Perspectives
The art of medicine
Obstetric violence in historical perspective
Although improvements in perinatal care have helped
save many lives worldwide, reproductive health inequities
remain rife. Racial, geographical, and class-based disparities
shape divergent maternal and infant health outcomes,
as well as unequal access to vital forms of health care
such as abortion. Present-day reproductive injustices are
contextualised by many factors, including the under-
recognised history of obstetric violence. Obstetric
violence refers to harm inflicted during or in relation to
pregnancy, childbearing, and the post-partum period.
Such violence can be both interpersonal and structural,
arising from the actions of health-care providers and also
from broader political and economic arrangements that
disproportionately harm marginalised populations. By
focusing on obstetric violence, we centre the long and
enduring history of biological reproduction as a site of social
violence. In doing so, we elucidate how obstetric violence
has reflected and amplified different forms of social and
political discrimination, oppression, and exclusion.
The connection between obstetric violence and
social inequity reaches back centuries, as suggested by
examples from the early modern period. In 16th-century
papal Rome, for instance, Roman Catholic authorities in
houses of catechumens (institutions for non-Christians)
sequestered Jewish women’s babies unless they consented
to Christianisation via baptism. Here obstetric violence
arose from and perpetuated religious discrimination,
since women were forced to choose between religious
conversion and family separation in the post-partum
period. Obstetric violence also occurred during colonisation
by the Spanish Empire in the Americas, especially in the late
18th-century viceroyalties of New Spain and Peru. There,
priests performed forced caesarean sections on some
women who struggled to give birth. Crown officials made
the operations obligatory and emphasised that the priority
was to save the souls of fetuses and not the lives of their
mothers. Again theological mandates shaped women’s
childbearing experiences, while the broader contexts of
Christianisation and colonisation conditioned this specific
form of obstetric violence.
Reproduction in the 16th century through to the
19th century was also shaped by the institution of
slavery. Obstetric violence lay at the heart of slavery in
the Americas, which relied on the exploitation of Black
women’s reproductive labour for economic profit. In
the system of hereditary slavery, enslaved women’s
childbearing was appropriated to enrich their oppressors,
and women faced violent punishment and abuse for
failing to conceive and give birth to healthy offspring.
Additionally, enslaved women were forced to undertake
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strenuous physical labour throughout their pregnancies,
and they were frequently denied care and recovery time
after giving birth. Enslaved childbearing women also faced
violence from the growing medical fields of obstetrics and
gynaecology. Antebellum physicians in the USA developed Further reading
new medical procedures by continually experimenting Abuya T, Warren CE, Miller N, et
al. Exploring the prevalence of
on the bodies of enslaved women—and other individuals
disrespect and abuse during
marginalised on the basis of race, class, and citizenship childbirth in Kenya. PLoS One
status—while denying them the standards of care afforded 2015; 10: e0123606
to other patients. The accelerated medicalisation of birth Bowser D, Hill K. Exploring
evidence for disrespect and
during the late 19th and 20th centuries also led to broader
abuse in facility-based childbirth:
forms of gendered violence, as the male-dominated report of a landscape analysis.
specialty of obstetrics sought to displace traditional female Boston, MA: Harvard School of
birth attendants and establish authority over childbearing. Public Health and University
Research Co, LLC, 2010
Positioned as subordinate to their physicians, women
Caffiero M. Cochrane L, trans.
were subjected to needlessly aggressive interventions and Forced baptisms: histories of Jews,
routinely denied the ability to make decisions about their Christians, and converts in papal
own bodies and health. Rome. Berkeley, CA: University of
California Press, 2012
The expansion of obstetrics was marked by
Davis D-A. Reproductive
discriminatory practices in the assessment and treatment injustice: racism, pregnancy, and
of childbirth pain. 19th-century physicians in multiple premature birth. New York, NY:
regions claimed that middle-class and upper-class white New York University Press, 2019
women experienced more pain in childbirth, and they Equal Justice Initiative. Shackling
of pregnant women in prisons
focused their efforts of pain relief on this subset of and jails continues. Jan 29, 2020.
patients. Even today racial disparities persist in obstetric https://eji.org/news/shackling-
pain management, with practitioners in the USA providing of-pregnant-women-in-jails-
and-prisons-continues/
less pain treatment to Black and Latina obstetric patients
(accessed May 19, 2022)
than to their white counterparts.
