Original Research Article

Violence Against Women

2022, Vol. 28(11) 2700–2721
Obstetric Violence in Their © The Author(s) 2021
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DOI: 10.1177/10778012211037375
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Expect, Experience, and

Respond to Violence

Vania Smith-Oka1 , Sarah E. Rubin2, and

Lydia Z. Dixon3

Abstract
This article, based on ethnographic research in Mexico and South Africa, presents two
central arguments about obstetric violence: (a) structural inequalities across diverse
global sites are primarily linked to gender and lead to similar patterns of obstetric vio-
lence, and (b) ethnography is a powerful method to give voice to women’s stories.
Connecting these two arguments is a temporal model to understand how women
across the world come to expect, experience, and respond to obstetric violence—
that is, before, during, and after the encounter. This temporal approach is a core fea-
ture of ethnography, which requires long-term immersion and attention to context.

Keywords
gender-based violence, obstetric violence, ethnography, Mexico, South Africa

As violence against women in obstetric care has garnered increased scholarly atten-
tion over the past decade, unnerving patterns of how this violence is enacted and
experienced have emerged worldwide. This article ethnographically examines these
patterns through the voices of women in diverse global settings and analyzes struc-
tural similarities in how obstetric violence is expected, experienced, and described.

1
University of Notre Dame, Notre Dame, IN, USA
2
Ohio University Heritage College of Osteopathic Medicine, Warrensville Heights, OH, USA
3
California State University, Channel Islands, Camarillo, CA, USA
Corresponding Author:
Vania Smith-Oka, Anthropology, University of Notre Dame, 296 Corbett Family Hall, Notre Dame,
IN 46556, USA.
Email: vsmithok@nd.edu
Smith-Oka et al. 2701

Many of the obstetric practices we describe in this article are widespread, generally
unquestioned, and thus normalized. We build on scholarship that has begun to cat-
alogue definitions and manifestations of obstetric violence and show how ethno-
graphic methods can deepen understandings of the root causes by tracing
women’s experiences of violence over time. Specifically, we respond to Savage
and Castro’s (2017) review article on mistreatment in birth, in which the authors
posit that mixed methods, including direct observations, can be effective to under-
stand the issue. They urge scholars to investigate the frequencies of mistreatment,
to understand the macro and micro forces affecting it, and to assess how mistreat-
ment affects maternal and child health.
After reading Savage and Castro’s piece, we discussed how our ethnographic
research responded to what we saw as one of their key appeals: the need to keep
women’s voices and experiences central to the analysis of obstetric violence (especially
those of marginalized women). Indeed, we argue here that it is precisely through long-
term engagement and contextual understanding that ethnographic inquiry reveals the
scope of obstetric violence and provides new ways to think about systemic
interventions.
We present women’s stories about their negative experiences as obstetrics patients
to think critically about what women say when they talk about obstetric violence
(whether physical, verbal, or emotional) and how their own words, and our direct
observations, can together identify patterns across geographic regions. This collabora-
tive article was born out of the commonalities we recognized across our data collected
in Mexico and South Africa—familiar conditions of inequality that shape women’s
expectations, experiences, and responses to violence in obstetrics—and out of our
shared goal of uncovering structural inequalities that perpetuate such violence.
Multisited and cross-cultural ethnography allows us to identify structural similarities
between these diverse settings, understand the temporal components of the violence,
and move from the local experiences to broader analyses that can inform scholarship
and interventions.
Through our analysis of our ethnographic data, we present two central arguments.
First, that structural inequalities across diverse global sites are primarily linked to
gender and lead to similar patterns of obstetric violence. Second, that ethnography is
a powerful method to give voice to women’s stories while revealing how individual
experiences of obstetric violence connect to underlying structures of gender inequality.
Connecting these two arguments, we employ a temporal model to understand how
women in different parts of the world come to expect, experience, and respond to
obstetric violence—before, during, and after the encounter. That is, these acts of vio-
lence are not single, bounded events but inflect every stage of the birthing process,
including patients’ expectations, actual experiences, and responses to violence. This
temporal approach is a core feature of ethnography, which requires long-term immer-
sion and attention to context. Our analysis reveals consistencies in women’s stories
about obstetric violence that stem from their shared experiences of gender violence.
By providing ethnographic narratives from our three distinct research sites, we illus-
trate how ethnography helps draw connections from the specific to the global and
2702 Violence Against Women 28(11)

how obstetric violence is not a singular occurrence, but instead is another instance in a
lifetime of violence against women’s reproductive lives.
Women’s stories make clear the very local ways that violence is enacted and per-
ceived, something that is lost in the large-scale attempts to define obstetric violence.
This is not to say that obstetric violence emerges only from unique local circumstances;
rather, women’s stories reveal that shared patterns of gender inequality manifest in
diverse ways that are not always captured by other forms of data collection that
cannot reflect the broader context of women’s experiences. This violence is often
clearly and inherently gendered—visited on women because they are women, not
simply a result of inadequate resources or training or of racial or class dynamics. By
considering women’s stories within their broader social context, we purposively
move away from the goal of improving maternity care (which, while a tangible part
of the problem, is not the underlying root cause), and, like the recent UN Report on
violence against women (Šimonović , 2019), we also advocate for scalable efforts
that address broader patterns of reproductive injustice, inequality, and structural
violence.
Below, we briefly outline the obstetric violence scholarship and discuss the under-
lying structures of gender-based violence that give rise to obstetric violence across the
world. To do so, we present three ethnographic examples from our field sites in Mexico
and South Africa that are representative of how women talk about violence in their
obstetric experiences. Our shared observations and data suggest that obstetric violence
against women is based on universal and underlying inequalities and discrimination
against women, not simply fostered by certain cultural or geographical settings or
embedded in particular medical contexts and practices, and thus require clearer analy-
ses and sustained efforts to change gender dynamics and inequalities more broadly.
Finally, we conclude the artical with an invitation to other scholars to use ethnography
in the larger monumental project of laying bare and dismantling the mechanisms of
gender oppression that enable and entrench all forms of gender violence.

