Abstract

Studies on disrespect and abuse/mistreatment/obstetric violence during pregnancy, childbirth and puerperium have increased in recent decades. However, researchers interested in the subject face many theoretical and methodological difficulties. In this sense, this study aims to discuss and reflect on how issues related to definition and terminology, measurement, and public policies in Brazil have hindered research on this topic and the mitigation of these acts. The first problem addressed was the lack of consensus regarding the terminology and definition of this construct. This situation causes a cascading effect, impacting the use of non-validated measurement instruments and, consequently, a lack of accuracy and comparability between studies. Another issue mentioned is the lack of studies exploring the consequences of these acts on women’s and newborn’s health, which is one of the main gaps on the subject today. The absence of causal studies affects health decision-making, impairing the elaboration of specific public policies.

Key words:
Violence; Violence against women; Pregnancy; Childbirth; Puerperium; Epidemiology

Introduction

The Sustainable Development Goals (SDGs) recognize that the gender inequality issue is of paramount importance in combating gender differences in terms of study opportunities, work, income, political participation and other areas¹1 Nações Unidas no Brasil. Glossário de termos do Objetivo de Desenvolvimento Sustentável 5: alcançar a igualdade de gênero e empoderar todas as mulheres e meninas. Brasília: ONU Brasil; 2016.. In this context, confronting all forms of violence against women is one of the themes to be addressed to achieve this equity¹1 Nações Unidas no Brasil. Glossário de termos do Objetivo de Desenvolvimento Sustentável 5: alcançar a igualdade de gênero e empoderar todas as mulheres e meninas. Brasília: ONU Brasil; 2016..

Violence against women is classified into two distinct types of manifestations of violence: collective violence and interpersonal violence. The first contemplates acts perpetrated by the state or institutions, such as violence and sexual slavery during wars and conflicts, police violence, terrorism, and others. The second refers to violence perpetrated by individuals with or without a personal/intimate relationship with the victim. This can occur within the home or in the community and includes domestic violence (psychological, physical and sexual), reproductive coercion, sexual harassment, rape, genital mutilation, and other forms of abuse²2 Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet 2002; 360(9339):1083-1088..

According to some researchers on the subject, societies whose cultures accept and tolerate violence against women are more likely to naturalize these acts, including those that occur within health services³3 Bohren MA, Mehrtash H, Fawole B, Maung TM, Balde MD, Maya E, Thwin SS, Aderoba AK, Vogel JP, Irinyenikan TA, Adeyanju AO, Mon NO, Adu-Bonsaffoh K, Landoulsi S, Guure C, Adanu R, Diallo BA, Gülmezoglu AM, Soumah AM, Sall AO, Tunçalp Ö. How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys. Lancet 2019; 6736(19):1750-1763.. However, recent publications have shown that many women worldwide suffer maltreatment, disrespect, abuse, or even violence during pregnancy, childbirth and puerperium from health professionals⁴4 Castro R, Frías SM. Obstetric violence in Mexico: results from a 2016 National Household Survey. Violence Against Women 2019; 26(6-7):555-572.

5 Sando D, Kendall T, Lyatuu G, Ratcliffe H, McDonald K, Mwanyika-Sando M, Emil F, Chalamilla G, Langer A. Disrespect and abuse during childbirth in Tanzania: are women living with HIV more vulnerable? J Acquir Immune Defic Syndr 2014; 67(Suppl. 4):S228-S234.^-66 Mesenburg MA, Victora CG, Jacob Serruya S, Ponce de León R, Damaso AH, Domingues MR, Silveira MF. Disrespect and abuse of women during the process of childbirth in the 2015 Pelotas birth cohort. Reprod Health 2018;15(1):54.. The same is true for women undergoing abortion⁷7 Tobasía-Hege C, Pinart M, Madeira S, Guedes A, Reveiz L, Valdez-Santiago R, Pileggi V, Arenas-Monreal L, Rojas-Carmona A, Piña-Pozas M, Gómez Ponce de León R, Souza JP. Irrespeto y maltrato durante el parto y el aborto en América Latina: revisión sistemática y metaanálisis. Rev Panam Salud Publica 2019; 43:e36. In Brazil, according to hospital studies carried out in 2011 and 2015, the prevalence was 44.3% and 18.3%, respectively⁶6 Mesenburg MA, Victora CG, Jacob Serruya S, Ponce de León R, Damaso AH, Domingues MR, Silveira MF. Disrespect and abuse of women during the process of childbirth in the 2015 Pelotas birth cohort. Reprod Health 2018;15(1):54.^,88 Leite TH, Pereira APE, Leal MC, Silva AAM. Disrespect and abuse of women during birth and postpartum depression: findings from a national survey on childbirth in Brazil. J Affect Disord 2020; 273:391-401.. Due to its high prevalence, disrespect, abuse, maltreatment and violence during childbirth are considered a serious form of gender violence, compromising the fundamental human rights of women, in addition to being a global public health problem⁹9 World Health Organization (WHO). The prevention and elimination of disrespect and abuse during facility-based childbirth. Geneva: WHO 2015..

