763351

research-article2018
QHRXXX10.1177/1049732318763351Qualitative Health ResearchBriceño Morales et al.

Research Article
Qualitative Health Research

Neither Medicine Nor Health Care

1­–12
© The Author(s) 2018
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DOI: 10.1177/1049732318763351
https://doi.org/10.1177/1049732318763351

Obstetric Violence From an journals.sagepub.com/home/qhr

Interactionist Perspective

Ximena Briceño Morales1, Laura Victoria Enciso Chaves1,

and Carlos Enrique Yepes Delgado1

Abstract
This study sought to understand the meaning that women place on the health care practices carried out during labor.
We used techniques from Grounded Theory such as coding, categorization, and constant comparison. A total of 18
interviews were conducted with 16 women who had given birth at least once in Colombia. Based on our results,
we argue that obstetric violence is an expression of violence during the provision of health care, which occurs in a
social environment favoring the development of power relationships between patients and health care staff. Its origin
might lie in a health care system whose political and economic foundations encourage inequality on the basis of the
patients’ purchasing power. We conclude that rethinking and redefining the concept of obstetric violence is essential
for understanding its nature and having an impact on it.

Keywords
Violence against women; violence; users’ experiences; health care; power; empowerment; childbirth; reproduction;
qualitative; Grounded Theory; South America.

Introduction To discuss obstetric violence (OV), it is necessary to

When declaring violence as a generalized and diffuse phe-
nomenon, the World Health Organization admits that defin-
ing it is no easy task, as this issue is considered a subjective
matter. Violence can be defined and classified in a number of
manners, which rely on the purpose and the person perform-
ing this task (Krug, Mercy, Dahlberg, & Zwi, 2002). In this
article, we decided to use Galtung’s concept of structural
violence (Farmer, Nizeye, Stulac, & Keshavjee, 2006),
which states that violence occurs when humans are influ-
enced in such a way that their somatic and mental realities
are below their potential realization (Galtung, 1969). Thus,
this notion transcends the restricted concept of threat or
physical, sexual or psychological damage traditionally
attributed to violence (Stanko, 2001). Furthermore, violence
can be expressed through inequitable access to resources
such as education, legal or political power, and health care
(Audet, Dumas, Binette, & Dionne, 2017; Basnyat, 2017).
Structural violence is “closely related to social injustice and
the social machinery of oppression” (Farmer, 2004), as the
ones in charge of perpetuating said inequities are not sub-
jected to this type of violence (Farmer et al., 2006).
acknowledge the unequivocal existence of violence
against women (Aguiar, d’Oliveira, & Schraiber, 2013;
d’Oliveira, Diniz, & Schraiber, 2002; Faneite, Feo, &
Toro-Merlo, 2012). This phenomenon is grounded in
cultural patterns of inequality between men and women,
the latter bearing the stigma of natural or biologically
inherent inferiority (Facio, 2005). The term OV was
defined a decade ago as a crime consisting in the “health-
care staff’s appropriation of the body and reproductive
processes of women expressed via dehumanizing treat-
ment; abuse of the medicalization and pathologization of
natural processes, which entails a loss of their autonomy
and ability to make free decisions regarding their own
bodies and sexuality, ultimately affecting women’s qual-
ity of life” (“Venezuela,” 2007).
1
University of Antioquia, Medellín, Antioquia, Colombia
Corresponding Author:
Carlos Enrique Yepes Delgado, Preventive Medicine, University of
Antioquia, Carrera 51D #62-29, Medellín, Antioquia 1226, Colombia.
Email: caenyede@gmail.com
2 Qualitative Health Research 00(0)
However, basing a debate about OV purely on the
issue of gender violence would lead to a reductionist view
of the matter. OV transcends the central thesis of gender
violence, which is defined as a type of violence directed
against women because they are women (United Nations,
2015). This calls for a discussion analyzing the context
that facilitates the occurrence of OV and generates
unequal social relationships between health care staff and
women. OV is better conceived from the standpoint of
structural violence, particularly in countries with strati-
fied health care systems, as these are more likely to favor
its incidence.
The health care systems in Latin America (LA) often
segregate people by providing different kinds of care
based on purchasing power. This entails to separate health
care models: one for those who can pay, another one for
salaried employees with their families, and, finally, a sub-
sidy-based model for the poorest. It is this segmentation
that limits access and quality, leads to more social segre-
gation, and perpetuates the long-standing economic
inequalities in Colombia and other similar countries
(Cotlear et al., 2015). This scenario is aggravated with the
addition of private insurance companies to the Latin
American Social Security market. This was, allegedly, a
strategy to contain health expenditure by managing risk.