Defining and Diagnosing the Problem of Mistreatment in

Childbirth
A difficulty in studying and addressing obstetric violence lies in its manifold presen-
tations and causes. Over the past decade, scholars have increasingly examined the
prevalence, types, and pernicious effects of the mistreatment of women during child-
birth in multiple settings around the globe in an effort to map out the diversity or uni-
versality of the problem (Bohren et al., 2017; Bowser & Hill, 2010; Castro & Savage,
2019; Pickles, 2015; Sadler et al., 2016). Numerous categories of abuse have been
offered by researchers, including: physical, sexual, and verbal, stigma/discrimination,
cultural insensitivity, failure to meet professional standards of care, poor rapport
between patients and providers, health system conditions and constraints, abandon-
ment, detention in facilities, and a lack of consented, confidential, and dignified
care. Such violence emerges at three different levels: the macro level (e.g., structural
Smith-Oka et al. 2703

inequality, colonial legacy, and broader health policies), the meso level (e.g., power
and control of bodies and knowledge), and the micro level (e.g., day-to-day dyadic
interactions between mothers and clinicians) (Bradley et al., 2016).
Some scholars argue that abuse might arise not from inherently violent practitioners
but from a disabling work environment that increases the stress of healthcare workers
(Bohren et al., 2017; Jewkes et al., 1998) or where healthcare practitioners are social-
ized within—and thus driven to exercise—violence (Sadler et al., 2016, p. 51;
Smith-Oka, 2013). Other scholars (Freedman et al., 2018) indicate that disrespect
and abuse are often internalized and normalized by both providers and patients;
these practices might even be considered acceptable ways of gaining patient compli-
ance under difficult circumstances (Bohren et al., 2017). What women subjectively
experience as violence may not be easy to categorize or list, but must be recognized
and validated nonetheless (Freedman et al., 2014).
While these analyses have provided considerable insight about strengthening and
transforming health systems, they have not adequately addressed the underlying
issue, which is that violence is directed at women because they are women and, further-
more, where the gendered nature of the violence reveals how it has been institutional-
ized and normalized (Chadwick, 2016; Sadler et al., 2016; Shabot, 2016). We
distinguish between obstetric violence and the problems of having inadequate facilities
that constrain women’s access to good reproductive (or other) care. While it is very
important to change and fix inadequate healthcare systems, here we argue that until
we understand gender inequality and discrimination as the root of obstetric violence,
it will be impossible to adequately recognize and eliminate it. By tracing women’s
expectations of, experiences with, and responses to obstetric violence through ethno-
graphic inquiry, we illustrate the specificity of obstetric violence as both a product
of structural inequalities and a manifestation of gender inequality.

The Underlying Context of Gender-Based Violence

The origins and uses of the term “obstetric violence” reinforce our position that abuses
of women in obstetric care are specific, gendered forms of violence. The term “obstetric
violence” is itself important to interrogate; it goes beyond pure description as it con-
nects two seemingly disparate words. It also comes out of specific histories and
places and is purposeful in its jarring pairing. Its origins and growing usage reflect
intersecting histories of gender-based oppression and violence; the term seeks to
bring attention to these gendered experiences in new ways. Like Chadwick (2016)
and other scholars and activists (Erdman, 2015), we choose to use the term obstetric
violence to describe the phenomena addressed in this analysis rather than more polit-
ically neutral terms like abuse or mistreatment, so as to directly confront those practices
and situate them within broader systems of social inequality and coercion. The use of
the term obstetric violence both reveals and reinforces the existence of gender-based
violence. According to the UN (2010), sexual and gender-based violence is the perpe-
tration of any act—physical, emotional, sexual, psychological—against someone else
because of their gender, depriving them of dignity and perpetuating female
2704 Violence Against Women 28(11)

subordination. It is one of the world’s most pervasive and least recognized social prob-
lems, which leads to many negative consequences for its victims (Heise et al., 2002;
WHO, 2013). This form of violence is rooted in unequal power relations, where insti-
tutions might legitimate, deny, and obscure the abuse (Heise et al., 2002). The rates and
forms of gender-based violence across the world are staggering. UN Women (2019)
estimates that anywhere from 35% to 70% of women worldwide have been victims
of intimate partner violence; more than half of the women intentionally murdered
were killed by an intimate partner or family member. These deep-rooted forms of
gender-based violence are pervasive and, in many places, so commonplace and
accepted that they are rarely recognized as violence. The inferior status of women is
woven into the fabric of so many places as to be seen as natural.
When violence happens in obstetric contexts, then, it not only perpetuates gender
inequality, it also contributes to and is evidence of its normalization: this is just how
things are done. Entrenched gender violence manifests in obstetrics across the world
through different avenues; legacies of oppression and inequality collide with local
infrastructures, policies, and histories to allow for violence to continue. Obstetric vio-
lence is naturalized in societies where violence against women is prevalent. South
Africa and Mexico provide particularly useful sites for examining systematic similar-
ities in obstetric violence around the world because, despite their different historical
legacies, both are places that have been ranked as having high rates of gender-based
violence (PRIO 2017; UN Women, 2019) and where obstetric violence has already
been recognized as a problem at activist, practitioner, and policy levels.
In the South African context, pervasive gender violence occurs in a cauldron of
masculinist patriarchal norms and entrenched poverty framed by the legacy of
centuries-long racial and political regimes of violence. Despite difficulties in measur-
ing gendered violence (Jewkes & Abrahams, 2002), two decades of research has
evinced a high prevalence of physical/sexual partner violence (Dunkle et al., 2004;
Kalichman et al., 2005) and mortality due to interpersonal violence (Abrahams
et al., 2009, 2013). When this underlying context of pervasive gender violence collides
with struggling healthcare institutions, maternal healthcare is bound to suffer. The
public healthcare system in South Africa is overburdened and underfunded: annual
per capita expenditure on health in the private sector is 100 times that of the public
sector; the public sector is staffed by 30% of the nation’s doctors while serving 84%
of the population (Mayosi & Benatar, 2014). However, understanding obstetric vio-
lence in South Africa as only the legacy of a dysfunctional racialized medical
system obfuscates its social roots in the prevalent gendered violence (Chadwick,
2016, 2017; Pickles, 2015), especially in the historically segregated and impoverished
areas that surround the public maternity clinic in which the cases described in this
article took place.
Mexico, like South Africa, is a country marked by deep ethnic and class-based fis-
sures that compound the effects of gender inequality. Its health expenditure has steadily
decreased over the past decade, with only 5.5% of the country’s GDP going towards
healthcare (World Bank, 2017), resulting in a struggling public medical system that
remains significantly underfunded, with overcrowded public hospitals and poor
Smith-Oka et al. 2705

installations that disproportionately affect already-marginalized populations (INEGI