In the last decade, interest in studying this form of violence against women during childbirth has grown, mainly due to the feminist movement and groups that seek to claim the individual rights of women, reinforcing their freedom and autonomy in this very special moment of life¹⁰10 Diniz SG, Salgado HO, Andrezzo HFA, Carvalho PGC, Carvalho PCA, Aguiar CA, Niy DY. Violência obstétrica como questão para a saúde pública no brasil: origens, definições, tipologia, impactos sobre a saúde materna, e propostas para sua prevenção. J Hum Growth Dev 2015; 25(3):1-8.^,1111 Diniz SG, Silveira LP, Mirim LA. Violência contra a mulher: estratégias e respostas do movimento feminista no Brasil (1980-2005). In: Diniz SG, Silveira LP, Mirim LA. Vinte e cinco anos de respostas brasileiras em violência contra a mulher (1980-2005): alcances e limites. 2006.. The increase in women’s education, entry into the labor market and the achievement of sexual and reproductive rights made the scenario quite favorable to broaden the discussion.

Despite the increase in scientific and civil society interest in the subject, many theoretical and methodological difficulties are imposed on researchers who wish to explore this research topic. These include a lack of consensus between the terminologies and definitions used and consequently, the difficulty of measuring the problem, which hinder the identification and knowledge of the magnitude and conducting causal studies on the consequences of these acts on maternal and child health, the latter being scarce in the literature¹²12 Leite TH, Carvalho TDG, Marques ES, Pereira APE, Silva AAM, Nakamura-Pereira M, Leal MC. The association between mistreatment of women during childbirth and postnatal maternal and child health care: findings from "Birth in Brazil". Women and Birth 2021; no prelo.. Therefore, the objective of this study is to discuss the conceptual and methodological issues that hinder and restrict research on this topic based on the existing scientific literature.

Terminologies and definitions

There is no consensus in the literature on the terminology and definition that best express the acts of disrespect, abuse, ill-treatment and violence against women perpetrated by health professionals during the pregnancy and puerperal cycle. The most commonly used terms are “disrespect and abuse in facility-based childbirth”¹³13 Bowser D, Hill K. Exploring evidence for disrespect and abuse in facility-based childbirth report of a landscape analysis [Internet]. Harvard School of Public Health University Research Co., LLC; 2010. [cited 2019 23 Jan]. Available from: https://www.harpnet.org/resource/exploring-evidence-for-disrespect-and-abuse-in-facility-based-childbirth-report-of-a-landscape-analysis/
https://www.harpnet.org/resource/explori... , “mistreatment of women in childbirth at health facilities”¹⁴14 Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, Aguiar C, Saraiva Coneglian F, Diniz AL, Tunçalp Ö, Javadi D, Oladapo OT, Khosla R, Hindin MJ, Gülmezoglu AM. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med 2015; 12(6):e1001847., and “obstetric violence”¹⁰10 Diniz SG, Salgado HO, Andrezzo HFA, Carvalho PGC, Carvalho PCA, Aguiar CA, Niy DY. Violência obstétrica como questão para a saúde pública no brasil: origens, definições, tipologia, impactos sobre a saúde materna, e propostas para sua prevenção. J Hum Growth Dev 2015; 25(3):1-8.. These terms are often used interchangeably. However, they have different definitions, criticisms and gaps¹²12 Leite TH, Carvalho TDG, Marques ES, Pereira APE, Silva AAM, Nakamura-Pereira M, Leal MC. The association between mistreatment of women during childbirth and postnatal maternal and child health care: findings from "Birth in Brazil". Women and Birth 2021; no prelo..