With partially saturated markets such as the North
American one, investors such as the Health Maintenance
Organizations direct their interest toward our countries,
maximizing their profit and strengthening the stratified,
for-profit health care systems (Drechsler & Jütting, 2007).
In Colombia, although “Social Security (which
includes health) is a mandatory public service that must
be delivered under the administration, coordination and
control of the State” (Colombia, 1991), access to health is
not yet guaranteed for all its citizens. The employed and
their families receive insurance and health care services
through a contributory model that has its own health care
plan (Atun et al., 2015) and is funded by the employers’
taxes and the employees’ payroll. However, the unem-
ployed with no purchasing power do not have access to
this, although, theoretically, they have the right to a com-
prehensive plan with health care benefits. Therefore,
many of their health needs remain unattended because
they are part of a subsidy-based model. Yet, at the top are
people with a very high purchasing power who, because
of their wealth, have more benefits than the average pop-
ulation, and that includes a better form of medical care
and an easier access to it.
Finally, the review of the literature shows that research
on OV is being conducted from an empirical and hege-
monic standpoint, rendering OV, as perceived by women,
invisible. There is extensive knowledge about the theo-
retical discussions on this issue, but there is scarce infor-
mation regarding women’s perspectives (Andrade, da
Silva, Diniz, & Caminha, 2016; Faneite et al., 2012; Grilo
Diniz et al., 2015; Pereira, Domínguez, & Toro-Merlo,
2015; Pintado-Cucarella, Penagos-Corzo, & Casas-
Arellano, 2015; Silva, Marcelino, Rodrigues, Toro, &
Shimo, 2014). The latter is precisely what we try to
approach in this document, which is part of a larger
research project whose aim was to explore the meaning
that women place on health care practices performed dur-
ing delivery care.
Method
This is a qualitative study based on constructivism
(Lincoln, Lynham, & Guba, 2011). We used techniques
from Grounded Theory (GT), such as coding, categoriza-
tion, and constant comparison (Corbin & Strauss, 2015).
This methodology is based on the sociological school of
symbolic interactionism (Blumer, 1969). GT produces
conceptualizations based on explanatory patterns brought
to light in the categories and their properties. Unlike
purely descriptive studies, the conceptualization of GT
should be abstracted from person, time, and place vari-
ables. Therefore, GT is a general method whose theoreti-
cal abstractions become relevant in different contexts
because they endure time (Glaser, 2002).
Data were collected via semistructured interviews. A
total of 18 interviews were conducted between 2015 and
2016, with 16 participants in three Colombian cities. The
inclusion criteria were women above the age of 14 years
who agreed to participate in the study and had given birth
at least once in a Colombian health care institution
belonging to the current health care system. The exclu-
sion criteria were women with high-risk pregnancies, a
history of stillbirth, perinatal death, or unhealthy new-
borns. The participants were women with sufficient com-
munication skills to establish a fluid and coherent
conversation, with a certain degree of empowerment
about their rights as women, who remembered their
childbirth experiences and expressed a genuine interest in
sharing them. The participants also agreed to meet with
us in places that were comfortable for both parties and
signed an informed consent form created by the research-
ers and approved by the institutional review board (IRB).
The form explained the objectives of the study, the type
of risk it meant for them, and the voluntary nature of their
participation.
The population was first selected by convenience and
later by considering the participants’ contribution to the
emerging categories. This is how the theoretical sam-
pling was conducted (Charmaz, 2006; Glaser, 2002).
That approach made it possible to develop the theoreti-
cal categories resulting from the analysis of the data
obtained up to that moment. None of the selected infor-
mants refused to participate in the research. The
Briceño Morales et al. 3
participants’ ages ranged from 21 to 43 years in 12 of
the interviews and from 43 to 50 years in five of them.
Only one participant was older than 50 years. In addi-
tion, during 12 of the interviews, it was mentioned that
the women had given birth 1 or 2 years prior. In the
remaining interviews the participants stated that the
births had taken place more than 2 years ago. It is impor-
tant to point out that the participants did not state that
the time elapsed since their childbirth experience
affected their perception of the treatment received dur-
ing it. In fact, the finesse in the accounts narrated by
these women is a clear example of this. On the contrary,
14 participants were affiliated to the contributory health
care model, one belonged to the private insurance
model, and another to the subsidized model. Moreover,
three interviews were conducted with women who had
gone only to elementary school, 10 held a professional
degree, and five had postgraduate studies. By last, 11 of
the interviews were applied to single women and seven
to women with partners. Confidentiality was ensured by
replacing the first and last names of the participants
with a system of codes known only to the researchers.
