Monday marks the International Day for the Elimination of Violence against Women around the world.

However, the abuse of women during the childbirth process, also known as obstetric violence, remains largely undocumented and unspoken about. An October study led by the World Health Organization (WHO) concluded that around 42% of the women in the report said they experienced physical or verbal abuse or discrimination during childbirth in health centers, with some of the women being punched, slapped, shouted at, mocked, or forcibly held down.

The study followed 2,016 women during labor and interviewed 2,672 women after childbirth.

According to the study, more than one third of women in Ghana, Guinea, Nigeria and Myanmar experienced such abuse but suggested that the mistreatment of women during childbirth, occurs worldwide, including in developed countries.

Mistreatment during childbirth "could be a powerful disincentive from seeking facility-based maternity care," the study warned.

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What is obstetric violence?

Obstetric violence is the abuse of women during pregnancy, childbirth, and the postpartum period.

According to the Brazilian researchers, Danubia Barbosa Jardim and Celina Modena, obstetric violence is "revealed in the form of negligent, reckless, discriminatory and disrespectful acts by health professionals and legitimized by the symbolic relations of power that naturalize and trivialize their occurrence."

They argue that the abuse is a violation of human rights and a serious public health problem.

Examples of obstetric violence include practices such as episiotomies (a surgical cut made at the opening of the vagina during childbirth, usually to assist a difficult delivery) without consent, pain that goes unattended, use of force such as abdominal compression, a lack of information given to women, or excessive or inappropriate vaginal touching during birth or when anaesthetized.

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In pictures: Demanding an end to violence against women Rape without consent Only a handful of countries in Europe, including Germany and Belgium, define rape as sex without consent. Other countries often require proof of intimidation or violence. In Brussels, Belgium, red shoes were lined up on the ground to mark International Day for the Elimination of Violence Against Women.

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The WHO study

Most of the physical and verbal abuse peaked 30 minutes before birth until 15 minutes after birth.

Thirteen percent of the caesarean sections and 75% of the episiotomies were performed without consent — and often without a painkiller. Fifty-seven percent of the women interviewed after childbirth said they had not been offered any relief for pain.

In 59% of cases, vaginal examinations were performed without consent.

Some women were then detained after giving birth at the health centers for failing to pay the bill.

Obstetric violence, along with gynecological violence, is a form of abuse that exclusively affects women and tends to be swept under the rug because it's still a taboo subject. It remains largely unreported due to the impunity and silence surrounding it.

Women themselves are not always aware that their experiences can be counted as abuse.

"Younger, unmarried women were more likely to have non-consented vaginal examinations," the study said.

The study cited research that found that "midwives and doctors described women as 'uncooperative' during this period and some justified using physical and verbal abuse as 'punishment.'"

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Minorities and refugee women at higher risk

Earlier studies have documented the physical abuse of women of Roma descent in eastern Europe, where some of the women were also forcibly separated from their newborns for several days.

Refugee women in Greece have reported being refused pain relief during labor and given non-consensual procedures including forced caesareans.

US tennis champion Serena Williams brought global awareness to obstetric violence against black women living in the United States after she opened up about the birth of her daughter in 2017, igniting debates about the abuse and negligence black women face around the world.

Two years later, the Centers for Disease Control and Prevention reported that black women, along with Native Americans and Alaska natives, are over three times more likely to die from pregnancy or childbirth-related causes in the US, highlighting the racial disparities that exist during and after childbirth.

Tennis champion Serena Williams brought global awareness to obstetric violence against black women

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Taking action

To combat abusive practices during maternal care, the study called for improving the informed consent process in childbirth. It also suggested redesigning maternity wards for better privacy and permitting women to have a companion of their choice present during the birth.

After obstetric violence cases were widely reported across Latin America, Venezuela became the first country to take legal action against specific unethical practices by adopting a law in 2007 to ban obstetric violence.

Luxembourg has recently called for the integration of obstetric and gynecological practices into health education on their national agenda.

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Doctor says economy to blame

A 30-year-old Swedish male doctor, who wanted to remain anonymous, spoke of his experiences working in an acclaimed hospital in Vellore, southern India. "It's impossible to differentiate between actual violence against women and what came as a result from endless years of insufficient economy, tired doctors and nurses."

He described how "high-risk" women (e.g. with diabetes) were all put together into a room with 10 beds, and "low-risk" women into a room with 20 beds. Only one to two doctors, who worked 16 hour shifts up to 30 days in a row, were assigned to each room.

Due to a lack of economic resources and therefore time constriction, "there are a lot of procedures being done without consent," he said.

"Vaginal cutting is very common due to fast labors; medicines are given to make it quicker. This is not discussed with the patient, but all countries make medical decisions in acute situations," he said.

While the doctor saw "absolutely no hitting or physical abuse," women were "shut down verbally" when they cried out in pain. "This might be seen as a form of abuse but might be necessary in a room of 20 beds," he claimed.

He emphasized the role of perspective, saying how "easy" it is for someone from a wealthier healthcare system such as Sweden to portray people who work in a limited healthcare system "as having no empathy, evil or careless" when the "actual problem is limited resources and time."

But the Swedish doctor acknowledged that at the end of the day, "the ones who suffer are the women, which isn't OK," suggesting that the labor process could be improved with a better economy.

"I can't answer if labor healthcare would look different if it was men that were giving birth, but I guess it would!"

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