The term “disrespect and abuse in facility-based childbirth” was the first to be used to endorse situations of disrespect, mistreatment and violence perpetrated by health teams during pregnancy and childbirth. The term was proposed by Bowser and Hill¹³13 Bowser D, Hill K. Exploring evidence for disrespect and abuse in facility-based childbirth report of a landscape analysis [Internet]. Harvard School of Public Health University Research Co., LLC; 2010. [cited 2019 23 Jan]. Available from: https://www.harpnet.org/resource/exploring-evidence-for-disrespect-and-abuse-in-facility-based-childbirth-report-of-a-landscape-analysis/
https://www.harpnet.org/resource/explori... (2010) and includes seven dimensions in its definition: 1) Physical abuse, 2) Nonconsented care, 3) Nonconfidential care, 4) Nondignified care (including verbal abuse), 5) Discrimination based on specific patient attributes, 6) Abandonment of care, and 7) Detection in facilities. This term and its definition were the first to give visibility to the issue worldwide as it served as the basis for an important publication by the World Health Organization in 2015 entitled “The prevention and elimination of disrespect and abuse during facility-based childbirth”⁹9 World Health Organization (WHO). The prevention and elimination of disrespect and abuse during facility-based childbirth. Geneva: WHO 2015.. Furthermore, from the creation of this term and its definition, epidemiological studies in the area were conducted, and its development aimed to identify and better understand the then little studied subject⁴4 Castro R, Frías SM. Obstetric violence in Mexico: results from a 2016 National Household Survey. Violence Against Women 2019; 26(6-7):555-572.^,1515 Okafor II, Ugwu EO, Obi SN. Disrespect and abuse during facility-based childbirth in a low-income country. Int J Gynaecol Obs 2015;128(2):110-113.^,1616 Jungari S, Sharma B, Wagh D. Beyond maternal mortality: a systematic review of evidences on mistreatment and disrespect during childbirth in health facilities in India. Trauma Violence Abuse 2021; 22(4):739-751.. However, both the term and its definition have some limitations. The insufficiency of its categories to characterize all forms of existing disrespect and abuse and the lack of mention of the need for intentionality of the perpetrator are highlighted¹⁷17 Freedman LP, Ramsey K, Abuya T, Bellows B, Ndwiga C, Warren CE, Kujawski S, Moyo W, Kruk ME, Mbaruku G. Defining disrespect and abuse of women in childbirth: a research, policy and rights agenda. Bull World Health Organ 2014; 92(12):915-917.. In addition, this definition emphasizes that acts of disrespect and abuse are exclusive to childbirth situations and birth and does not consider that these events can also occur during pregnancy (prenatal care), postpartum and abortion situations. Finally, authors such as Savage and Castro¹²12 Leite TH, Carvalho TDG, Marques ES, Pereira APE, Silva AAM, Nakamura-Pereira M, Leal MC. The association between mistreatment of women during childbirth and postnatal maternal and child health care: findings from "Birth in Brazil". Women and Birth 2021; no prelo. and Bohren et al.¹⁹19 Coletivo Margarida Alves. Violência obstétrica no abortamento. Coletivo Margarida Alves; 2020. point out the difficulty of operationalizing the proposed dimensions¹²12 Leite TH, Carvalho TDG, Marques ES, Pereira APE, Silva AAM, Nakamura-Pereira M, Leal MC. The association between mistreatment of women during childbirth and postnatal maternal and child health care: findings from "Birth in Brazil". Women and Birth 2021; no prelo.^,1818 Bohren MA, Vogel JP, Fawole B, Maya ET, Maung TM, Baldé MD, Oyeniran AA, Ogunlade M, Adu-Bonsaffoh K, Mon NO, Diallo BA, Bangoura A, Adanu R, Landoulsi S, Gülmezoglu AM, Tunçalp Ö. Methodological development of tools to measure how women are treated during facility-based childbirth in four countries: labor observation and community survey. BMC Med Res Methodol 2018;18(1):132., and, according to them, this was the reason why there was no proposed instrument for use in epidemiological studies.

In order to solve some of the limitations mentioned above, Bohren et al.¹⁴14 Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, Aguiar C, Saraiva Coneglian F, Diniz AL, Tunçalp Ö, Javadi D, Oladapo OT, Khosla R, Hindin MJ, Gülmezoglu AM. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med 2015; 12(6):e1001847. (2015) proposed a new term, “mistreatment of women in childbirth at health facilities”. This term also has seven dimensions, called third-order terms: 1) Physical abuse, 2) Sexual abuse, 3) Verbal abuse, 4) Stigma and discrimination, 5) Failure to meet professional standards of care, 6) Poor rapport between women and providers, and 7) Health system condition and constraints. Each third-order term is divided into second- and first-order terms. Examples include physical abuse (third-order theme) - second-order themes of the (1) use of force and (2) physical restraint and - first-order themes of (1) women beaten, slapped, kicked, or pinched during delivery and (2) women physically restrained to the bed or gagged during delivery¹⁷17 Freedman LP, Ramsey K, Abuya T, Bellows B, Ndwiga C, Warren CE, Kujawski S, Moyo W, Kruk ME, Mbaruku G. Defining disrespect and abuse of women in childbirth: a research, policy and rights agenda. Bull World Health Organ 2014; 92(12):915-917..

The definition proposed by Bohren et al.¹⁴14 Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, Aguiar C, Saraiva Coneglian F, Diniz AL, Tunçalp Ö, Javadi D, Oladapo OT, Khosla R, Hindin MJ, Gülmezoglu AM. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med 2015; 12(6):e1001847. (2015) advances by listing a greater number of acts that are considered mistreatment, making the concept more inclusive than the previous one. This definition allowed the expansion of some discussions involving the context of care during labor and birth and the intentionality of acts of abuse. Regarding the context, it is known that the working conditions of health professionals are related to the quality of care offered to women. Maternity wards that often operate beyond their capabilities can leave many women feeling neglected and having difficulty communicating with the health team. Thus, the condition of the health system is an important element that must be considered to explain possible motivations for mistreatment and negative experiences during childbirth¹⁷17 Freedman LP, Ramsey K, Abuya T, Bellows B, Ndwiga C, Warren CE, Kujawski S, Moyo W, Kruk ME, Mbaruku G. Defining disrespect and abuse of women in childbirth: a research, policy and rights agenda. Bull World Health Organ 2014; 92(12):915-917.. Furthermore, the lack of structure available in the care of women is an important component since it does not depend on the health team and is considered institutional violence. Inadequate structure has the potential to harm women’s dignity and privacy, as well as reduce the hospital/maternity ward’s capacity to offer the best possible care, considering the scientific evidence¹⁷17 Freedman LP, Ramsey K, Abuya T, Bellows B, Ndwiga C, Warren CE, Kujawski S, Moyo W, Kruk ME, Mbaruku G. Defining disrespect and abuse of women in childbirth: a research, policy and rights agenda. Bull World Health Organ 2014; 92(12):915-917..