Grobman WA, Sandoval G,
Another recurrent form of obstetric violence involved Rice MM, et al. Prediction of
coercive sterilisation by medical practitioners to prevent vaginal birth after cesarean
delivery in term gestations: a
future childbearing. In the early 20th century, eugenic
calculator without race and
movements in multiple countries promoted the ethnicity. Am J Obstet Gynecol
involuntary sterilisation of those deemed hereditarily 2021; 225: 664.e1–64.e7
“unfit”, which disproportionately impacted disabled, Gurr B. Reproductive justice:
impoverished, and racially marginalised women. Sterili- politics of health care for Native
American women. New
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most eugenic laws were formally repealed. In the USA, Press, 2015
thousands of Native American women were sterilised in Lawrence J. The Indian Health
Indian Health Service (IHS) hospitals during the 1970s, Service and the sterilization of
Native American women.
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physician Connie Pinkerton-Uri, of Choctaw and Cherokee Lira N. Laboratory of deficiency:
heritage, estimated that IHS hospitals sterilised around sterilization and confinement in
a quarter of Native American women of childbearing California, 1900–1950s.
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age during this period. The 1974 case of Relf v Weinberger California Press, 2021
exposed the forced sterilisation of low-income African
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American patients; in the 1978 case of Madrigal v Quilligan, Urrunaga-Pastor D, Mendoza-
ten Mexican immigrant women brought a class-action Chuctaya G, et al. Disrespect and
abuse during childbirth in
lawsuit against the Los Angeles County Hospital for a
fourteen hospitals in nine cities
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 Perspectives
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Ricardo Ceppi Stringer/Getty Images
Activists celebrate the legalisation of abortion in Argentina in December, 2020
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about the nature of the procedure being performed;
women were also pressured into signing sterilisation
consent forms while in labour or while heavily sedated
after caesarean sections. In some cases, impoverished
women were told they would lose social support services
or custody of their children if they did not agree to be
sterilised. A pattern of sterilisation abuse also occurred in
Peru, where between 250 000 and 300 000 women were
sterilised between 1996 and 2001. These operations were
explicitly racialised, with the country’s president at that
time Alberto Fujimori referring to them as a solution for
the country’s “Indian problem”. These histories reveal how
widespread coerced sterilisation has been within medical
practice, and illustrate how obstetric violence historically
reinforces vulnerabilities along lines of gender, race,
poverty, disability, and nationality.
In mid-to-late 20th century Latin America, certain kinds
of obstetric violence happened in the context of organised
political terror. Military dictatorships in Argentina, Brazil,
and Chile were notable for repression against political
opposition. Government regimes during this period
abducted, tortured, disappeared, or killed thousands of
people, claiming that they were enemies of the state.
Military officials committed acts of sexual violence against
those detained; infants born to detainees were almost
always confiscated and raised by families who supported
the regimes in power. In this context, authorities used
obstetric violence to terrorise childbearing women and
sever their kinship ties.
Some of these historical forms of obstetric violence have
persisted during the 21st century, often enabled by new
contexts. Mass incarceration in the USA facilitates obstetric
violence including the forced separation of mothers and
infants after birth as well as coercive sterilisation, which
was documented in the California prison system between
2006 and 2013. In addition, many jails and prisons still
shackle incarcerated women during pregnancy and
childbirth, inflicting both physical and psychological harm.
The obstetric violence faced by incarcerated people—
who are disproportionately likely to be Black or Latina in
the USA—represents another instance in which obstetric
violence both reflects and perpetuates systemic racism.
Although its impacts are unevenly distributed,
obstetric violence today is a global phenomenon. There
have been reports of abusive maternity care in facilities
across numerous countries. In their 2010 framework,
Diana Bowser and Kathleen Hill identified seven categories
of disrespect and abuse in childbirth: physical abuse, non-
consented care, non-confidential care, non-dignified care,
discrimination, abandonment, and detention in facilities.
