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Merette Khalil 1,2 *, Kashi Barbara Carasso 2 and Tamar Kabakian-Khasholian 3 | 1 Your Egyptian Doula, Cairo, Egypt, 2 International Course for Health and Development, Health Unit, KIT Royal Tropical Institute, Amsterdam, Netherlands, 3 Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
Globally, over a third of women experience disrespect and abuse (D&A) during childbirth, and in the Eastern Mediterranean Region (EMR), women's narratives reveal the normalization of obstetric violence (OV) in intrapartum care. To ensure respectful, rights-based, and evidence-based childbirth in the EMR, multi-sectoral and multi-level actions are essential. Recommendations should be tailored to country-specific contexts, focusing on advocacy, education, and empowerment at individual and community levels. At the health facility and system levels, cultural and infrastructural changes are needed, including multi-disciplinary team approaches and cultural competency training for health workers. Implementing WHO recommendations, such as reducing routine interventions and providing adequate pain relief options, is crucial. Strengthening health information systems and referral pathways can alleviate overcrowding and improve patient flow. Establishing mechanisms to report abuses and integrating public health experts into management teams are vital for accountability. Generating evidence and conducting research to document experiences and measure intervention impacts are necessary. Policymakers must prioritize eliminating OV to ensure dignified, respectful maternal care and improve health outcomes.
CAMBOGIA
Clémence Schantz,a Kruy Leang Sim,b Ek Meng Ly,b Hubert Barennes,c,d So Sudaroth,b Sophie Goyete | a Centre Population & Développement (CEPED)-UMR 196: IRD (Institut de Recherche pour le Développement) and Université Paris Descartes, Paris, France. Correspondence: clemschantz@hotmail.com b Calmette Maternity Hospital, Phnom Penh, Cambodia c ANRS (Agence Nationale de Recherche sur le VIH et les Hépatites), and Epidemiology Unit, Pasteur Institute, Phnom Penh, Cambodia d Isped (Institut de Santé Publique d’Epidémiologie et de Développement), Centre INSERM (Institut National de la Santé et de la Recherche Médicale) U897-Epidemiologie-Biostatistique, Université de Bordeaux, Bordeaux, France e Independent Researcher, Annecy le Vieux, France
L’épisiotomie, documentée pour la première fois en 1741, s'est largement développée au XXe siècle, mais il a été démontré qu'elle n'est pas efficace pour réduire les traumatismes périnéaux graves et peut être dommageable. Une étude réalisée en 2013-2014 à Phnom Penh, Cambodge, a examiné les raisons pour lesquelles cette pratique systématique persiste. Elle comprenait une analyse des dossiers médicaux de 365 patientes, parmi lesquelles 94,5% avaient subi une épisiotomie, ainsi que des entretiens avec des professionnels de santé et de jeunes accouchées. Les motivations citées incluaient la peur des déchirures, des croyances sur les caractéristiques physiques des femmes asiatiques, le manque de temps en salle d’accouchement surchargée, et des perceptions esthétiques. L'étude recommande une politique restrictive sur l’épisiotomie et une meilleure information prénatale pour les femmes enceintes.
Clémence Schantz, « ‘Cousue pour être belle’ : quand l’institution médicale construit le corps féminin au Cambodge », Cahiers du Genre 2016/2 (n° 61), p. 131-150. DOI 10.3917/cdge.061.0131
La périnéorraphie est une pratique chirurgicale biomédicale visant à resserrer fortement le périnée des femmes après un accouchement par voie basse. Au Cambodge, cette pratique, à travers l'institution biomédicale, façonne un corps féminin conforme à des représentations genrées, où le corps féminin, perçu comme faible et vulnérable, est modifié pour répondre aux attentes du corps masculin. Cet article montre que, en conformant les femmes à leur rôle d'épouse, l'institution biomédicale participe à la reproduction de structures sociales genrées. Il interroge également les motivations des acteurs, notamment des soignantes, qui croient rendre service aux femmes par cette pratique.
2020, Modeler son sexe au Cambodge pour «garder son mari à la maison»
Clémence Schantz est sociodémographe et mène des recherches sur les logiques sociales qui déterminent les pratiques biomédicales autour de l’accouchement. Après avoir montré avec sa recherche doctorale que les pratiques obstétricales construisent et façonnent le corps féminin au Cambodge, elle a mené une recherche postdoctorale sur la pratique de la césarienne et les violences institutionnelles au Bénin et au Mali. Elle conduit aujourd’hui des recherches sur les violences de genre en structures de santé et développe notamment des recherches sur la circulation des violences et des pratiques gynéco-obstétricales en santé entre l’Asie et l’Afrique. Clémence Schantz est chercheure associée au Ceped UMR 196 (IRD-Université Paris Descartes).