The data collection process and the analysis took
place simultaneously. We started with nine interviews
and conducted the remaining nine after adjusting the
interview script. The analysis focused on the most rele-
vant emerging topics as well as on deepening the under-
standing of the information obtained continuously, and
on advancing toward theoretical saturation. Data collec-
tion and analysis were performed through a constant
comparative analysis (Morse et al., 2009) with an inter-
active, iterative, and systematic process involving codes,
categories, theory, and researchers.
The data analysis had three steps: (a) descriptive, (b)
analytical, and (c) interpretive (Corbin & Strauss, 2015).
The descriptive moment included open coding and the
identification of codes or abstractions in the participant’s
discourses. After reaching an agreement regarding the
coding standard, the three researchers compared the
abstractions obtained by each of them. These codes were
grouped into descriptive categories and, within these, the
properties and dimensions accounting for the variation
nuances and the features of the initial categories were
identified (Table 1). Subsequently, the properties and
dimensions were used to build the analytical categories
through axial coding. The latter identified some phenom-
ena that enabled the discovery of context, causes, action–
interaction relations and consequences. This ultimately
led to a paradigmatic matrix (Corbin & Strauss, 2015).
Finally, such analytical categories were refined using
theoretical memos and related in a more abstract manner
by means of a selective coding that leveraged the paradig-
matic matrix once again to identify a phenomenon or cen-
tral category, which was prioritized in this document.
Table 1.  Example of a Category Along With the Codes That
Generated It.
Category
  Most health care procedures are based on power
relationships where the physician is in charge of ordering
the actions to be performed.
Codes
  Being threatened with nonperformance of a procedure if
she moves
  Being considered an object upon which physicians can act
at will
  Being told to refrain from pushing
  Being made to feel guilty about her cesarean section
  Noticing an authoritarian tone in the communications with
health care staff
  Not being asked for her consent when a gynecologist
describes the procedure to be performed
  Giving into the physician’s orders
  Not being asked for authorization when a vaginal touch is
performed
  Realizing the existence of hierarchies governing the
execution of a medical order
  Being put down by the physician
  Being told by physicians that they are the ones who know
about labor, not her
  Understanding physicians as repression agents
  Feeling that her labor process was influenced by a power
relationship established between the physician and her
  Feeling that the protagonist of the labor process was the
physician, as they were the ones saying what to do
  Perceiving physicians as arrogant due to their medical
knowledge
  Feeling that physicians underestimated her as a patient due
to her lack of medical knowledge
  Being reprimanded by the physician for being very late to
the hospital
  Considering that physicians go too far when establishing
power and superiority relationships with their patients
  Feeling that the nurse isolated her during labor and failed to
allow contact with the rest of the health care staff
After the abovementioned analytical process, the theory
was no longer specific to the interviewees, hence it
enabled the understanding of more general psychological
and social behaviors (Glaser, 2002; Morse, 1993).
To give more validity to our work, we introduced our-
selves as scholars interested in understanding the partici-
pants’ experience without promising anything in return.
We offered them respectful treatment and showed interest
in their labor-related experiences. Consequently, they
agreed to participate and expressed themselves openly
and in detail when narrating their experiences. Interview
transcription and verification was rigorous.
Finally, we triangulated the initial codes and the sto-
ries from the interviews; then the codes and the emerging
4 Qualitative Health Research 00(0)
Figure 1.  Paradigm matrix (Strauss and Corbin) that shows that OV is not the exclusive responsibility of health personnel.
Note. OV = obstetric violence.
categories. Likewise, we also triangulated such catego-
ries and the theory found during the process. It is worth
mentioning that we compared our views as researchers
permanently (Jeon, 2004; Lincoln et al., 2011; Yeasmin &
Rahman, 2012) and used our reflexivity to discuss and
become aware of the constructs that we used as starting
points. Similarly, we openly discussed the decisions made
throughout the study, all while acknowledging our own
limitations with honesty (Engward & Davis, 2015). This
entire study was approved by the IRB of the academic
institution that led the investigation, as was the above-
mentioned informed consent form.
Results
For the interviewed women, OV results from the natural-
ization of a violent and discriminatory social context, all
within a health care system, which favors the develop-
ment of power relationships between its staff and
patients. Women admitted that neither medicine nor vio-
lent health care staff are violent by nature, despite the
authoritarian medical habitus they often display in their
behavior. When facing this situation, women feel afraid,
take on the role of institutionalized patients, and normal-
ize hierarchical, authoritarian, and often violent health
care. The results presented below are structured in such a
way as to expose the central analytical category that
emerged during the investigation, as well as the context,
causes, action–interaction relations and the conse-
quences that respond to that main category (Figure 1).
Authoritarian Medical Habitus
For the participants, the authoritarian medical habitus
generated OV, and was acknowledged as the most
important characteristic determining the perceived qual-
ity of the received health care. This condition estab-
lished unequal human relationships between the health
care staff and the women, as they were based on a verti-
cal power hierarchy. The authoritarian medical habitus
was exposed when the health care staff assumed a posi-
tion of superiority, reprimanding or intimidating women.