Drawing on this approach, studies in 2015 from Kenya,
Ethiopia, Tanzania, and Nigeria found the prevalence
of reported disrespect and abuse varied between 15%
and 98% among childbearing women in the different
countries. Similarly, a 2017 study of 1528 women in
Peruvian hospitals found that about 97% of the women
had encountered at least one category of disrespect and
abuse during childbirth, with non-dignified and non-
consented care the most common. About 55% of the
women experienced four or more concurrent categories
of mistreatment. Discrimination was most frequent in
regions with large Indigenous populations, who have
marginal access to state-based rights.
Another widespread form of contemporary obstetric
violence involves the denial or obstruction of access to
legal abortion, resulting in harms associated with forced
childbearing and unsafe illegal abortion. Although some
countries have recently expanded access to abortion,
including Argentina in 2020, Mexico and Benin in 2021, and
Colombia in 2022, abortion is illegal or heavily restricted
in numerous locations. In May, 2022, a leaked draft of
a Supreme Court majority opinion by Associate Justice
Samuel A Alito, Jr revealed plans to reverse the legalisation
of abortion in the USA. Lack of access to safe abortion results
in medical harms, such as increased rates of preventable
death from sepsis and haemorrhage, and economic and
political harms related to exclusion and loss of autonomy.
The criminalisation of abortion thus bolsters patriarchal
norms that punish women for rejecting motherhood.
These broad-ranging harms illustrate how obstetric
violence can be enacted through what Lynn Morgan and
Elizabeth Roberts have called reproductive governance,
which refers to the way authorities exert influence and
control over reproductive behaviours through legislative,
economic, moralistic, and physical means.
Both historically and in the present day, activists play a
crucial role in naming and addressing obstetric violence.
Latin American activists popularised the term obstetric
violence in the 1990s, using it to call attention to human
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rights abuses that occurred in the context of medicalised
childbirth. In the USA, the category of obstetric violence has
garnered increasing attention from activists in recent years,
drawing on insights from Dorothy Roberts, Loretta Ross,
and others into the pervasive violence that has shaped
Black women’s experiences of reproduction. The framework
of reproductive justice, developed by a group of Black
feminists in the 1990s, reoriented the conversation around
reproductive rights to encompass both the right not to
reproduce and the right to have children, which includes
the ability to bear and raise those children in healthy
environments safe from myriad forms of structural and
interpersonal violence. Within this framework, addressing
obstetric violence is an imperative for those seeking
reproductive justice. Birthing justice activists have brought
widespread attention to racial disparities in birth outcomes,
and have called for greater use of doulas and midwives as
well as changes in obstetric practice. In the past few years,
advocates have successfully challenged the inclusion of race
and ethnicity as variables in a clinical algorithm known as
the Vaginal Birth After Cesarean (VBAC) calculator. The
calculator promoted the disproportionate use of caesarean
sections for patients identified as African American or
Hispanic; research and advocacy-based efforts spurred the
development of an updated VBAC calculator in 2021.
Activism against obstetric violence in Latin America
often occurs through formal legal channels. Countries
including Venezuela (2007), Argentina (2009), Chile
(2015), Colombia (2017), and Ecuador and Uruguay
(2018) have passed legislation defining and outlining
sanctions against obstetric violence, which is categorised
as gender violence, and which in many places is punishable
by law. Human rights commissions and working groups
have sought recompense for situations spanning injury,
mistreatment, and neglect during childbirth. Many
who have filed obstetric violence complaints over the
past decade have been Indigenous women. Activists
have suggested the need for interventions at policy and
community levels, including expanded public resources
and infrastructure. Recent Latin American efforts to define,
sanction, and punish obstetric violence have provoked
backlash from some medical providers. But since 2014
some women who endured obstetric violence have been
met with sympathy from national and international
human rights courts that have awarded them monetary
damages and benefits such as free schooling for their
children. Activists recognise that obstetric violence is an
imprecise semantic category, but argue for its value as a
conceptual framework. Framing diverse violations under
the umbrella of obstetric violence shifts the discourse away
from individual cases and isolated medical malpractice and
towards structural conditions—permitted or supported by
some health-care systems—that infringe on the collective
dignity and wellbeing of childbearing people.
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Perspectives
Los Angeles Times/Getty
Activists with the Committee to Stop Forced Sterilization march outside a hospital in Los Angeles, CA, USA,
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