Another point mentioned by Bohren et al.¹⁴14 Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, Aguiar C, Saraiva Coneglian F, Diniz AL, Tunçalp Ö, Javadi D, Oladapo OT, Khosla R, Hindin MJ, Gülmezoglu AM. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med 2015; 12(6):e1001847. concerns the intentionality of acts of mistreatment. The authors recognize that these acts may be intentional or unintentional, but they do not deem it necessary to make this distinction, claiming that there is no difference in the assessment of the impact for the woman and the newborn. However, this position can be questioned since it does not agree with the definition of interpersonal violence proposed by the WHO²2 Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet 2002; 360(9339):1083-1088.. In this definition, violence is described as “acts of an intentional nature with the potential to cause harm”, which it associates the intentionality of the act of violence itself, regardless of the result it produces²2 Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet 2002; 360(9339):1083-1088.. It is important to point out that this definition of violence proposed by the WHO considers the possible negative effects of violence on the health and well-being of individuals. In the absence of a consensus on the terms and definitions in this area, it is necessary to critically analyze the positive and negative points of a definition that considers intentional and unintentional acts. As a positive point, the possibility of capturing subtle and subjective negative experiences stands out. The downside of incorporating this issue is the expansion of the scope of acts included in the definition, which can make operationalization through an instrument more difficult.

In addition to having enabled important discussions on the topic, such as those mentioned above, the main progress of the proposal by Bohren et al.¹⁴14 Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, Aguiar C, Saraiva Coneglian F, Diniz AL, Tunçalp Ö, Javadi D, Oladapo OT, Khosla R, Hindin MJ, Gülmezoglu AM. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med 2015; 12(6):e1001847. (2015) was the creation of a questionnaire with the objective of measuring mistreatment in childbirth in a standardized way. The main objective is estimating the prevalence, allowing a greater comparison between studies and encouraging the development of causal studies²¹21 Leal MC, Pereira AP, Domingues RM, Theme Filha MM, Dias MA, Nakamura-Pereira M, Bastos MH, Gama SG. Obstetric interventions during labor and childbirth in Brazilian low-risk women. Cad Saude Publica 2014; 30(Suppl. 1):S1-16.. Since the creation of this term and its definition, the WHO has adopted the term mistreatment in all its publications³3 Bohren MA, Mehrtash H, Fawole B, Maung TM, Balde MD, Maya E, Thwin SS, Aderoba AK, Vogel JP, Irinyenikan TA, Adeyanju AO, Mon NO, Adu-Bonsaffoh K, Landoulsi S, Guure C, Adanu R, Diallo BA, Gülmezoglu AM, Soumah AM, Sall AO, Tunçalp Ö. How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys. Lancet 2019; 6736(19):1750-1763..

Another very popular term, especially in Latin America, but not restricted to these countries, is the term “obstetric violence”. Venezuela pioneered the construction of the term and its definition in the form of legislation in 2007. The Venezuelan definition considers obstetric violence to be any direct or indirect conduct, action or omission of a health team in the public or private sphere characterized by the appropriation of the woman’s body and reproductive processes by the health professional, which is expressed by a dehumanized care, abuse of medicalization and pathologization of natural processes, resulting in loss of autonomy and ability to freely decide about their body and their sexuality, negatively affecting their quality of life22. In Argentina, in 2009, a law was passed that defines both obstetric violence and violence against reproductive freedom. According to this law, obstetric violence is defined as acts performed by health professionals on the body, also involving the reproductive processes of women, which can be expressed through dehumanized treatment, abuse of medicalization and pathologization of natural processes in childbirth, birth and puerperium of the woman and her baby²²22 World Health Organization (WHO). Intrapartum care for a positive childbirth experience [Internet]. 2018. [cited 2019 23 Jan]. Available from: http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf?ua=1%0Ahttp://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/
http://apps.who.int/iris/bitstream/10665... .