It also became evident when they threatened mothers
with not supporting them if they refused to follow
instructions, and when they reduced communication to
unidirectional conversations where mothers were
always information receptors.
The epidural anesthesia made me jump a little. He then told
me: if you move again, I won’t administer anything to you.
(21 years old)
I wanted to push but the doctor told me not to because he
knew what this was about. He told me that he’d let me suffer
those pains for hours before the C-section. (25 years old)
Briceño Morales et al. 5
Women stated that they had experienced a degradation of
their values and dignities. They felt deprived of their sta-
tus as human beings as they were seen only as patients in
labor, not as women with a life history that is more than a
clinical record. They declared that the health care staff
determined the course of their deliveries, thus making
them feel like work objects in the maternity rooms,
undervalued as people.
Patients are things. I felt they were treating me as a lump of
meat. . . they put you on medication, they stick needles in
your body, but you’re nothing as a human being; you have
no role there. (50 years old)
Medicine per se was perceived as a professional practice,
which often becomes violent. Nonconsensual, repeated,
or painful vaginal touch was cited assiduously. This was
coupled with a disrespectful behavior when done without
the least intimacy. The uterine fundal pressure maneuver
was associated with a violent treatment because it was
painful, its purpose was not understood, and it resembled
a form of physical abuse toward women, particularly
toward their pregnant abdomen. For the same reasons
postpartum uterine massages and the manual extraction
of milk were perceived likewise. An abrupt, excessively
energetic, and unmoved execution was also a common
trait in these procedures, thus leading women to invari-
ably consider them as an aggression.
Touching is like raping: they just put their hand in there
almost without warning. (47 years old)
These women also criticized some behaviors of the health
care staff that are discouraged today and might be delete-
rious to the mother and her newborn: early hospitaliza-
tion and labor induction without a clear medical
indication, lack of general support during labor, unjusti-
fied restriction of food, making it impossible to adopt a
more comfortable position, and so on. Although women
were not fully aware of the inadequacy of those practices,
their experiences allowed them to infer that these were
not in tune with physiological and natural deliveries.
I told the doctor: not yet, I think I should walk around, I
haven’t even felt the first contraction. But he told me: you
have to stay and lie down. Then he made me break waters; I
knew that’s supposed to happen naturally. When I was sent
for C-section because I hadn’t dilated I thought: he should’ve
let me walk around. (57 years old)
For the participants, OV did not manifest itself only
through the authoritarian medical habitus, but also through
other forms of violence, for example, verbal and psycho-
logical, or via the systematic denial of their fundamental,
sexual, and reproductive rights. Likewise, certain attitudes
of the health care staff—which were perceived by mothers
as a total lack of empathy toward them or as proof of mini-
mal importance being given to their experience—were
also considered OV.
They were talking and laughing while stitching my body.
My pain was horrible but they didn’t say anything to me. (36
years old)
Supposedly they didn’t send me for surgery because my
husband had to sign the authorization. (37 years old)
Naturalization of Social Violence
Colombian society expresses undeniable traits of vio-
lence (Human Rights Watch, 2010). This was observed
when women stated they had been victims of various
types of violence in many scenarios of their lives. At fam-
ily level, they reported having been beaten, offended, and
punished by their own mothers, brothers, and partners,
who transformed domestic differences and conflicts into
domestic violence. This type of aggressive family behav-
ior could have left (and still leaves) a deep mark in the
construction of their parental bonds, which was mani-
fested during their pregnancy. Moreover, women experi-
enced domestic violence during their pregnancy because
the historical development of their parental relationships
favored this.
Perhaps my husband started beating me because I lost my
parents. (37 years old)
My mother reacted very badly [to my pregnancy], she beat
me. (25 years old)
Going deeper into the social scenario as a context of gen-
eral violence, which favors the subsequent development
of OV, women stated that they had suffered social trage-
dies, which affected them and determined their views of
the world and their own lives. Some of them had been
victims of the war in Colombia, experienced forced dis-
placement, and lived in very poor conditions with their
families, even during pregnancy. Women reported being
abused by people indirectly related to them, before, dur-
ing, and after their pregnancies. Usually, the abusers
belonged to a heterogeneous group including members of
insurgent groups and unknown passersby.
I was displaced from neighborhood [suburb] by some
hooded people. . . I was displaced by violence. One day they
arrived and even stole the gas cylinder from the kitchen. . . I
lost everything. (42 years old)
Discrimination as another form of violence became evi-
dent when women made a list of scenarios in which they
6 Qualitative Health Research 00(0)
were (and still are) discriminated. They noted that they had
been excluded in their childhood for belonging to an ethnic
minority, being obese, and not complying with the current
beauty standards or being too young or old to be pregnant.