2015). The COVID-19 pandemic has further exacerbated these effects. Alongside
this struggling healthcare system, Mexico has experienced more than a decade of
intense drug-cartel violence that has increased insecurity nationwide. As in South
Africa, obstetric violence in Mexico must be framed within this broader context of
gender violence. It has one of the highest rates of gender harassment, intimate
partner violence, disappearances, and femicides in the world. In 2016, the National
Survey for the Household Relations Dynamic (which investigated the violence faced
by women in Mexico) stated that for every 100 women over the age of 15, 42% of
married and 59% of widowed, separated, or divorced women reported being victims
of some form of violence; of those, 43.9% reported experiencing partner violence,
with 20% experiencing very severe violence (INEGI 2018). Awareness of gender vio-
lence in the country has increased over the past decade, and in 2019 a national commis-
sion designated more than half of Mexico as officially under an Alert of Gender
Violence against Women (Gobierno de México, 2019).
Amid this context, obstetric violence has come to be seen as widespread and perva-
sive by many female victims and by scholars engaging in this research. As Dixon
(2015) has noted, obstetric violence in Mexico is a form of gender-based violence
emerging from larger country-wide violence and “deeper patterns of inequality and
violence that play out in hospital delivery rooms” (p. 438). According to Castro and
Frías (2020), 33.3% of the Mexican women they surveyed reported experiencing
obstetric violence during their last birth. Despite growing attention around this issue,
change has been slow; in 2003, Castro and Erviti (2003) presented their findings of vio-
lence in Mexican reproductive healthcare and called for changes to medical training
and supervision, as well as for clearer ways for women to complain when violated.
Based on our research, women in Mexico do not always expect recourse from the vio-
lence they experience in hospital settings, and they may fear the consequences of
speaking out. Midwives have emerged as one group speaking up for women and advo-
cating for systemic changes to address and eradicate obstetric violence and lend cre-
dence to placing obstetric violence within the category of gender violence. As our
data illustrate, our conversations with women in Mexico and South Africa provided
rich and nuanced versions of their particular experiences and interpretations of obstet-
ric violence.

The Importance of Ethnography in Studying and Highlighting

Violence
Here we argue that ethnography is a nuanced and effective method to understand
behaviors, patterns, and underlying root causes of obstetric violence, particularly
how they emerge as expectations, experiences, and responses for female victims.
Ethnography, by its very nature, is immersive and long term. This means that it can
allow researchers to uncover the temporality of behaviors, thus showing how violence
unfolds, how it affects participants, and how they, in turn, respond to it. We
2706 Violence Against Women 28(11)

deliberately chose the three narratives below to show the powerful ability of ethnogra-
phy to uncover obstetric violence.
Each of us in our larger research projects draws specifically from feminist modes of
ethnography (Davis & Craven, 2016), where we emphasize research with groups that
are vulnerable—in this case, pregnant and laboring women. We place importance on
making women’s lives visible as a political imperative, paying attention to broader
structures, actors, and power dynamics in our observations and analysis.
Ethnography allows us to shine a bright light on these symbolic and literal forms of
violence enacted on female bodies, which we witness during observations of women
in labor and hear the women recount.
An ethnographer in these spaces can become a witness. Witnessing is not simply
observing or being present. It is a conscious process that incorporates self-reflexivity
and allows people (whether physicians, nurses, or ethnographers) to shift from
seeing patients as objects of analysis to subjects of experiences (Davenport, 2000).
Though the women we spent time with experienced very different situations and
“degrees of violence,” their stories are all about suffering—losing one’s child in a still-
birth, experiencing a vaginal birth with episiotomy without consent, and suffering post-
cesarean mistreatment. As we describe, in all three cases, the women knew that
something was not right, but there was not always a recourse for them or clear vocab-
ulary to express their concerns. This is where ethnography is most effective: through
long immersive periods of fieldwork, Ethnographers enter these spaces with women
and are able to receive stories that would be difficult or impossible for them to tell
otherwise.

In Their Own Words: How Women Experience, Expect, and

Respond to Obstetric Violence
Below are three narratives that we have identified within our data as illustrative of the
ways that women feel, experience, and talk about their obstetrically violent experi-
ences. These heterogeneous narratives emerge from systematic data collection and
are representative examples of phenomena we observed more widely in our fieldwork.
They show the nuanced ways that obstetric violence occurs and highlight how many
women struggle to make sense of what happened to them and why. It is important
to add, however, that these narratives are simply a small part of our data about gendered
violence and only a drop in the bucket in terms of broader data on obstetric violence.
Through a sustained focus on women’s stories, we can see how women expect, expe-
rience, and respond to violence in obstetrics.

“They Scold You Too Much”: Hospital Birth in Mexico

Between 2008 and 2016, I [Vania] collected data in three hospitals (two public, one
private) in the city of Puebla, Mexico. I used a mixed methods approach, combining
deep ethnographic “hanging out” and more structured methods (surveys and
Smith-Oka et al. 2707