Then, based on the proposals of Venezuela and Argentina, several Latin American countries approved specific laws addressing the term obstetric violence. In 2013, this occurred in Panama and Bolivia²²22 World Health Organization (WHO). Intrapartum care for a positive childbirth experience [Internet]. 2018. [cited 2019 23 Jan]. Available from: http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf?ua=1%0Ahttp://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/
http://apps.who.int/iris/bitstream/10665... . Between 2007 and 2018, several Mexican states passed laws that defined and punished obstetric violence in the country. Finally, in 2017, Uruguay adhered to the use of this term²²22 World Health Organization (WHO). Intrapartum care for a positive childbirth experience [Internet]. 2018. [cited 2019 23 Jan]. Available from: http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf?ua=1%0Ahttp://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/
http://apps.who.int/iris/bitstream/10665... . In Brazil, there is no specific federal law that addresses the issue of obstetric violence. However, the Brazilian Federal Constitution subjectively contemplates protection against the occurrence of this type of violence as it makes it clear that the state must guarantee the right to health, physical and mental integrity and nondiscrimination. Another important milestone was the convention in Belém do Pará, where the rights of all women to live free from violence was recognized. Furthermore, to complement this, the medical code of ethics establishes patient secrecy and confidentiality in its fundamental principles²²22 World Health Organization (WHO). Intrapartum care for a positive childbirth experience [Internet]. 2018. [cited 2019 23 Jan]. Available from: http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf?ua=1%0Ahttp://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/
http://apps.who.int/iris/bitstream/10665... .

However, the term obstetric violence has been rejected among health professionals who work in childbirth care, especially in Brazil. The main reason for its low acceptance is mainly due to the incorporation of the pathologization and medicalization of labor and birth into the definition. Thus, although some acts can be more easily understood as violence, others, claimed by activists for the humanization of childbirth, are related to routine medical procedures. In this way, the denunciation of acts of obstetric violence, from the perspective of the social movement, is a way of questioning a certain worldview about what constitutes ideal childbirth care. In an attempt to alleviate this conflict, but without failing to reinforce the importance of a respectful birth/birth, the Network for the Humanization of Childbirth (ReHuNa, acronym in Portuguese), for example, has chosen to establish a counterpoint using positive terms such as “humanization of childbirth” and “the promotion of women’s human rights” as opposed to the use of the term obstetric violence¹³13 Bowser D, Hill K. Exploring evidence for disrespect and abuse in facility-based childbirth report of a landscape analysis [Internet]. Harvard School of Public Health University Research Co., LLC; 2010. [cited 2019 23 Jan]. Available from: https://www.harpnet.org/resource/exploring-evidence-for-disrespect-and-abuse-in-facility-based-childbirth-report-of-a-landscape-analysis/
https://www.harpnet.org/resource/explori... .

Some empirical evidence found in Brazil reinforces the hypothesis that the unnecessary medicalization of childbirth may not be interpreted as a form of violence by the health team and even for some women. For example, all indicators of quality of care in childbirth are evaluated worse by black women with low education²³23 Diniz CSG, Rattner D, d'Oliveira AFPL, Aguiar JM, Niy DY. Disrespect and abuse in childbirth in Brazil: social activism, public policies and providers' training. Reprod Health Matters 2018; 26(53):19-35.. However, some interventions, such as episiotomy and elective cesarean sections, are more frequent in white women with high education²⁴24 Leite TH, Pereira APE, Leal MC, Silva AAM. Disrespect and abuse towards women during childbirth and postpartum depression: findings from Birth in Brazil Study. J Affect Disord 2020; 273:391-401., creating an apparent paradox. It is important to note that according to the WHO, excessive vaginal and multiple professional touches, routine episiotomy, the Kristeller maneuver, early amniotomy, routine use of oxytocin, cesarean sections without clinical indication and imposition of the delivery position are not recommended practices in childbirth care²⁵25 Silveira MF, Mesenburg MA, Bertoldi AD, Mola CL, Bassani DG, Domingues MR, Stein A, Coll CVN. The association between disrespect and abuse of women during childbirth and postpartum depression: findings from the 2015 Pelotas birth cohort study. J Affect Disord 2019; 256:441-447.. However, many health professionals in Brazil do not view these practices as abusive but as acts inherent to childbirth care²⁴24 Leite TH, Pereira APE, Leal MC, Silva AAM. Disrespect and abuse towards women during childbirth and postpartum depression: findings from Birth in Brazil Study. J Affect Disord 2020; 273:391-401..

To break this paradigm, some researchers believe that it is necessary to change the way professionals who work during the pregnancy-puerperal cycle are taught and learn, emphasizing the approach based on scientific evidence and respect for the autonomy and dignity of women²⁶26 Souza KJ, Rattner D, Gubert MB. Institutional violence and quality of service in obstetrics are associated with postpartum depression. Rev Saude Publica 2017; 51:69..

Measurement

The lack of consensus in the terminology and definitions used in acts of disrespect, abuse, maltreatment and obstetric violence and the absence of a validated instrument to measure this construct make epidemiological studies complex and difficult to compare.

