Over the last several years, a new legal construct has emerged in Latin America that encompasses elements of quality of obstetric care and mistreatment of women during childbirth - both issues of global maternal health import. Termed "obstetric violence," this legal construct refers to disrespectful and abusive treatment that women may experience from health care providers during pregnancy, childbirth, and the postpartum period, as well as other elements of poor quality care, such as failure to adhere to evidence-based best practices. This new legal term emerged out of concerted efforts by women's groups and networks, feminists, professional organizations, international and regional bodies, and public health agents and researchers to improve the quality of care that women receive across the region.Fil: Williams, Caitlin R.. University of North Carolina; Estados UnidosFil: Jerez, Celeste. Universidad de Buenos Aires. Facultad de Filosofía y Letras. Instituto Interdisciplinario de Estudios de Género; ArgentinaFil: Klein, Karen. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Correa, Malena. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Belizan, Jose. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Cormick, Gabriela. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. University of Cape Town; Sudáfric

Belizan, Jose

Cormick, Gabriela

Correa, Malena

Jerez, Celeste

Klein, Karen

Williams, Caitlin R.

BJOG An International Journal of Obstetrics & Gynaecology

English

CONICET Digital

Accepted ArticleThis article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/1471-0528.15270 This article is protected by copyright. All rights reserved. Article Type: Commentary Manuscript type: Commentary   Obstetric violence: A Latin American legal response to mistreatment during childbirth   Running Title: Obstetric violence: A Latin American legal response  Authors: Caitlin R. Williams a,  Celeste Jerez b,  Karen Klein c,  Malena Correa c,  José M Belizán c,  Gabriela Cormick c, d gabmick@yahoo.co.uk*  a Gillings School of Global Public Health, University of North Carolina at Chapel Hill  b Interdisciplinary Institute of Gender Studies, School of Philosophy and Liberal Arts, University of Buenos Aires (IIEGE, FILO, UBA)  c Institute for Clinical Effectiveness and Health Policy (IECS- CONICET), Buenos Aires, Argentina.  d Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.  * Corresponding author: Gabriela Cormick, Institute for Clinical Effectiveness and Health Policy (IECS), Emilio Ravignani 2024, Buenos Aires, Argentina. Phone number: (+54-11) 4777-8767, gabmick@yahoo.co.uk  Keywords: Obstetric Violence, Law, Gender, Latin America, mistreatment    Accepted ArticleThis article is protected by copyright. All rights reserved. Commentary:  Over the last several years, a new legal construct has emerged in Latin America that encompasses elements of quality of obstetric care and mistreatment of women during childbirth – both issues of global maternal health import. 1, 2, 3 Termed “obstetric violence,” this legal construct refers to disrespectful and abusive treatment that women may experience from health care providers during pregnancy, childbirth, and the postpartum period, 4, 5 as well as other elements of poor quality care, such as failure to adhere to evidence-based best practices.6 This new legal term emerged out of concerted efforts by women’s groups and networks, feminists, professional organizations, international and regional bodies, and public health agents and researchers to improve the quality of care that women receive across the region.7, 8 In Latin America, the intense scrutiny these groups brought to mistreatment of women during pregnancy and childbirth resulted in the development of a legal framework addressing it -- one which specifically locates “obstetric violence” at the nexus of gender-based violence and clinical malpractice, and interweaves elements of both respectful treatment and quality care.  Initially, the movement around obstetric violence grew out of a focus on quality of care. The Latin American Centre for Perinatology, Women and Reproductive Health’s (a division of the Pan American Health Organization (CLAP/WH-PAHO)) dissemination of evidence-based practices during labour and delivery9 in the region increased health professionals’ knowledge of the benefits of continuous support during labour and delivery, and eventually led to the passage of laws in Argentina and Uruguay that provided women with the right to be accompanied by a birth companion of their choosing.10 These two initial laws paved the way for a broader legal focus on the experiences of women during childbirth in the region, whereas Argentina passed the law on obstetric violence, Uruguay did not take further steps. Each of the five countries with legislation addressing obstetric violence have chosen to do so in slightly different ways, but the similarities suggest a shared regional legislative approach that may provide useful lessons for other countries seeking to use legal avenues to combat mistreatment of women during childbirth. Three of these approaches are discussed in detail below, while all five are summarized in Table 1. 