interviews) with 45 physicians and residents, nine nurses, 29 medical interns, 12 mid-
wives, and 71 female patients (Smith-Oka, 2013). The birth narrative of one female
patient I met is below.
One of the women I interviewed, Bárbara, was 17 when she gave birth to a baby boy
in a public hospital in 2011. Though I was unable to be at the birth itself, she later
invited me to her home to discuss her birth experience. When I arrived at their tene-
ment, her very pregnant mother opened the main gate and motioned for me to
follow her across the patio to their apartment. There I found Bárbara lying comfortably
on an unmade bed and nursing her baby, who was swaddled in blankets. Giving me a
shy smile, she reported, “I’m getting used to [motherhood]. The first days I slept a lot,
but now I’m fine.” She noted that her sister-in-law was currently in labor at the same
hospital where she had given birth a few days ago. Her mother explained that the
soon-to-be-newborn was the child of her 16-year-old son, who also lived in the
home, and that soon they would have three babies in the home.
As Bárbara described her birth experience, she said that she first had mild contrac-
tions for several days until her water broke, but that even then the doctors sent her
home because her contractions were not yet strong enough and “They gave me med-
ication so I would have contractions.” When she finally returned to the hospital she said
she was worried about her baby’s health because its “heart rate dropped and dropped.
So, I requested a cesarean. And I was only two [centimeters] dilated. […] I requested
[a cesarean] because the baby wasn’t moving at all.” When she told the obstetricians in
the hospital that a general practitioner had examined her before she entered the hospital
and had told her she was between two and four centimeters dilated, they were not sen-
sitive to her fears for her baby’s health, saying, “Who’s going to know more, us or a
general practitioner?”
Bárbara described how she and her baby were treated by clinicians at the hospital.
She said that her experience was really painful, emotionally as well as physically,
“They really hurt me when they did the pelvic exam. […] You know what those
who do the exam are like; ¡ay! The [doctors] scold you!” Although she disliked
walking around with amniotic fluid dripping out while she had contractions, the
doctors told her, “Your labor will begin soon” and ordered her to keep walking.
When she complained to the clinicians about having to walk around rather than receiv-
ing a cesarean, they simply gave her “medication, more medication, and more medica-
tion.” She once again begged for a cesarean because she felt her son’s life to be at risk.
Although she said that the doctors who attended to her were not directly rude or harsh,
“They left me in a lot of pain and cut up around the vagina, waist, stomach.” She
reported that her vaginal area was very sore “because they did the pelvic exam all
the time, even days before as well,” and that “the [intravenous] medication for the con-
tractions” also hurt her body. She believed that the hospital personnel were indifferent
to her discomfort and that if she hadn’t requested the cesarean, they “wouldn’t have
done it until the next day. They paid no attention to me.” Ultimately, she was scheduled
for a cesarean. She said that as she was being wheeled into surgery, and despite being in
great fear, she was regañada (scolded) by one of the obstetricians for being difficult
because she was “the lady who is complaining that her water broke.” She observed
2708 Violence Against Women 28(11)

other women besides herself also being ignored or mistreated, such as “an older woman
who was losing a lot of blood” and was ignored and “a woman whose baby was almost
out, and they still wanted to do the pelvic exam because it wasn’t yet time.”
She reported that this neglect continued after the cesarean. Even though she was in
significant pain from the surgery and from the catheter, “no nurse checks on you, not
even at night. I was really thirsty, and I asked [a nurse] if she would give me a little bit
of water. And she said no, not until the next day. And my baby was really cold, and I
grabbed my gown and the sheet off the bed [to wrap him]. They scolded me, but he was
getting cold.” At one point, according to Bárbara, she called out to a passing nurse,
“Excuse me, nurse?” but when the nurse turned around abruptly and said curtly
“What?” she just replied meekly, “No, nothing,” as the nurse walked out of the ward.
As her baby squirmed and whimpered softly in her arms as she told her story, she
nursed him again. She said at first she did not know how to breastfeed, leading the
nurses at the hospital to scold her as they seemed to assume that breastfeeding and care-
giving were a natural instinctive ability and that any transgression could be punished.
She said they told her “That I wasn’t feeding him and that they would take him away to
an incubator. They really [scold] you too much, too much … too much.” Bárbara’s
mother echoed this opinion, describing doctors as despots who do what they want.

Punishment Instead of Care: South Africa’s Midwife Obstetrics Units

I [Sarah] collected data for 22 consecutive months between 2010 and 2011 at one
public Midwife Obstetrics Unit (MOU) in Our Hope Township (a pseudonym) on
the outskirts of Cape Town, South Africa, and visited a variety of other clinics,
hospitals, and community centers in the area (Rubin, 2014, 2015, 2018). I used mul-
tiple methods including observations, structured questionnaires, and ethnographic,
open-ended, and semi-structured interviews to interview eight Xhosa-speaking mid-
wives, three clerks, one counselor, one social worker, four community health
workers, as well as longitudinal interviewing of 37 patients who were pregnant at
their first interview and mothers of 9–12-month-old infants at their last. Twelve of
the 37 mothers were key informants who were interviewed up to 11 times each over
the 22 months.
Obstetric violence permeated women’s reproductive experiences at the MOU: it
was woven into the organization’s rules, procedures, and rituals and was routinely
enacted by nurses and midwives. Patients were well aware of the potential for becom-
ing a victim of this violence, and some mentioned that they had changed MOUs after
their previous pregnancy because they had “heard” that the nurses at Our Hope MOU
were “nicer.” Others were disappointed that they booked at Our Hope because they
heard or knew from experience that their nurses were the “mean” ones. Another
method of resistance was minimizing the time spent under the care of MOU nurses
by “booking late,” often well into their ninth month. In addition, patients regularly
fought against the lack of privacy and perceived judgmental nature of the nursing
staff by misrepresenting their medical history and previous pregnancies. Participants
didn’t mention to the nurses details like alcohol use, domestic violence, or even
Smith-Oka et al. 2709

previous pregnancies; patients who were unmarried or HIV-positive often misrepre-