The most popular instrument existing at the present time was proposed by Borhen et al.¹⁴14 Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, Aguiar C, Saraiva Coneglian F, Diniz AL, Tunçalp Ö, Javadi D, Oladapo OT, Khosla R, Hindin MJ, Gülmezoglu AM. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med 2015; 12(6):e1001847. (2015). This instrument was created and used in some studies conducted in African countries²¹21 Leal MC, Pereira AP, Domingues RM, Theme Filha MM, Dias MA, Nakamura-Pereira M, Bastos MH, Gama SG. Obstetric interventions during labor and childbirth in Brazilian low-risk women. Cad Saude Publica 2014; 30(Suppl. 1):S1-16.. Despite advances in the measurement process, this instrument has important limitations. The main dimension refers to the dimensions (or 3rd-order terms) contemplated, which clearly cover only three of the seven dimensions described (psychological/verbal violence, physical violence and stigma and discrimination). The instrument also presents questions about vaginal exams, nonpharmacological methods for pain relief, mobility, nutrition, and the presence of a companion during labor and delivery, but it does not describe in which dimension these questions are inserted. There is also a block of questions focusing on unreasonable demands, tariff structure and negligence, which mixes different situations that do not seem to be directly connected. Finally, sexual violence was completely excluded from this instrument.

Borhen et al.¹⁴14 Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, Aguiar C, Saraiva Coneglian F, Diniz AL, Tunçalp Ö, Javadi D, Oladapo OT, Khosla R, Hindin MJ, Gülmezoglu AM. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med 2015; 12(6):e1001847. do not clarify whether they consider this set of proposed questions as a factual instrument or a questionnaire. The authors did not conduct any analysis of the psychometric properties of this instrument or a form of systematization of information and, consequently, the classification of women in relation to the violence experienced. In addition to the aforementioned limitations, the instrument is considered inadequate to assess possible situations of mistreatment against women during prenatal care and abortions.

The absence of valid and accurate instruments for measuring this problem leads to the impossibility of accurately estimating the prevalence of the event of interest, a lack of comparability between existing studies in different contexts and populations, difficulty in monitoring estimates over time, and an absence of studies focusing on the risk factors and consequences of these events on the health of women and newborns.

An example of the lack of precision in estimating prevalence and comparing data can be seen between the two hospital-based studies recently published in Brazil. Both studies used the term “disrespect and abuse in childbirth”. In the first study, a national survey on labor and birth conducted in 2011/2012, the prevalence of disrespect and abuse was approximately 44.3%. This study considered seven indicators that encompassed the occurrence of physical and psychological violence, disrespectful treatment, a lack of information, privacy and communication with the health team, the inability to ask questions and loss of autonomy¹¹11 Diniz SG, Silveira LP, Mirim LA. Violência contra a mulher: estratégias e respostas do movimento feminista no Brasil (1980-2005). In: Diniz SG, Silveira LP, Mirim LA. Vinte e cinco anos de respostas brasileiras em violência contra a mulher (1980-2005): alcances e limites. 2006.. In the second survey, using data from the Pelotas cohort (2015), a prevalence of disrespect and abuse of 18.3% was estimated considering four questions about verbal violence, physical violence, interventions against the woman’s will and negligence. In this case, the difference in prevalence is mainly due to the different measurement methods⁶6 Mesenburg MA, Victora CG, Jacob Serruya S, Ponce de León R, Damaso AH, Domingues MR, Silveira MF. Disrespect and abuse of women during the process of childbirth in the 2015 Pelotas birth cohort. Reprod Health 2018;15(1):54..

Lack of studies that evaluate the consequences of disrespect, abuse, maltreatment and obstetric violence

The literature on disrespect, abuse, maltreatment and obstetric violence includes a small number of studies focusing on the consequences of these acts on women’s health and, in some cases, on the newborn. The scarcity of this type of study is one of the main gaps on the subject today¹¹11 Diniz SG, Silveira LP, Mirim LA. Violência contra a mulher: estratégias e respostas do movimento feminista no Brasil (1980-2005). In: Diniz SG, Silveira LP, Mirim LA. Vinte e cinco anos de respostas brasileiras em violência contra a mulher (1980-2005): alcances e limites. 2006.^,1515 Okafor II, Ugwu EO, Obi SN. Disrespect and abuse during facility-based childbirth in a low-income country. Int J Gynaecol Obs 2015;128(2):110-113.. This lack of causal studies involving this theme are, in fact, consequences of the lack of consensus regarding the terminology and definition of this theoretical field and, mainly, the lack of a validated instrument to capture this construct more accurately.