Age, weight, and race also determined discriminatory
behaviors directed at them during pregnancy. Nevertheless,
economic conditions were at the core of the segregation
experienced during labor, as the participants perceived a
discriminatory behavior when priority was given to moth-
ers with higher purchasing power or who paid a high fee
for the services received. The latter fact is mandatory in the
analysis of OV, as perceived by the participants.
I still think that they humiliated me by saying things like “of
course, she is black” and stuff like that. (21 years old)
There’s a big difference of classes: those with money aren’t
sent back home. (33 years old)
It is essential to note that women basically described their
physician–patient relationship as one of the power
marked by a pattern of social hierarchy, which has been
established as the natural and unmodifiable order of
maternity services. Physicians were the central figures
during labor. They were exclusively in charge of the pro-
cess and any decision making was unilateral. Women
were not asked for their opinions or for their consents.
The doctor does say hello but communication isn’t friendly.
I know why he’s here for and he knows what he has to do
too. So, I just do it: I spread my legs and he puts his hand in.
(43 years old)
Based on the data collected, the participants did not feel
that their status as pregnant women protects them from
experiencing OV.
We have obstetric violence because women who are about to
become moms are not respected. (37 years old)
An Inequitable Health Care System, Which
Favors Power Relationships
According to the interviewed women, two great phenomena
may explain the origin of OV. On one hand, it is the conse-
quence of the historical construction of Colombian society
and its health care system. On the other hand, it is the result
of the social and interpersonal relationships among the dif-
ferent actors of the health care system and women.
They first argued that a society whose health care
system promotes inequality based on people’s purchas-
ing power and classifies the needs of patients according
to their type of affiliation to this system is a society that
openly violates human rights. This trait of the Colombian
health care system causes segregation of people at all
levels and ultimately turns into discrimination during
health care provision. According to this study’s partici-
pants, Colombia’s health care model deliberately limits
the opportunity that all pregnant women should have
that of being cared for equally. Even worse is that this
could eventually endanger the health and life of women
and their babies because priority would be dictated by
the economic aspects surrounding health care, not the
maternal–fetal conditions themselves.
I did experience obstetric violence during my second
pregnancy. It didn’t happen during the first one because I
paid for the service directly. You have to pay to be treated
nicely. (36 years old)
Seriously, healthcare in this country is like that. Some get
more, some get less. (33 years old)
The second phenomenon highlights the role of the health
care staff as the initiator and perpetuator of OV, and
emphasizes the disrespectful and violent attitudes
assumed by it toward the mothers. The interviewed
women knew intuitively that OV is partly the result of an
excessive amount of protocols and the subsequent mech-
anization of delivery care, which undermine the human
aspects surrounding this moment.
Everything’s so mechanical that (doctors) start thinking it’s
the only way. They forget the human aspect. (25 years old)
Both explanations address different phenomena that are,
nevertheless, related to each other. The interviewed
women argued that the first phenomenon is the root of the
second. According to this perspective, the physician–
patient relationship reflects—within the context of health
care—the relationships that are woven macrostructurally
within a given community. Two key points are worth
mentioning. First, the women deduced that the mechani-
zation of delivery care is the result of a health care system
seeking to homogenize health care: on one hand, because
it conceives people as mass-produced entities needing to
be quickly processed by the system, and on the other
hand, because it is overloaded, saturated, and thus unable
to provide humanized and individualized encounters with
physicians. Second, they proposed that countries with
societies such as Colombia’s—where the different or
nondominant are stigmatized and discriminated against—
cannot be expected to be different in terms of health care.
I felt lonely in the delivery room; you’re just a product, a
thing for which the hospital is getting paid by the healthcare
provider; it’s a commercial exchange. The same thing
happens with OV; the rights of the pregnant women are
infringed upon because the idea of respecting others does
not exist. (45 years old)
Briceño Morales et al. 7
Coping With OV
When experiencing OV, women reacted with attitudes of
acceptance and submission. They said they submitted to
the power of the health care staff to avoid putting their
babies at risk. They also mentioned not being interested
in modifying the social interactions of maternity services.
Although OV was evident, women tended to minimize
and forget about it. This is likely a defense mechanism
against a traumatic memory.
I was thinking: I’m not going to stir things up, I won’t fight.