sented their dedication to condom use, saying that “they forgot only one time”
which resulted in the pregnancy. In this way, patients deftly avoided the nurses’ judg-
mental attitudes or diatribes, but at the same time, they potentially compromised their
own healthcare.
Although women who had routine, vaginal births also reported violence (e.g., being
yelled at, having their thighs slapped, or being refused help to the toilet), the most
shocking violence occurred when women’s pregnant bodies defied the normal
course of pregnancy and birth. A few days after her first interview, we (my
Xhosa-language interpreter and I) saw Zola, between 10 and 12 weeks pregnant,
sitting in a folding chair outside the labor ward, looking pensive and withdrawn; we
greeted each other warmly, but we could tell she was in distress. She told us a few
weeks later that the day we saw her, she was bleeding excessively and was left
waiting for hours; a few days later, she miscarried at home. As a matter of MOU
policy (as we were told by patients), Zola was told she had to bring the fetus to the
clinic or hospital in a bag as “proof” that she actually miscarried to receive postpartum
care. She describes how emotionally painful, traumatizing even, it was to see the fetus
and place it into a bag: “So to me, I’ve still got that picture of my baby—taking my
baby out of the [toilet] bucket and put it … then put him in a plastic [bag], do you
understand. They came out of me. So, I am still not [feeling al]right.” Like in the
United States, abortion is legal in South Africa, but that does not preclude these gro-
tesque policies.
Another participant, Phumeza, wept during her prenatal interviews when she
recounted the story of how her previous pregnancy had ended in a stillbirth; she
already knew from a medical examination that her baby had died inside her, but
the nurses left her alone while she was in labor, and when she gave birth, the baby
fell onto the floor. The nurses simply came over and picked up the baby off the
floor, she recounted, and they did not apologize to her for their neglect or callousness.
Another woman we observed, but did not speak to, was sitting in the same spot as
Zola had, hugely pregnant, waiting to be admitted to the labor ward. She was left
waiting for hours as “punishment” for not seeking prenatal care at the MOU; eventu-
ally, she collapsed onto the floor, the baby crowning. Midwives rushed over to deliver
the baby, laughing and jeering, calling her “Miss Tights” because they had to cut
through her leggings to get the baby out.

“Next Time I Have a Baby, I Am Going to Come Here, Where They Don’t Cut
You”: The Contrast of Midwifery Birth in Mexico
I, [Lydia], have worked in Mexico with midwives and women’s health organizations
since 2002 as a volunteer, educator, and researcher. Between 2009 and 2012, I con-
ducted 17 months of ethnographic research with midwives, midwifery students, admin-
istrators, activists, and local politicians involved in three midwifery schools across
Mexico. Much of my time was spent at CASA (Center for the Adolescents of San
Miguel de Allende), in San Miguel de Allende, Guanajuato.
2710 Violence Against Women 28(11)

A central finding of my research was that obstetric violence was becoming a topic
that was increasingly discussed by all categories of actors, from politicians to providers
to students and even some patients. One place where discussions about it were quite
candid were the consult rooms at the CASA midwifery clinic, where midwives met
with women for family planning, wellness checks, and prenatal exams and often
opened up about the details of their previous encounters with the public healthcare
system. Through their conversations with patients and with each other, midwives
and midwifery students built a repository of information about how violence was expe-
rienced by their patients and how patients felt about it. These spaces also allowed mid-
wives to help their patients navigate past experiences and offer options for better future
care.
One afternoon while I was observing with Anita, a staff midwife, and Gabriela, the
student assigned to her that day, a patient named Alejandra arrived to get a pap smear.
As Gabriela checked her vital signs and asked her questions for her files, Alejandra
explained that she had come to CASA after first trying to go to the hospital to get a
free exam there, but the staff had told her she could only come between 8 and 9am,
a time frame that did not work with her work schedule. “Really?” asked Anita, as
she prepared the bed for Alejandra. “I had not heard they were doing that up there.”
“Yes!" replied Alejandra, “They are just so rude at the hospital. It’s even worse if
you look Indigenous at all. Last time I was there, there was this Indigenous woman
with her baby and everyone was so mean to her—she just wanted to get help for her
baby but they spoke to her like she was stupid,” she continued, sounding frustrated.
Anita nodded her head, and said, “I know, that is how they treat women there.”
Anita sent Alejandra to the bathroom to change into a gown. When she emerged,
Anita began the exam, pausing now and then to show Gabriela what she was doing.
Alejandra began to talk about her birth experience at the hospital. “It was horrible,”
she said. “They would not let my husband come with me and I did not want to be
alone. And then once I was in there, they cut me—down there.” “Well, everything
looks very pretty down here,” Anita said. “Actually, it looks as though you never
even had a baby!” This made Alejandra appear to relax. Anita finished up and sent
her to change back into her clothes.
While Alejandra was gone, Anita told Gabriela that she knew how things were done
at public hospitals because she had spent her year of social service in one of them (most
medical professionals in Mexico provide a year of service after receiving their degree).
“By the end of my year, I had become like them—medicalized. It has taken me years to
change; to not cut women, to not put in an IV until necessary, to let them walk around.
I have had to unlearn so many things that they taught me there.”
Alejandra came back out of the bathroom, looking concerned. “But why did they cut
me?” she asked Anita as she gathered up her things to leave. Anita sighed and told her
that, “They don’t need to do that in most cases. In fact, when they cut you, you can end
up tearing much worse. So, they really should not cut people unless there is a medical
need.” “Well, next time I have a baby, I am going to come here, where they don’t cut
you!” said Alejandra with conviction. “You should!” agreed Gabriela, as Alejandra
said goodbye.
Smith-Oka et al. 2711

In the short time between consults, the midwives and their students processed what
their patients had told them and shared things they witnessed while rotating through the
hospital or during their year of service. Anita turned to us then and said,

See, the hospital is not the best place to have a baby. Just last week I helped a woman who
tried to go to the hospital in labor, but the staff there told her she had two weeks to go, even
though she was already having contractions. They just sent her away! Then she called me
on the phone and things happened so quickly, I ended up having to help her give birth over
the phone. Her last birth had been a cesarean birth, too, so I did not know how this would
go. Luckily, everything turned out fine.

The Temporal Arc of Obstetric Violence: Expectations,

Experiences, and Responses
These ethnographic narratives demonstrate the wide scope of obstetric violence
across cultures and institutions and the different ways that it is understood and nar-
rated by the women themselves. Although there are demonstrable differences
across institutions and cultures, there is also a troubling structural universality to
obstetric violence. As we unpack the stories in these narratives, thinking through
the complexities and putting the events and turns of phrase in context, we can
begin to see the roots of gender-based violence and systemic gender inequity
beneath the surface. Below we discuss the temporal and structural universalities
of how women expect violence prior to it taking place (fear of caregivers, expect-
ing rude and harsh care based on the stories and experiences of others, and aware-
ness of the potential for care becoming violent); how they experience the violence
as it takes place (as an embodied, fearful, painful experience; as neglect or lack of
information); and how, after the violence is over, they respond to it (tactically
avoiding certain places, choosing a different caregiver, or employing “weapons
of the weak” (Scott, 1985), like gossip or complaints to friends). We argue that
regardless of where in space or place a woman is, there is a basic set of structures
undergirding their obstetric care that are shared. In the process, our findings point
to the need for legal, medical, and societal interventions that address the root
causes of obstetric violence; they also point to the potential for making such inter-
ventions scalable.