Many causal hypotheses have been suggested by researchers in the field, but few have scientific support. Some research suggests that disrespect, abuse, maltreatment and obstetric violence may be associated with negative health outcomes for their victims, such as an increased probability of developing anxiety, posttraumatic stress disorder and postpartum depression¹¹11 Diniz SG, Silveira LP, Mirim LA. Violência contra a mulher: estratégias e respostas do movimento feminista no Brasil (1980-2005). In: Diniz SG, Silveira LP, Mirim LA. Vinte e cinco anos de respostas brasileiras em violência contra a mulher (1980-2005): alcances e limites. 2006.^,2727 d'Oliveira AF, Diniz SG, Schraiber LB. Violence against women in health-care institutions: an emerging problem. Lancet 2002; 359(9318):1681-1685.^,2828 Oliveira S. Por um recorte genealógico da categoria violência obstétrica [Dissertação] Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2019., low use of health services by women and newborns in the postpartum period¹⁵15 Okafor II, Ugwu EO, Obi SN. Disrespect and abuse during facility-based childbirth in a low-income country. Int J Gynaecol Obs 2015;128(2):110-113. and greater difficulty breastfeeding¹⁵15 Okafor II, Ugwu EO, Obi SN. Disrespect and abuse during facility-based childbirth in a low-income country. Int J Gynaecol Obs 2015;128(2):110-113.. Considering that one of the components of disrespect, abuse, maltreatment and obstetric violence is negligence, likely outcomes cited are the increase in the occurrence of maternal near misses and maternal and fetal mortality¹³13 Bowser D, Hill K. Exploring evidence for disrespect and abuse in facility-based childbirth report of a landscape analysis [Internet]. Harvard School of Public Health University Research Co., LLC; 2010. [cited 2019 23 Jan]. Available from: https://www.harpnet.org/resource/exploring-evidence-for-disrespect-and-abuse-in-facility-based-childbirth-report-of-a-landscape-analysis/
https://www.harpnet.org/resource/explori... . It is also possible that the experience of obstetric violence alters the decision regarding the delivery mode in subsequent pregnancies (e.g., women who suffered maltreatment during a vaginal delivery may opt for an elective cesarean section in future pregnancies). However, most of the outcomes mentioned are based on hypotheses with little or no empirical scientific evidence.

In addition, it is noteworthy that the occurrence of disrespect, maltreatment and obstetric violence during the pregnancy-puerperal cycle can also negatively impact more subjective issues, such as the perception of the quality of care received and satisfaction with childbirth, among others.

A new look at the terms, definitions, and forms of operationalization of obstetric violence

The elaboration of a term and, consequently, a definition that endorses most of the acts of disrespect, mistreatment and violence perpetrated by health professionals against women during the pregnancy and childbirth cycle and that is accepted by researchers and becomes a consensus in the area is still a major challenge. However, this question is of paramount importance to better understand the phenomena related to this problem. It is necessary to delimit these acts in a way that captures the negative and subjective experiences of the victim. Moreover, the definition cannot be so broad as to lose its meaning and marginalize any and all actions taken by the health team in the care of women. Furthermore, it is necessary to demarcate which acts are perpetrated by health professionals during the care of women and which are due to the lack of investment in the structure, materials and equipment in the health sector²2 Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet 2002; 360(9339):1083-1088.. With this in mind, the use of the term obstetric violence to characterize the acts of psychological/verbal, physical, sexual violence, and intentional neglect by health teams in the prenatal care, childbirth, and abortion situations for women can be quite advantageous since it covers a delimited scope of manifestations, which are well defined in the literature²2 Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet 2002; 360(9339):1083-1088..

In this sense, Bohren et al.¹⁴14 Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, Aguiar C, Saraiva Coneglian F, Diniz AL, Tunçalp Ö, Javadi D, Oladapo OT, Khosla R, Hindin MJ, Gülmezoglu AM. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med 2015; 12(6):e1001847. (2015) has already taken the first steps in the development of an instrument. It is important to point out that the questionnaire proposed by these researchers encompasses three of these four dimensions already considered in the definition of obstetric violence. The development of an instrument could facilitate the execution of descriptive and causal studies in order to make it possible to understand the magnitude of the problem and to support the elaboration of public policies with the objective of mitigating and managing this problem with scientific evidence. Even so, the challenge would be the development of items for the dimension of sexual violence not included in the version proposed by Bohren et al.¹⁴14 Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, Aguiar C, Saraiva Coneglian F, Diniz AL, Tunçalp Ö, Javadi D, Oladapo OT, Khosla R, Hindin MJ, Gülmezoglu AM. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med 2015; 12(6):e1001847. (2015) and conducting psychometric analyses to assess the instrument itself.

The use of the term obstetric violence restricted to these four dimensions would also be in accordance with the typology used by the WHO to define these same manifestations of violence in other subtypes of violence, such as interpersonal violence - which includes violence between intimate partners, violence against children and adolescents and violence against the elderly. Importantly, Bowser and Hill (2010) and Bohren et al.¹⁴14 Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, Aguiar C, Saraiva Coneglian F, Diniz AL, Tunçalp Ö, Javadi D, Oladapo OT, Khosla R, Hindin MJ, Gülmezoglu AM. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med 2015; 12(6):e1001847. (2015) also identified these dimensions in their respective definitions of disrespect, abuse and mistreatment.