La périnéorraphie au Cambodge est pratiquée sur des femmes jeunes et en bonne santé pour resserrer leur vagin et augmenter leur capital érotique, visant à accroître le plaisir sexuel masculin. Cet article décrit cette pratique et montre qu'elle est détournée de son objectif médical pour répondre à une demande sociale. Grâce à une observation participante de onze mois dans des maternités de Phnom Penh et à l’analyse des discours recueillis entre 2013 et 2016, il apparaît que cette pratique mutilante émerge dans un contexte de mutation du modèle conjugal et familial, où les femmes cherchent à limiter le recours de leurs maris à la prostitution.
INDIA
Sreeparna Chattopadhyay, Arima Mishra, Suraj Jacob
The majority of maternal health interventions in India focus on increasing institutional deliveries to reduce maternal mortality, typically by incentivizing village health workers to register births and making conditional cash transfers to mothers for hospital births. Based on over 15 months of ethnographically informed fieldwork conducted between 2015 and 2017 in rural Assam, the Indian state with the highest recorded rate of maternal deaths, we find that while there has been an expansion in institutional deliveries, the experience of childbirth in government facilities is characterized by obstetric violence. Poor and indigenous women who disproportionately use state facilities report both tangible and symbolic violence, including iatrogenic procedures such as episiotomies, in some instances done without anesthesia, improper pelvic examinations, beating, and verbal abuse during labor, with sometimes the shouting directed at accompanying relatives. While the expansion of institutional deliveries and access to emergency obstetric care is likely to reduce maternal mortality, in the absence of humane care during labor, institutional deliveries will continue to be characterized by the paradox of “safe” births (defined as simply reducing maternal deaths) and the deployment of violent practices during labor, underscoring the unequal and complex relationship between maternal health policies and actual experiences of childbirth.
Nadia Diamond-Smith, Emily Treleaven, Nirmala Murthy, and May Sudhinaraset
Results: We found that women who held more equitable views about the role of women were less likely to report experiencing mistreatment during childbirth. These findings suggest that dimensions of women’s empowerment related to social norms about women’s value and role are associated with experiences of mistreatment during childbirth. || Conclusions: This expands our understanding of empowerment and women’s health, and also suggests that the GEM scale can be used to measure certain domains of empowerment from a women’s perspective in this setting.
Shreeporna Bhattacharya and T. K. Sundari Ravindran
The prevalence of disrespect and abuse during labor and delivery was high among women, irrespective of their socio-demographic background or delivery conditions, in both government and private health facilities. If the problem of disrespect and abuse is not addressed, it can be assumed that such harsh practices might promote home deliveries, which, despite being more unsafe, provide an empathetic environment in lieu of safe facility-based birthing options.
Gita Sen, Bhavya Reddy, Aditi Iyer
Concerns about disrespect and abuse (D&A) experienced by women during institutional birth have become critical to the discourse on maternal health. The rapid growth of the field from diverse points of origin has given rise to multiple and, at times, confusing interpretations of D&A, highlighting the need for greater clarity in the concepts themselves. Furthermore, the focus on measuring the problem has been excessive in relation to the small amount of work on critical drivers of disrespect and abuse. This paper raises some key issues of conceptualization and measurement for the field, puts forward a working definition, and explores two critical drivers of D&A – intersecting social and economic inequality, and the institutional structures and processes that frame the practice of obstetric care. By identifying gaps and raising questions about the deeper causes of D&A, we point to potentially fruitful directions for research and action.
Surbhi Shrivastava and Muthusamy Sivakami
The term 'obstetric violence' describes mistreatment, disrespect, abuse, or dehumanized care of women during childbirth by healthcare providers. This review examines literature in India on this issue, using Bohren et al.'s (2015) typology. Sixteen studies were identified, including case studies, ethnographic, mixed-methods, qualitative, and quantitative studies. The studies were analyzed based on seven categories of mistreatment and an additional category of harmful traditional practices. The research highlighted varying prevalences of obstetric violence in both public and private facilities, with socio-demographic factors influencing levels of mistreatment. A rights-based framework is proposed to address the issue in India.