Shared Expectations
Ethnography encourages women to use their voices to make sense of their experiences,
and we can see in the narratives how obstetric violence makes women feel at once out-
raged, defiant, confused, scared, resigned, and, above all, vulnerable. The women
whose stories we shared recognize their position as extremely vulnerable in these sit-
uations: because of their gender, their lack of power relative to the clinical hierarchy
within the hospital, and the liability of looking like “the other” (poor/Indigenous/
young). Thus their suffering and the cruelty to which they are subjected is particularly
2712 Violence Against Women 28(11)

troubling. Like in Davis’s (2019) work in the United States, for many of the women in
our study, the intersection of their gender and their social background compounded
their fears and expectations of what might occur. Significantly, our data show that
women recognize the ubiquitous nature of the violence. That is, they know that at
some point they will experience violence, even if not during every medical encounter.
They all clearly understood that what was happening to them was not right (they were
not under the illusion that they had received great care), but they seemed unsure of why
they had such experiences or what to do about it. They may have been taken off guard
that things progressed the way they did, but they were not overly surprised that these
things happened in their public hospitals. They seemed resigned to the continuation of
such treatment.
Put another way, the women in our studies (and women in many more places around
the world) already know they will be subjected to mistreatment in these medical set-
tings, but often have no choice ultimately but to go there. They do what they can to
avoid the obstetric violence but, as we describe ahead, often they cannot. This vulner-
ability illustrates the way that obstetric violence is rooted in broader, systemic gender-
based violence: the abuse they experience in obstetric settings feels familiar and reso-
nates as inescapable just like the violence they encounter as women in other institu-
tions, at home with their partners, and in larger society. These narratives also render
obstetric violence visible whereas it otherwise remains intangible, absorbed into ubiq-
uitous and mundane forms of gender-based violence. The heart-wrenching way that
women come to terms with their abuse in these narratives demonstrates the ways
that it is embedded in systems of gender inequity that delegitimize and erase
women’s suffering.
Ethnography allows scholars to contextualize institutional practices and policies
that prey upon women’s vulnerability; our data highlight the emotionally harrowing
consequences of isolation and the burden of proof. Across most public hospitals in
Mexico and South Africa, social support from kin or loved ones during labor is
rarely allowed; women expect that they will enter into these spaces and have to expe-
rience birth alone with no labor companions for physical or emotional support. This
isolation can precipitate and heighten violence against already-vulnerable women,
because they do not have witnesses or supporters. That is, where women are already
the most vulnerable, policies exist to strip them of support and witnesses. This situation
demonstrates the way that medical institutions can sometimes rely on, rather than fight
against, structures that disempower and imperil women.

Shared Experiences
One way that ethnography shines its light on the violence is in capturing the details of
women’s experiences of obstetric violence, as in the seemingly offhand (but often
repeated) remarks made to women in labor by care providers. This verbal violence
in clinical encounters during labor and birth appeared in several ways, such as scolding
(“Shut up, lady”), humiliating patients about their sexual lives (“Now you may scream
in pain, but nine months ago you were screaming in pleasure”), threats (“One little cut
Smith-Oka et al. 2713

or your baby dies”), or comments about their suitability for motherhood (“These irre-
sponsible women don’t give a damn”). Statements such as these use explicitly gen-
dered ways of referring to women and their mothering, reproductive, or sexual
“missteps.” As our own fieldwork and that of other scholars around the world have
shown (e.g., Castro & Savage, 2019; Chadwick, 2017; Shabot & Korem, 2018),
such supposed missteps are subsequently used as a justification for scolding and
shaming women that medical personnel view as defying expectations for pregnancy
and birth, such as Bárbara’s youth and seemingly problematic demands. The women
whose stories we described were themselves within this intersection, and were
labeled as “unruly” because they were behaving against the norm. These “moral
regimes” become ways of enacting reproductive governance (Morgan & Roberts,
2012, p. 242) and allow those in power to distinguish between populations whose
reproduction is supported and those who are not, which, as Castro and Savage
(2019) state, is stratified reproduction that feeds into obstetric violence.
This kind of verbal abuse and shaming occurred with all the women in the vignettes
above, from Bárbara’s experience of being scolded and threatened about how she fed
her child, to midwives jeering at and calling the observed Xhosa woman by rude epi-
thets when she collapsed on the floor, and to Alejandra overwhelmingly concluding
that patients are treated rudely in hospital by clinicians. Evincing the intersectional
nature of obstetric violence, this form of verbal abuse is frequently exacerbated if
someone is “the other,” whether because their background is impoverished or indige-
nous, and are treated as inferior (“spoke to her like she was stupid”), or because they
have not hewn to the policies and rules of the clinical institution (“left waiting for hours
as ‘punishment’ for not seeking prenatal care”). Consequently, their behavior is
marked as aberrant and in need of control and punishment (see Davis, 2019) or as
“automatically morally suspect” because of their particular social backgrounds
(Chadwick, 2017, p. 501).
In our research settings, the broader structures that undergirded obstetric violence
included a synergy between gender and class. The forms of obstetric violence, their
institutionalization, and the direction that the resistance to obstetric violence has
taken in countries such as Mexico and South Africa all reflect distinct patterns of gen-
dered and racial discrimination, perceptions of motherhood, development, and resource
scarcity that impact many aspects of life. However, in addition to understanding obstet-
ric violence as the legacy of a dysfunctional racialized medical system—which it is to a
large extent—in this article, we understand obstetric violence as a form of gendered
violence in a context where violence against women is prevalent, persistent, and
widely acknowledged as problematic.
Violence caused the women in our studies to experience negative emotions, such as
fear, sadness, confusion, concern, or loneliness. These emotions seemed to most
sharply arise from the abandonment they experienced in these contexts, from the
lack of information about why procedures were done (or not), and from the marked
lack of social support (in some cases engineered by the clinics, thus a form of violence
as well as a symptom). Zola’s and Phumeza’s labors and losses illustrate this abandon-
ment the most clearly and most horrifyingly. Both of them were ignored by the
2714 Violence Against Women 28(11)