I had another priority: making sure my daughter was born
properly. (25 years old)
In spite of all this, my delivery wasn’t that violent, I have a
friend who told me she had it worse. (27 years old)
“Fear Pervades Everything”
For the interviewed women, the consequences of OV
may be summed up in four main feelings: inability to give
birth, fear of everything associated with labor, feeling
lonely during the process, and feeling abandoned by both
health care staff and loved ones. These feelings affected
negatively their ability to face labor, controlled them, and
affected their identity, thus decreasing their responsive-
ness, revictimizing them, and pushing them into second-
ary roles. When they did not obtain the expected results,
women came to think that they had failed in their role as
parturients, and that the effort they had put into this was
insufficient and unworthy of a mother.
I didn’t do my job right, as a woman in labor I had a mental
block. I thought: I’m not properly dilated; I’m not cut out for
this. (50 years old)
The participants said they feared almost everything. They
feared having uterine contractions without analgesia, but
they also feared the application of the epidural anesthesia.
Likewise, they feared giving birth vaginally as well as
undergoing surgery. There was also a fear of a very long
childbirth process, but they also feared an emergency cesar-
ean section. Moreover, they feared the unknown nature of
the event, but those who had given birth before also feared
repeating the experience. Some women even felt that they
were losing control of the situation to the point of thinking
that they would die in the attempt to give birth.
The word that defines what I felt when I was giving birth
was fear; I was really afraid. I thought I was going to die
along with the baby. (36 years old)
Finally, women said they felt lonely and abandoned when
their partners or relatives were not with them during
labor. Similarly, they experienced the same feeling when
the health care staff disregarded their needs or left them
on their own, with no periodic evaluation of their needs
and feelings.
In the delivery room women are alone, staring at each other;
one can’t even help the others. (50 years old)
Discussion
Analyzing OV requires putting into context the circum-
stances underlying its occurrence. Acknowledging that
violence is a global public health problem is important
because it enables us to understand the social weaving
favoring the subsequent appearance of OV. Our health
care system, in recreating the social and economic
inequalities that characterize capitalist governments,
facilitates discrimination scenarios that infringe upon
the human rights. This is thus understood as a form of
violence in the context of health care.
The abovementioned situation is intensified by the role
of the health care staff members who, instead of assuming
a critical attitude toward the functioning of the health care
system and institutions, perpetuate the authoritarian social,
institutional and medical habitus. In this context, habitus
refers to the active presence of experiences and practices
that transcend individual behavior, are above regulations
and guarantee the permanence in time of said practices,
which is the continuation of the habitus itself (Bourdieu,
1990; Castro & Erviti, 2014). This ensures that the current
system continues to operate in the same manner, even
when it does not cater to the needs of most people.
We argue that neither medicine nor health care staff
are violent by nature. Rather, they are the useful puppets
of those governments which, based on capitalist develop-
ment models and neoliberal health care policies with
underlying mercantilist philosophical paradigms, con-
ceive men and women as goods whose value is given by
their economic wealth (Hernández, 2002), which is what
dictates the care and treatment that they deserve.
Colombian society has suffered for years a social and
armed conflict that has left permanent scars in the histori-
cal memory of all its citizens and their collective behav-
ior. Its permanence in time, daily presence, and intensity
have conferred it a degree of normality that has allowed it
to exist spontaneously within a violent social order, as an
embodiment of the naturalization of social violence. The
excessive frequency with which these violent social phe-
nomena occur has caused them to be underestimated. It
has also increased the citizen’s tolerance of them while
weakening individual and collective response. This
encourages the assumption of a generalized indifference
toward it, which places violence in the category of incon-
sequential social phenomena (Franco Agudelo, 1997).
8 Qualitative Health Research 00(0)
Every violent thought, discourse, or action is condi-
tioned by a number of social factors along with the cultural
environment originating them; the latter can be considered
a sociological indicator conditioning other ideas, strate-
gies, and special practices (Sosa Sánchez & Sosa Lugo,
2015). Some authors suggest that to understand the phe-
nomenon of OV, it is necessary to look at the structure of
medical education, which is designed based on a hierarchi-
cal order with chains of command that consist of people
with different ranks. Students from a lower category are
disciplined, punished, or discriminated against as part of a
pedagogical model seeking to perpetuate an authoritarian
system of interpersonal relationships. The educational sys-
tem plays a decisive role in the origin of authoritarian
health care practices (the habitus), as the students will later
reproduce the teaching practices to which they were sub-
jected (Castro, 2014).
The historical and social context in which the inter-
viewed women were immersed had played a key role in
the occurrence of OV. This fact is also acknowledged in
many of the papers reviewed which describe studies con-
ducted in poor countries with a history of violence and
inequity (Bradley, McCourt, Rayment, & Parmar, 2016).
They state that the normalization of this type of social
behaviors is one of the most important factors contribut-
ing to the mistreatment and abuse of women during deliv-
ery care (Bowser & Hill, 2010; Kruk et al., 2018).
