm the researchers introduced, which is assumed to have informed their approach and analysis, any conclusions must be based on the patient and contextual factors to sufficiently identify acts of violence. Importantly, the authors identified multiple data sources used to retrieve information, and therefore, these multiple sources have to be examined and interpreted together to guide any emergent conclusion that should stem from convergent analysis. If this is not the case, then the authors must provide more in-depth information about not simply the methods but the methodology used to arrive at an answer that would suggest heavily weighting the observed and perceived experience and putting less weight on the contextual influencers.

The authors conclude that patients’ voices and agency have to be “considered.” They also suggest that context must inform language use and explicitly surmise that terminology used can cause harm and be obstructive to change. Context does matter and, yes, without question, it has to be considered in relation to the patient, the situation, and the circumstances. With that in mind, the use of the term “violence” does not exclude the consideration of context. In fact, language is “part of,” not separate from, context, and not using the specific terminology does not mean that the experience implied by the term does not exist. I find extrapolations to be helpful in deepening our understanding. For example, if there is sexism occurring and it not perceived and it is not named, does it still exist? Furthering their understanding in the nuances of discourse would strengthen the exploration of the use of language in relation to context. The authors have made great effort to discuss discourse and use of language in a separate manner without deepening their exploration as to how they intersect and work interdiscursively as a critical element of social practice. In my views, this is where the argument strays.

Discourse analysis of this nature, especially within a feminist orientation, requires critical examination. The fore thinker of critical discourse analysis is Fairclough (2005, 2010, 2012), whose theoretical approach is situated within realist social ontology—inquiry that focuses on the dialectic between structure and agency and elements of social practice (Fairclough, 2012). According to Fairclough, there are intersections of practices, structures, and agents which can be mediating. Texts are produced through these elements and require interdiscursive analysis to introduce context and relationship between these elements which influence change (Fairclough, 2005, 2012).

Using discourse analysis to understand the nuances of the term “violence” is better suited as a more encompassing approach to unpacking the traditional definition of violence, the assuaged use of violence as “gentle” or “slow,” and agency. Language is in semiosis with discourse and represented within practices as part of social structure. Potter’s (2004) approach to discourse analysis supports Fairclough’s assertion that discourse is situated and constructed in that it reflects both words and the world; in essence, it is a by-product of both. Potter (2004) goes on to warn that

One of the difficulties in dealing with texts is their designed mobility encourages the analyst to treat them in a decontextualized manner which is inattentive to the practices that they are part of. At the same time, working with decontextualized texts provides temptation to speculate about their abstraction relation to structures posited by social or psychological theory. (p. 614)

Conclusion

In summary, the authors’ mention of context in relation to the appropriate use of “gentle” or “slow” violence based on setting is a preliminary step in the right direction. A more comprehensive approach is required to reorient this inquiry to one guided by a critical discourse analysis framework that could offer a more robust exploration of the terminology and better inform their initial exploration around the use of the word violence. In the intimate partner violence policy study by Burnett et al. (2015), a critical discourse analysis framework was used to help facilitate an integrated analysis that identifies and links between intention, practices, the lived experience, intended and unintended consequences, social practices, and structures.

If we were to now revisit the earlier definition of violence offered by the WHO (2019) and cited by the authors, it does cause pause in the limitations of its generalizability to what we know and have come to encapsulate as violence. Use of the term violence is language that reflects a discourse in transition that needs to be recontextualized to meet the demands of today. The process of recontextualization which is taking the discourse into new contexts requires decontextualization, removing it from the old contexts (Fairclough, 2010). This study is a launching point for discussion on that transition.