Another point that deserves to be highlighted is the use of the term obstetric, as opposed to childbirth, which is more commonly used. This decision would show that this type of violence can occur in pregnancy, childbirth, puerperium and abortion, that is, in all events of the pregnancy-puerperal cycle. It is important to mention that the use of this term has also been suggested by other researchers from Latin America²⁶26 Souza KJ, Rattner D, Gubert MB. Institutional violence and quality of service in obstetrics are associated with postpartum depression. Rev Saude Publica 2017; 51:69.^,2929 Leal MC, Szwarcwald CL, Almeida PVB, Aquino EML, Barreto ML, Barros F, Victora Cesar. Saúde reprodutiva, materna, neonatal e infantil nos 30 anos do Sistema Único de Saúde (SUS). Cien Saude Colet 2018; 23(6):1915-1928. and has been used by researchers from other countries¹⁵15 Okafor II, Ugwu EO, Obi SN. Disrespect and abuse during facility-based childbirth in a low-income country. Int J Gynaecol Obs 2015;128(2):110-113..

It is noteworthy that the option to use the term obstetric violence to characterize acts of violence and negligence does not prevent the use of the term “mistreatment”. Both terms and their respective definitions can and should coexist. For this, it is necessary to consider the fact that the term “mistreatment” refers to episodes of disrespect and violations of women’s rights and dignity and has a broader meaning. In this way, “mistreatment” contemplates both acts of violence per se and more subtle acts. Therefore, obstetric violence would be just one component of this larger construct called “mistreatment”.

However, we must mention that the redefinition of the term obstetric violence from the perspective of facilitating the measurement and adapting the WHO’s conceptual proposal may not be unanimous. It should be noted that the exclusion of the issue of medicalization and pathologization of the labor and birth process may not please everyone since the subject circulates in different discursive fields such as law, health and feminist movements³⁰30 Pulhez MM. "Parem a violência obstétrica!". Rev Bras Sociol das Emoções 2013; 12(35):544-564.. Although there is a dialog among the fields, each of these fields has different rationales and will produce its own meanings of obstetric violence with perspectives that do not always coincide. The breadth of perspectives can also be understood, in a sense, as part of a process of clashes and disputes³⁰30 Pulhez MM. "Parem a violência obstétrica!". Rev Bras Sociol das Emoções 2013; 12(35):544-564.. Opting for a narrow definition of violence and intentional neglect, we favor measurement, but we employ a term that is very dear to social movements that have a combative agenda against the excessive medicalization and pathologization of childbirth care in the Brazilian context.

Finally, it is important to mention that in Brazil, there are some public policies to improve the quality of care for women in prenatal care and childbirth with a potential impact on the reduction of obstetric violence, such as the National Program for the Humanization of Childbirth (2000), the Companion Law (2005), the Stork Network - Maternal-Infant Care Network (2011) and the National Guideline for Pregnant Women Care (2015/2016)³¹. In addition, the work of some social movements is also noteworthy, with emphasis on ReHuNa, which made the term “humanized childbirth” accessible to the general public and contributed to the dissemination of information through NGOs, social networks and films²⁶26 Souza KJ, Rattner D, Gubert MB. Institutional violence and quality of service in obstetrics are associated with postpartum depression. Rev Saude Publica 2017; 51:69.. However, these documents do not openly discuss obstetric violence or any of its “synonyms”.

In 2019, the Brazilian Ministry of Health published Official Letter No. 017/19 - JUR/SEC making the term obstetric violence inappropriate and banning its use in legal documents and public policies. After this controversial decision, based on the recommendation of the Federal Public Ministry, the Ministry of Health published a note recognizing the legitimate right of women to use the term obstetric violence to portray the experiences of disrespect, abuse, mistreatment and violence experienced, as well as the use of practices not based on scientific evidence in health care situations³². However, official texts and Brazilian health policies still do not address the term. This omission by the state can be partially explained by the lack of reliable statistics on the prevalence of these acts in the Brazilian population and scientific evidence on the harmful consequences on the health of women and newborns who have experienced some of these acts. Finally, it is important to mention the resistance of health professionals to the use of the term obstetric violence.

Conclusion

There is much to be done in terms of scientific research involving the theme of disrespect, abuse, mistreatment and violence against women perpetrated by health professionals in the pregnancy-puerperal cycle. The lack of a consensus regarding the terminology and definition of this construct causes a cascade effect causing a lack of precision in the estimation of the magnitudes of these acts, difficulty in comparing different studies and countries (different definitions and, consequently, different forms of measurement), and a scarcity of analytical studies focusing on possible negative outcomes of this problem for the health and well-being of women and newborns.

The absence of causal epidemiological studies involving the subject impacts health care decision-making since the knowledge generated by these studies influences the elaboration of specific public policies for the prevention of these acts by health managers. Given the issues mentioned, future studies focusing on the creation of a term and a consensual definition in the area and, consequently, on the development of an instrument with good psychometric properties to assess situations of disrespect, abuse, maltreatment and obstetric violence during pregnancy, childbirth, puerperium and abortion situations are necessary.

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