At times the terms violence and power have been used
interchangeably, however, they refer to different phenom-
ena. Nevertheless, the reality is that the more power an
actor has, the higher the probability of having to legiti-
mate it through violence. Thus, not every power relation-
ship implies violence, but every violent action does imply
a power relationship (Aróstegui, 1994). This allows us to
understand why subordinates may feel under attack when,
during the provision of health care, decisions are made in
a unilateral and imposing manner, and from a privileged
position that involves the exercise of power. According to
several authors, here is where we can observe the debate
on the construction of the health care staff’s identity. The
latter being considered a strategy to keep their status
above that of women (Bradley et al., 2016).
The results of our study show that social violence
alone is not enough to fully explain OV; hence, we sug-
gest to consider an additional analysis from the stand-
point of structural violence (Galtung, 1969). The health
care model established by the Colombian ruling classes
aims to cater to the health needs of the population by
imposing health care massively. It is not uncommon that
providing health care massively leads to providing it in
series (excessive amount of protocols). This strategy
seeks to be a response to the oversaturated demand for
health care services, but provides a false sense of equity
that ends up negatively influencing the work of the staff.
Health care does not behave as a right but as a service
ruled by market principles. This is known as “the mer-
chandization of health,” where efficiency, profitability,
and revenue play a key role (Hernández Gómez, 2002).
The Colombian health care system was identified as
one of the most important determinants for the occur-
rence of OV because it limits a possibility that all moth-
ers should have that of accessing adequate and respectful
obstetric care, as this type of care is reserved for women
with good purchasing power. Women from less favored
social groups are treated differently when compared
with those of higher social classes (Bradley et al., 2016).
OV was closely related to the low quality of health care,
which depended on the pregnant women’s inability to
pay for good health care to satisfy their needs. Similar
findings have been reported in other studies (Mamdani
& Bangser, 2004; McMahon et al., 2014; Spangler &
Bloom, 2010).
The laws concerning OV passed by some countries
have placed health care staff at the center of the most
heated discussions. These state that OV is “the appro-
priation of women’s bodies and reproductive processes
by the health care staff” (“Venezuela,” 2007). Another
claim is that these laws state that “acts constituting OV
are performed by the health care staff while carrying out
their profession” (“Argentina,” 2009; “México,” 2008;
“Venezuela,” 2007). It is clear that these laws have a
reductionist and biased view of the phenomenon. They
all perceive health care staff members as isolated actors
being violent against pregnant women, disregarding the
staff’s context and work environment.
Most studies approaching OV have considered it an
issue arising from the ethical problems or “individual-
level experiences and factors contributing to the mis-
treatment of women during childbirth” (Bohren et al.,
2015), “focusing mainly on the mother-healthcare
worker dyad” (Bradley et al., 2016). Although they try to
elucidate the social and structural factors involved in this
phenomenon, many conclude that the “solution lies in
humanizing physicians or addressing the crisis of values
in today’s medicine” (Castro & Erviti, 2014). Therefore,
a sociological approach to this issue might be more
appropriate. Understanding the social structure and its
health care system would allow for the tracing of the ori-
gin and characteristics of OV, along with the health care
system conditions and constraints causing the health care
staff to infringe upon the rights of women. Understanding
that disrespect and abuse “can occur at the level of inter-
action between the woman and the provider, as well as
through systemic failures at the healthcare facility and
healthcare system levels” (Bohren et al., 2015; Sadler
et al., 2016), would transcend the simplistic and limited
view that OV results from a deficit in the ethical, moral,
or human training of the health care staff.
Briceño Morales et al. 9
It is noteworthy that laws concerning OV do not men-
tion that guaranteeing the right to respectful obstetric care
is the duty of the State. Even when it comes to criminal-
izing OV, some laws indicate that it is only exercised by
the health care staff (México, 2008), leaving out the
responsibility of social authorities, including the health
care system and the government, in this regard. The latter
aspect, which is mandatory when analyzing OV, has not
occurred randomly, but rather corresponds to a definite
political position of those in power, who legislate on peo-
ple’s health. Analyzing OV at the macrostructural level
will allow us to recognize that it is a “systemic problem
and therefore calls for systemic solutions” (Diaz-Tello,
2016). Typifying or categorizing disrespect and abuse
during labor from an individual perspective is not enough
(Bohren et al., 2015; Bowser & Hill, 2010; Freedman
et al., 2014). Any expression of this mistreatment should
not be tolerated. The conditions for health care together
with its capacity and quality reflect the status quo, which
a given government seeks to maintain through the estab-
lished health care system.