midwives at the MOU, aggravating their suffering and possibly directly affecting their
health. These clinical policies compound women’s tragedy, forcing them, and count-
less other women in a similar situation, to participate in the gruesome, unnecessary,
and heart-wrenching act of collecting and presenting their miscarried remains to
receive care. This rule places an undue emotional and physical burden on women to
provide “proof” of their misconception to the state. Clinical policies that compound
women’s vulnerability rather than alleviate it evince medical institutions’ complicity
in wider systems of gender-based violence. Only in a context of pervasive gender ineq-
uity and violence can violence occur in obstetric settings with such ubiquity and
impunity.

Shared Responses
In addition to understanding how women expect and experience obstetric violence, we
argue that it is important to examine their responses. Broader social fears of such vio-
lence may make patients willing to recognize obstetric violence as yet another form of
violence, while also tempering their responses for fear of the consequences of speaking
out against it. For this reason we describe here some of the unexpected ways that
women tactically act to avoid violence, how they brace themselves for its onslaught,
or even how they pragmatically justify it. Some of the women in our study may
have done what Chadwick (2017, p. 501) refers to as performing docility, where the
women in labor make sure to obey medical personnel in order to negotiate “care”
and to avoid trouble and hostility (quotation marks in original). In Bárbara’s case,
she first behaved assertively by requesting and then begging for a cesarean, but later
she shifted to meekness in her response to the nurse. Thus, she and other women
who performed docility avoided additional violence against them.
The narratives we describe show how women were shamed—through emphases on
engaging in “good” behavior during labor, conforming to expectations of “good
mothers,” acting according to social norms, or emphasizing the wellbeing of the
baby above the women’s. Shabot and Korem (2018, p. 393) state that this feeling of
shame can paralyze women, working “as an internal disciplinary mechanism” that
can prevent them from speaking up while the violence occurs. The women whose
stories we have shared were treated at times like children, or their bodies were seen
as shameful or as accessible without permission. Women’s responses tend to be tactical
in order to avoid future encounters, and so they engage in protective behaviors like
moving, lying about their address, or having a future child with a midwife instead
of in a public hospital in order to avoid potential future violence. Midwives can
often help to empower women with information and knowledge so they can be
better advocates of their health (Davis, 2019; Dixon, 2020). Women often lack the
resources and agency to respond adequately to obstetric violence, and hence their
choices are limited.
These patterns of violence we have described are not limited to one place. They span
the globe in spaces where women already occupy precarious positions (arguably,
everywhere). This article highlights the overlaps between Mexico and South Africa,
Smith-Oka et al. 2715

but these contexts are far from unique. By combining an ethnographic lens with a focus
and analysis of the broader political economy, we understand how the violence
emerges from broader systems of inequality that have become entrenched in institu-
tional practices and landscapes. Sometimes violence occurs because of the ways
resources are allocated (when laboring women are turned away because of a lack of
space, or there is not enough pain medication), or how spaces are designed (when
patients labor in rows of beds, without room for their partners or to get up and
move around). Rather than viewing these structural factors as causal, we see them as
symptoms of and perpetrators of underlying gender inequality (see also Jewkes &
Penn-Kekana, 2015).
Taken together, these shared expectations, experiences, and responses indicate that
there may be ways to address obstetric violence in sustainable and scalable ways.
However, the similarities captured through our ethnographic work reveal that, for inter-
ventions to have lasting and meaningful effects, they must target underlying gender
inequality and gender violence. Attempts to address only provider actions, resource
scarcity, or even structural limitations will not change the routes through which
gender violence manifests in obstetric care.

Conclusion
Bearing witness to obstetric violence as ethnographers entails grappling with what it
means to learn about or witness firsthand questionable and ethically problematic prac-
tices enacted on vulnerable women. As Davis and Craven (2016) state, part of the
process of doing ethnography is reflecting on what we have seen, thinking through
the ethical ramifications, and understanding how power—whether of the medical insti-
tutions, the women, or ourselves as anthropologists—is articulated and enacted in these
settings. We were often present during moments where women were unquestionably
suffering at the hands of a clinician and where we did not always know how to
respond. Questions regarding whether or not to get involved in the situation of violence
were often part of our reflections (Castro, 2019). In thinking collectively about our own
experiences in troubling births, we decided to prioritize the voices of the women we
met, rather than tell their birth stories from our own points of view. The rapport we
built during our ethnographic engagement allowed us to witness or be told by
women of violence in interactions where the pain caused by procedures was ignored
or ridiculed, when women’s labors were ignored, or when physical violence was
used as a threat.
What does this ethnographic evidence support? Ethnography is a powerful way to
study obstetric violence. Without hearing the actual voices or witnessing the experi-
ences of these women, we do not get the full story—because many women do not
have the words to express this as obstetric violence, or because their stories do not
get captured in numerical outcomes. Ethnography can be one of the avenues by
which women can articulate their struggles and be heard, and perhaps feel that,
through sharing their stories, they can work in opposition to and in defiance of these
violent institutional forces. Additionally, as we have argued, because of its long-term
2716 Violence Against Women 28(11)