11, 12, 13, 14, 15  In 2007, Venezuela became the first country in Latin America to develop legislation around “obstetric violence”, a term which encompasses such diverse concepts as disrespectful and abusive treatment of women during pregnancy, childbirth and the postpartum period; unconsented and non-medically indicated care; and negligence during obstetric emergencies.6, 12 Of note, Venezuela’s legislation explicitly interprets obstetric violence Accepted ArticleThis article is protected by copyright. All rights reserved. within the context of gender-based violence, and stipulates that eliminating obstetric violence is critical to ensuring that women can live a life free of violence.  Argentina uses a combination of two laws to combat obstetric violence, which draw on concepts from women’s rights and gender-based violence legislation.7, 11 National Law 25,929, enacted in 2004 and finally regulated in 2015, calls for “humanized childbirth” and explicitly emphasizes the rights of women, newborns, birth companions and families.16 In addition, Argentina followed the pathway of Venezuela and in 2009 enacted the National Law 26,485 (regulated in 2010), which prevents and sanctions gender violence, and includes a specific article on obstetric violence.11 Thus, Argentina’s legal framework builds on that of Venezuela to guarantee a broader set of rights to the childbearing woman, the newborn, and their family.  In contrast, the Plurinational State of Bolivia does not explicitly mention obstetric violence, but rather develops a legislative framework around violence within health services that includes a special focus on pregnant and childbearing women. In addition, the law defines a new term, “violence against reproductive rights” that extends beyond Argentina and Venezuela’s definitions to include miscarriage and breastfeeding.13  To date, there has been no comprehensive evaluation of these laws published in the literature, but there are some early signs that can be used to inform how to orient and evaluate implementation, process, and effectiveness. For example, in Venezuela, the National Institute for Women developed a triptych brochure defining obstetric violence, detailing who can report it, and indicating which institutions receive complaints.17 In addition, the Ministry of Popular Power for Women and Gender Equality has begun recruiting community promoters to be incorporated into the National Humanized Delivery Plan.17 Bolivia has incorporated questions about obstetric violence into the 2016 National Survey of the Prevalence and Characteristics of Violence Against Women.18 In Argentina, the Buenos Aires Provincial Ombudsman’s Office has begun developing intervention protocols for cases of obstetric violence and receiving complaints.19 Of note, the first trial for a case of obstetric violence in that country is currently being brought and tried.20   These laws offer a potentially promising approach to responding to obstetric mistreatment, a phenomenon that appears to be pervasive across many settings. Though the exact prevalence of treatment that would qualify as obstetric mistreatment is unknown, studies from Tanzania and Brazil report figures above 70% while figures from five European countries are around 20%.21, 22, 23 This suggest that the prevalence may be widespread and Accepted ArticleThis article is protected by copyright. All rights reserved. that it represents different challenges to guaranteeing good quality maternal healthcare. Though on the one hand the use of legislation with consequent criminalisation is controversial and could generate significant pushback from the medical community, on the other hand, legislation also creates an enabling environment for those seeking to engender change and improve the quality and dignity of intrapartum care. Discussion of the benefits and drawbacks of such legislation deserves to be had within the scientific community, to ultimately develop a path forward for guiding and evaluating the implementation, process and effectiveness of multi-faceted approaches to eliminating mistreatment.    The passage of these laws is a good start, as they empower women and families to claim their rights to a health care without discrimination. The legal concept of obstetric violence can serve as a framework for combating systemic failures in proper implementation of quality maternal care (including obstetric mistreatment) by encouraging women to take their cases of rights violation to the courts and clearly delineating responsibilities and obligations to health care providers.  Long term improvements will require collaborative, multi-sector efforts with health care institutions developing new guidelines and accountability procedures, advocacy groups informing women of their rights in obstetric settings, legal and human rights organizations developing case law to refine the legal framework, and public health researchers documenting and monitoring women’s experiences of care. Legislation alone will not solve the problem of maternal mistreatment, but it provides a solid foundation to build societies that protect the human right to dignified, quality maternity care.   