Tabassum Nawab, Uzma Erum, Ali Amir, Najam Khalique, Mohammed A. Ansari, and Ambreen Chauhan
More than 8 of 10 women experienced any DA during facility-based childbirth. It can be a barrier to utilization of facility for childbirth. Preventing DA is important to improve quality of maternal care and institutional deliveries.
Srinivas Goli, Dibyasree Ganguly, Swastika Chakravorty, Mohammad Zahid Siddiqui, Harchand Ram, Anu Rammohan, Sanghmitra Sheel Acharya
Result: About 15.12% of women are facing LRV in UP, India. Results from the logistic regression model (OR) show that LRV is higher among Muslim women (OR 1.8, 95% CI 0.7 to 4.3) relative to Hindu women (OR 1). The prevalence of LRV is higher among lower castes relative to the general category and is higher among those women who have no mass media exposure (OR 4.7, 95% CI 1.7 to 12.8) compared with those who have mass media exposure (OR 1). || Conclusion: In comparison with global evidence, the level of LRV in India is high. Women from socially disadvantaged communities are facing higher LRV than their counterparts.
Srinivas Goli, Dibyasree Ganguly, Swastika Chakravorty, Mohammad Zahid Siddiqui, Harchand Ram, Anu Rammohan, Sanghmitra Sheel Acharya
En las últimas décadas, el gobierno de India ha promovido el parto institucional para reducir la mortalidad materna. Sin embargo, esto no garantiza un parto seguro y digno, ya que hay frecuentes episodios de violencia obstétrica, que tiene efectos adversos a largo plazo en la salud y bienestar de las mujeres. Este estudio revisa la literatura de PubMed sobre la experiencia de las mujeres durante el parto en India. Se encontró que el maltrato verbal es la forma más común de violencia obstétrica, seguido del maltrato físico y otros comportamientos deshumanizantes. Las mujeres de castas inferiores, comunidades musulmanas y familias de bajos ingresos son más propensas a sufrir estos abusos. La violencia obstétrica surge de interacciones individuales, fallas del sistema de salud y un entorno institucional abusivo, lo cual genera temor y empeora los resultados de salud, disuadiendo a las mujeres de usar los servicios de salud. Es necesario garantizar un trato digno y amable durante el parto, además de aumentar el acceso a cuidados obstétricos de emergencia.
Abid Faheem. PhD Scholar, Centre of Social Medicine and Community Health, Jawaharlal Nehru University (JNU), New Delhi, India.
En las últimas décadas, el gobierno de India ha promovido el parto institucional para reducir la mortalidad materna. Sin embargo, esto no garantiza un parto seguro y digno, ya que hay frecuentes episodios de violencia obstétrica, que tiene efectos adversos a largo plazo en la salud y bienestar de las mujeres. Este estudio revisa la literatura de PubMed sobre la experiencia de las mujeres durante el parto en India. Se encontró que el maltrato verbal es la forma más común de violencia obstétrica, seguido del maltrato físico y otros comportamientos deshumanizantes. Las mujeres de castas inferiores, comunidades musulmanas y familias de bajos ingresos son más propensas a sufrir estos abusos. La violencia obstétrica surge de interacciones individuales, fallas del sistema de salud y un entorno institucional abusivo, lo cual genera temor y empeora los resultados de salud, disuadiendo a las mujeres de usar los servicios de salud. Es necesario garantizar un trato digno y amable durante el parto, además de aumentar el acceso a cuidados obstétricos de emergencia.
Raksha K. Shetty, Padmaja Y. Samant, Priyanka U. Honavar
The majority of the participants had witnessed some form of obstetric violence (OV). The need for practical training of healthcare personnel and better infrastructure in the healthcare system was emphasized, but there appeared to be a lack of awareness regarding the paternalistic mindset and approach to women in labor. Soft skills training of healthcare providers, with an emphasis on key ethical principles such as autonomy, respect, and dignity, is crucial to address the issue of OV.
The body maps capturing birth experiences, created through a participatory method, accurately portray women’s respectful and disrespectful births and are useful for understanding women’s experiences of a sensitive issue in a patriarchal culture. An in-depth understanding of women’s choices, experiences, and expectations can inform changes in practices and policies and help to develop a culture of sharing birth experiences.
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