engagement, ethnographic inquiry unveils the magnitude of obstetric violence and pro-
vides new ways to think about systemic interventions.
In this article, we have presented our combined ethnographic works to respond
to Savage and Castro’s call to keep women’s voices and experiences central to the
issue of obstetric violence, as we believe that ethnographic work can and should
inform policies and initiatives to mitigate the mistreatment (Castro & Frías,
2020). We also join the call from the UN’s Special Rapporteur on violence
against women in condemning this violence as a form of human rights abuse
(Šimonović , 2019). Because ethnography consists not only of listening but also
witnessing, its results can help researchers, practitioners, and activists fill in
missing information in contexts where mistreatment has become so normalized
as not to be reported (Bohren et al., 2017) and which can “perpetuate unjust
power structures within health facilities and possibly detract from optimal health
outcomes” (Savage & Castro, 2017, p. 23).
As we have shown throughout this article, listening to women describe their
encounters in labor and birth brings out the nuances of their experiences; these
stories also point to their sense of the impossibility of changing things—this is how
things are and how women “like them” are treated. What our article shows is that
obstetric violence is so widespread, ubiquitous, pervasive, commonplace, or
endemic that it can appear normal, unremarkable, natural, or acceptable. As ethnogra-
phers interested in global movements against obstetric violence, it is important for us to
keep in mind that the women experiencing this violence may not always be the ones at
the front lines of activism; despite recognizing that what happened to them was not
right, many seem resigned to the idea that things will remain as they currently are.
They may make different individual choices (such as having a future child with a
midwife instead of in a public hospital), but they may not always see obstetric violence
as something that could be regulated, legislated, and eradicated.
In this article, we interrogate the symbolic and literal violence in the medicalization
of childbirth and continue to expose biomedicine as an institution that is built on, nor-
malizes, and perpetuates gender inequality. However, we posit that any analysis of
obstetric violence needs to contextualize biomedicine and healthcare as part of the
wider structure of gender inequity that produces, and normalizes, all types of gender
violence. When these gendered structures are combined with the structures of medi-
cine, the violence becomes compounded. It is well known that the biomedical
system is imbued with practices that reflect a western, masculinist, white ethos that
often marginalizes and abuses those who “do not belong.” Women’s own fatalistic
view of obstetric violence and the structures of biomedicine make it difficult to trans-
late activism against obstetric violence into formal legislation. The legal application of
the term obstetric violence has been challenging because of its attempt to address both
systemic and direct forms of violence against women in obstetric settings (Chadwick,
2016; Dixon, 2015). While the link between these forms of violence is integral to an
understanding of obstetric violence, it may be harder to enforce regulations that seek
to address both of them. Additionally, some doctors and other biomedical caregivers
have responded negatively to the perception of them as violent, seeing it as a criticism
Smith-Oka et al. 2717

of them as individuals (Dixon, in press) rather than as part of a broader way of inter-
acting with their patients.
However, beyond the inconsistencies or inadequacies of legislation against obstetric
violence, we have shown how women may come to expect it, and to not expect any
recourse for their experiences, because of the broader gender violence to which they
have grown accustomed. This was a pattern that we found across the geographic
sites of our research. As the ethnographic narratives here show, the problem is not
that women are unaware that they are experiencing violence in obstetrics; it is that
many are experiencing violence all the time. To understand what that means to
them, we need to continue to listen. In this way, ethnography is a vital tool to let
women’s own experiences, perceptions, and needs be heard, and to contextualize
them within broader social patterns.
We conclude this article with our own dual recommendations. One is the need to
carry out research on obstetric violence among privileged populations that do not
usually encounter much violence in their daily lives or in countries where the presence
of violence is not systemic. Building on work carried out by scholars such as
Diaz-Tello (2016) among women in the United States, researchers would need to
address whether these women are better or worse equipped, epistemically, to recognize
these behaviors as violence, and how their responses differ. The other call is a recom-
mendation to scholars to continue using ethnography and deepen scholarship and
understanding on the temporal elements of how women expect, experience, and
respond to violence, in the process uncovering and dismantling the structures that con-
tribute to gendered violence and oppression. Together, such contributions will help
lead to a broader understanding of obstetric violence and point to sustainable, scalable
interventions.

Acknowledgment
Jeanne Barker-Nunn provided thoughtful copyediting support. VSO sincerely thanks the patients
and clinicians who generously gave so much of their time to this project. SER thanks her sup-
porters in the field: Dr. Simone Honikman, Director of the Perinatal Mental Health Project at
the University of Cape Town; Mrs. Minah Koela, her brilliant research assistant, translator, cul-
tural interlocutor, and dearest friend; her loving and supportive Cape Town cousins, Paul
Abrams, Jacqueline Dommisse, and Nosipho Abrams; and, above all, the Xhosa mothers who
so generously shared their stories and hearts. Back at home, she’d like to thank her family for
their unwavering support and love. LZD would like to thank all of the Mexican midwives, mid-
wifery students, and school administrators who shared their knowledge with her and who con-
tinue to fight for better healthcare for all.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.

Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or
publication of this article: VSO: Helen Kellogg Institute for International Studies and Institute for
2718 Violence Against Women 28(11)

Scholarship in the Liberal Arts, University of Notre Dame. SER: National Science Foundation
Social, Behavioral, and Economic Sciences Doctoral Dissertation Research Improvement Grant
(#1023741) and Fulbright Hays Doctoral Dissertation Research Abroad Fellowship. LZD:
Inter-American Foundation Dissertation Research Fellowship, UC MEXUS Summer Research
Grant, and the Center for Organizational Studies, a Global Health Framework Research and
Travel Fellowship, and the Department of Anthropology, UC Irvine.

ORCID iD
Vania Smith-Oka https://orcid.org/0000-0003-4121-3056

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Author Biographies
Vania Smith-Oka is an associate professor of anthropology at the University of Notre Dame.
Her work addresses questions of obstetric violence, medical decision-making, cesareans and
incisions, medical spaces, and medical training in Mexico and Kenya.

Sarah E. Rubin is an associate professor and medical anthropologist in the Department of Social
Medicine at Ohio University’s Heritage College of Osteopathic Medicine. Her research centers
on the intersections of maternal and infant health and culture. Her work focuses on associations
between daily experiences and broader structures that constrain those experiences to better
understand the context of racial disparities in health. Her primary methodologies are ethno-
graphic and phenomenological. Recent research includes investigating intersections of mental
health, motherhood, poverty, and culture in urban South Africa and stress, race, motherhood,
and poverty in relation to infant mortality risk in urban Ohio.

Lydia Z. Dixon is an assistant professor of health science at the California State University,
Channel Islands. Trained as a medical anthropologist, she has worked in the field of reproductive
health in Mexico for two decades and publishes on topics related to midwifery, childbirth, obstet-
ric violence, and global development.