Disclosure of Interests: None to declare. Completed disclosure of interest forms are available to view online as supporting information.  Contribution to Authorship: JB conceived the idea. CRW, CMJ, KK, MC, JB, and GC all contributed to the content and development of the article, and critically reviewed the draft manuscript and approved the final version.  Details of ethics approval: Not required for this commentary.  Funding: none to declare.  Acknowledgements: We would like to acknowledge Ms. Rachel Bishop for her thoughtful edits to improve the overall flow of the manuscript.      Accepted ArticleThis article is protected by copyright. All rights reserved. References                                                               1 World Health Organization. The prevention and elimination of disrespect and abuse during facility-based childbirth [Internet]. 2015. p. 1–4. Available from: http://apps.who.int/iris/bitstream/10665/134588/1/WHO_RHR_14.23_eng.pdf  2 Tunçalp  Ӧ, Were W, MacLennan C, Oladapo O, Gülmezoglu A, Bahl R, et al. Quality of care for pregnant women and newborns-the WHO vision. BJOG An Int J Obstet Gynaecol. 2015;1045–9.  3 Khosla R, Zampas C, Vogel JP, Bohren MA, Roseman M, Erdman JN. International human rights and the mistreatment of women during childbirth. Health Hum Rights. 2016;18(2)  4 Bowser D, Hill K. Exploring evidence for disrespect and abuse in facility-based childbirth: Report of a landscape analysis. USAID-TRAction Project. Harvard School of Public Health, University Research Co., LLC, 2010. [Internet]. Available from: http://www.urc-chs.com/uploads/resourceFiles/Live/RespectfulCareatBirth9-20-101Final.pdf  5 Bohren, M. A., Vogel, J. P., Hunter, E. C., Lutsiv, O., Makh, S. K., Souza, J. P., … Gülmezoglu, A. M. (2015). The mistreatment of women during childbirth in health facilities globally: A mixed-methods systematic review. PLoS Medicine, 12(6), 1–32. http://doi.org/10.1371/journal.pmed.1001847  6 Gherardi N. Serie Asuntos de género. Otras formas de violencia contra las mujeres que reconocer, nombrar y visibilizar. Cepal [Internet]. 2016; 64p. Available from: http://repositorio.cepal.org/bitstream/handle/11362/37878/S1500262_es.pdf?sequence=4  7 Jerez C. Partos “humanizados”, clase y género en la crítica a la violencia hacia las mujeres en los partos. Universidad de Buenos Aires; 2015.  8 Red Latinoamericana y del Caribe para la Humanización del Parto y el Nacimiento (Relacahupan). 2017 [Internet]. [cited 2017 Nov 10]. Available from: http://www.soniacavia.com.ar/relacahupan.com.ar/lared.html  9 Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2017;2017(7).  10 Belizan JM, Cafferata ML. The right to be accompanied at birth: new laws in Argentina and Uruguay. Reprod Health Matters. 2005;13(26):158–9.  11 Ley de Protección Integral para Prevenir, Sancionar y Erradicar la Violencia contra las Mujeres en los ámbitos en que se desarrollen sus relaciones interpersonales (Ley 26.485, Argentina 2009). Available from: http://servicios.infoleg.gob.ar/infolegInternet/anexos/150000-154999/152155/norma.htm  Accepted ArticleThis article is protected by copyright. All rights reserved.                                                                                                                                                                                              12 Ley Orga nica so re el  erecho de las Mu eres a una Vida Li re de Violencia (Ley   .   ,  e u lica Bolivariana de Venezuela 2007). Available from: http://www.derechos.org.ve/pw/wp-content/uploads/11.-Ley-Orgánica-sobre-el-Derecho-de-las-Mujeres-a-una-Vida-Libre-de-Violencia.pdf  13 Ley integral para garantizar a las mujeres una vida libre de violencia (Ley 348, Estado Plurinacional de Bolivia, 2013). Available from: http://www.gacetaoficialdebolivia.gob.bo/index.php/normas/descargar/141694  14 Ley que Tipifica el delito de femicidio y la violencia contra la mujer (Ley 82, Panamá 2013). Available from: http://www.organojudicial.gob.pa/wp-content/uploads/2016/11/Ley-82-de-2013.pdf  15 Ley de acceso de las mujeres a una vida libre de violencia para el distrito federal (Ley ID 180: 2007 reforma 2014, Estados Unidos Mexicanos, 2014). Available from: http://www.ordenjuridico.gob.mx/Documentos/Estatal/Ciudad%20de%20Mexico/wo75459.pdf  16 Belli LF. La violencia obstétrica: Otra forma de violación a los derechos humanos. Red Bioet UNESCO. 2013;1(7):25–34.  17 Instituto Nacional de la Mujer. Ministerio del Poder Popular para la Mujer y la Igualdad de Género. (2017). Inamujer. Retrieved February 26, 2018, from http://www.inamujer.gob.ve  18 Instituto Nacional de Estadística (INE). (2017). Encuesta de prevalencia y características de la violencia contra las mujeres. La Paz.  19 Observatorio de Violencia de Género de la Defensoría del Pueblo de la Provincia de Buenos Aires. (2016). Monitoreo de políticas públicas y violencia de género: Informe 2014/2015. Buenos Aires  20 Defensor del Pueblo de la Nación de la República Argentina. (2016). Resolución No 00002/2016 “P.A.M., sobre violencia obstétrica, intervención del DPN ante Clínica Bazterrica.” Buenos Aires. Retrieved from http://perlaprigoshin.com.ar/wp-content/uploads/2016/02/Res-02-2016-Petrella.pdf  21  Sando,  ., A uya, T., Asefa, A., Banks, K. P., Freedman, L. P., Ku awski, S., … Jolivet,  .  . (2017). Methods used in prevalence studies of disrespect and abuse during facility based childbirth: Lessons learned. Reproductive Health, 14(1), 1–18. http://doi.org/10.1186/s12978-017-0389-z  22 Andrade P de ON, Pereira da Silva JQ, Menino Diniz CM, Costa Caminha M de F. Factors associated with obstetric abuse in vaginal birth care at a high-complexity maternity unit in Recife, Pernambuco. Rev Bras Saúde Matern Infant [Internet]. 2016;16(1):29–37.  23 Lukasse M, Schroll AM, Karro H, Schei B, Steingrimsdottir T, Van Parys AS, et al. Prevalence of experienced abuse in healthcare and associated obstetric characteristics in six European countries. Acta Obstet Gynecol Scand. 2015; 94(5):508–17.  Accepted ArticleThis article is protected by copyright. All rights reserved.                                                                                                                                                                                              Table 1: Latin American countries with laws concerning obstetric violence Country Year Summary of legal rights  Venezuela (República Bolivariana de) 11 2007 Law Number 38,668, Articles 15.11 and 51 Defines obstetric violence as the “appropriation of women’s bodies and reproductive processes by health professionals, expressed as dehumanizing treatment and/or abusive medicalization and pathologization of natural processes, resulting in loss of autonomy and the capacity to decide freely about their own bodies and sexuality, negatively impacting women’s quality of life.” Provides specific examples of actions that constitute obstetric violence, including failing to provide timely and effective care during obstetric emergencies, intervening to accelerate labour without the woman’s express voluntary informed consent, and performing a non-medically indicated caesarean section without the woman’s express voluntary informed consent.  Argentina12 2009 Law Number 26,485, Article 6 Defines obstetric violence as “exercised by health personnel over a woman’s body and reproductive processes, expressed as dehumanizing treatment, and/or abusive over-medicalization and medicalization of the natural processes, in conformity with Law 25,929.”  Guarantees women the right to be treated as a healthy, informed, decision-making participant in her own labour, delivery and postpartum period; to have a natural birth that respects her timing and natural processes; to be accompanied by a trusted birth companion of her choosing throughout the entirety of labour, delivery and the postpartum period; to room in with her newborn; and to receive counselling and support for breastfeeding. Bolivia (Plurinational State of)13 2013 Law Number 348, Articles 7 and 8 Guarantees women the right to a life free from violence, including “violence against reproductive rights” and  “violence in health services”, defined as “actions or omissions that impede, limit or otherwise violate women’s right to information, orientation, comprehensive care and treatment during pregnancy or miscarriage, labour, birth, postpartum period, and breastfeeding” and “any discriminatory, humiliating, or dehumanizing action, and anything which omits, negates or restricts access to immediate, effective care and timely information, committed by health personnel, that puts the life and health of women at risk”, respectively.  Panamá 14 2013 Law Number 82, Article 4 Guarantees women the right to a life free of violence, including obstetric violence, which is defined as “exercised by health personnel over women’s bodies and reproductive processes, expressed as abusive, dehumanizing, humiliating or vulgar treatment.”  Article 27.3 Early detection and attention to all types and modalities of violence against women, essentially in primary health care, emergencies, clinical specialty, obstetrics, gynaecology, traumatology, paediatrics and mental health, specifying the procedure to be followed for the attention of women victims of violence, safeguarding the privacy of the person assisted and promoting a non-sexist medical practice. This procedure must ensure the obtaining and preservation of probative elements. Mexico 15 2014 Law Number 180: 2007 modified 2014, Article 6 - 7  Defines obstetric violence as “all actions or omissions by medical and health professionals that damages, harms, denigrates or causes the death of the woman during pregnancy, birth and the postpartum period.”  Penalizes obstetric violence and also negligence, non-medically indicated caesarean section, sterilization and/or use of contraceptive methods without voluntary consent, and anything that interferes with the early bonding of the mother and infant (including breastfeeding) without medical cause.  

Obstetric violence: a Latin American legal response to mistreatment during childbirth

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Obstetric violence: a Latin American legal response to mistreatment during childbirth

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