The interviewed women suffered a metamorphosis
that turned them into institutionalized patients. This
means that they abandoned their role as members of soci-
ety to become residents of a health care institution. People
in a state of institutionalization partially lose their auton-
omy as they are under a regulated system that prevents
them from deciding, thus modifying their behavior
(Goffman, 2001). Our research showed that the women
not only accepted that the environment where they were
giving birth was abusive and hostile, they also naturalized
it (Bohren et al., 2016). For them, OV was one of the
many forms of violence they have suffered during their
lives (Sadler et al., 2016). However, it has not always
been about unconsciously accepting disrespect and abuse
during labor; sometimes women acted consciously when
their objective became avoiding bad happenings during
labor, and they were trying to survive the process. They
were convinced that they would otherwise jeopardize
their lives or those of their babies, and therefore, decided
to accept the established social order existing in such
places (McMahon et al., 2014).
Being a victim of OV implies accepting that one’s dig-
nity has been infringed upon along with one’s human
rights, thus generating damage, pain, and suffering (Bello
Albarracín, 2014). The damages caused by OV are diffi-
cult to measure because they entail complex aspects such
as the resignification of pregnancy and labor, fear, feel-
ings of insecurity, powerlessness, abandonment, and
loneliness. Fear is one of the most common consequences
found among victims of violence. This feeling can be
incapacitating and mortifying, as it hinders one’s regular
reactions (Sosa Sánchez & Sosa Lugo, 2015). Women
who suffer OV typically are unable to pose any resistance
when faced with violent situations during labor. This is
even worse because a lack of reactions causes violence to
grow geometrically (Peirano, 2014).
Women who come to health care institutions seeking
pregnancy or delivery care are particularly sensitive to its
quality. Because they oversee another being’s life, they
might feel more fragile and vulnerable, and thus demand
or require more attention from health care personnel.
Pregnant women consider themselves abandoned patients
when the health care system is unable to guarantee access
to its services and when the health care staff ignore their
needs and disregard them (Tinoco-Zamudio, 2013).
Limitations
There is no extensive conceptualization for some of the
categories that emerged during the analysis of the data.
Furthermore, we did not achieve the expected level of
theoretical development for such categories. The reasons
behind this are the fact that the authors lack formal train-
ing in social sciences and the heterogeneous development
of the emerged categories, which could have resulted in
some degree of conceptual superficiality. After all, con-
ducting research in developing countries entails great
challenges, in this case with resources from the research-
ers themselves.
Conclusion
Our study made it possible to deepen our understanding of
OV and its significance as a social phenomenon. Although
different studies have shown OV as a subset of violence
against women, we consider that OV is rather the result of
a violent social framework that has naturalized violence in
all areas of human life, including health care.
OV manifests itself through the authoritarian medical
habitus and its different components: disrespect, abuse
and objectification of women, excessive medicalization of
birth, medical acts or procedures perceived as violent, and
so on. However, it is also perceived as a phenomenon
where health as a right is denied and the quality of and
access to health care are dependent on people’s wealth.
OV’s debate should include a structural discussion ques-
tioning not only the behaviors of the health care staff but
also the authoritarian institutional and social habitus, and
the macropolitical structure of capitalist societies with
neoliberal health care models. Analyzing OV structurally
also demands understanding the responsibility of a num-
ber of social agents (people, institutions, organizations,
nations, cultures, and ideologies), particularly the State
(i.e., the political structure of a country; Donovan, Morgan,
Potholm, & Weigle, 1993), concerning the appearance and
survival of various forms of violence; otherwise, OV risks
being discussed asocial and ahistorical.
10 Qualitative Health Research 00(0)
Recommendations
It is fundamental that the debate on OV moves away from
the health care staff and focuses on violence at all levels
and in any society. However, even if the above is true,
health care staff must assume their responsibility for dis-
respectful, abusive, and violent health care practices. In
this regard, health care staff members have an outstand-
ing task: to be critical of the neoliberal health care poli-
cies imposed by governments such as Colombia’s. The
merit lies in consciously reflecting upon their role as
health care providers in an adverse environment, and in
acting, being different and aiming to eliminate all types
of violence during their professional practice. This is not
easy: It involves fighting the current social order and lay-
ing down the foundations for a structural change that
clearly is not up to them alone, but requires people for its
fulfillment.
Finally, based on the approach presented in this article,
we would like to appeal to the scientific community to
rethink and redefine the concept of OV, as its constitutive
elements are not exclusive to the field of obstetrics and
are, indeed, common to medical care.
Authors’ Note
Carlos Enrique Yepes Delgado is also affiliated to Pablo Tobón
Uribe Hospital, Medellín, Colombia.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Author Biographies
Ximena Briceño Morales is a Gynecologists and Obstetricians
from the University of Antioquia.
Laura Victoria Enciso Chaves is a Gynecologists and
Obstetricians from the University of Antioquia.
Carlos Enrique Yepes Delgado is a doctor, a specialist in admin-
istration, a magister in public health and a PhD in epidemiology.