Questionnaire for Reflection on the Photographic Representation of Obstetric Violence

IPOV Project to Be Presented at the Semipyp Congress

January 22, 2025

Prevalence and Impact of Obstetric Violence in Europe

A Hidden Form of Gender-Based and Institutional Abuse

Obstetric violence (OV) is a specific form of violence that merges gender-based and institutional abuse, manifesting in various forms of mistreatment and disrespectful care during pregnancy, childbirth, and postpartum. This type of violence, whether through action or omission, results in harm to women in both public and private health services.

OV is characterised by a range of abusive practices that strip women of their autonomy to make informed decisions about their bodies, sexuality, and reproductive health. It also reflects a significant lack of quality and compassionate care. This violence is not only inflicted by individual healthcare providers—sometimes intentionally, but often as part of routine practices—but also by health systems as a whole, particularly when the conditions in healthcare facilities fall far below accepted standards.

The manifestations of OV are varied and include the overuse of medical interventions, such as unnecessary C-sections, episiotomies, and other procedures even in low-risk births. Women may also experience physical and verbal abuse, including infantilisation, discrimination, and coercive or unconsented medical procedures. Other forms of OV include breaches of confidentiality, failure to obtain fully informed consent, denial of pain relief, and violations of privacy.

Recognising the severity of this issue, international bodies such as the United Nations (2019), the Council of Europe (2021), the European Parliament (2019, 2024), and the European Commission (2024) have defined obstetric violence as a violation of human rights, categorising it as both gender-based and institutional violence.

It is important to note that most instances of OV are not intentional. Rather, they are perpetuated through normalised routines and a risk-based approach to pregnancy and childbirth. OV is deeply structural and intersectional, rooted in societal norms, health inequities, gender stereotypes, professional hierarchies, and the power dynamics between women and healthcare practitioners.

Crucially, all women, regardless of their economic status, level of education, or socio-cultural background, are at risk of experiencing obstetric violence. This pervasive issue demands urgent attention and action to ensure that all women receive the respectful and compassionate care they deserve during one of the most critical periods of their lives.

Graphic recording on the definition of the term “obstetric violence,” created during the IPOV Midterm Meeting. — Visual synthesis by Marta Bariáin Echániz for the IPOV Project, representing the collective process of reflection on defining “obstetric violence” from an interdisciplinary, ethical, and human rights-based perspective.

Prevalence and Impact of Obstetric Violence Worldwide

The widespread and systemic mistreatment and violence experienced by women during childbirth and other reproductive health services have increasingly gained international recognition. In 2014, the World Health Organization (WHO) acknowledged that “across the world, many women experience disrespectful, abusive, or neglectful treatment during childbirth in facilities.” In 2019, the UN Special Rapporteur on Violence Against Women identified mistreatment and violence in reproductive health services as “a serious violation of women’s human rights occurring across all geographical and income-level settings” in her dedicated report on the topic.

While governments across Latin America and the United Nations have taken steps to address this issue, progress in Europe has been comparatively slow. The conceptualisation and legal recognition of gynaecological and obstetric violence as a form of gender-based violence, as well as its criminalisation, began over 15 years ago in Venezuela, Argentina, and other Latin American countries. These nations led pioneering efforts to codify these practices into law.

In Europe, however, awareness and recognition of this form of violence have only started to grow significantly since 2017–2018. It has only recently become a topic on the agenda of decision-makers. Both the Council of Europe and the European Union have adopted resolutions highlighting the issue and calling for measures to address it at both national and European levels. Despite these efforts, significant progress is still required. To date, no European country has enacted legislation explicitly criminalising gynaecological and obstetric violence. At the sub-national level, Catalonia included obstetric violence in its 2020 law on violence against women, although this is not classified as criminal legislation.

Our project aims to examine the systemic and pervasive nature of gynaecological and obstetric violence across numerous European countries. It is designed to provide comprehensive and actionable recommendations to European and national policymakers, ensuring an effective and robust response to this critical human rights issue.

Prevalence of Obstetric Violence in Europe

The experience of many women during childbirth is far from ideal. Numerous studies highlight that this vital stage in life can often be marred by acts of obstetric and gynaecological violence.

In Italy, one in five women reported experiencing some form of obstetric violence during their first childbirth experience (2017). In Spain, this figure rises to one in three women (2018), while in Belgium, one in five women reported being subjected to unnecessary and potentially harmful interventions (2021).

One of the most controversial practices is the routine use of episiotomy, a surgical procedure that the World Health Organization (WHO) advises against unless medically necessary. In France, 20% of births result in an episiotomy, with peaks of 45% in some hospitals, and half of these interventions are performed without any explanation (2018). In Italy, 50% of women undergo routine episiotomies, a third of which are performed without consent. In Hungary, the rate increases to 70%, with more than half of these procedures carried out without informed consent (2018).

Another harmful and deeply sexist practice is the so-called “husband stitch,” where the episiotomy is sutured excessively to supposedly enhance the husband’s sexual pleasure. In Belgium, this procedure affects 6% of women, with peaks of up to 13% in certain hospitals. In Finland, one in three births is induced without medical justification and often without informed consent (2018). In Italy, 40% of mothers reported practices that undermined their dignity during childbirth, while in Belgium, one in four reported psychological violence in this context.

Intersection with Discrimination

Factors such as racism, migratory status, and socioeconomic background exacerbate the impact of obstetric and gynaecological violence. In Belgium, one in three racialised women reported experiencing obstetric violence (compared to one in five across the general population). In Greece, women living in refugee camps face high levels of disrespectful obstetric care, including over 60% undergoing unjustified caesarean sections and a complete lack of informed consent for medical interventions (2016). In Ireland, itinerant women have reported racism, neglect, and abuse in maternity facilities (2018). Furthermore, in Belgium, 25% of women with lower educational attainment have been victims of obstetric violence, surpassing the national average.

International Recognition and Slow Progress in Europe

Despite the severity of the issue, Europe’s response has been limited. In 2014, the WHO officially recognised obstetric violence as a global health issue. In 2019, the UN Special Rapporteur on Violence Against Women dedicated her annual report to mistreatment and obstetric and gynaecological violence. However, legislative progress in Europe has been insufficient. While the Council of Europe and the European Parliament have issued resolutions urging action, no European country has yet adopted specific legislation to address this form of violence.

Recommendations for Change

To tackle this issue, the following key actions are proposed:

Establish laws that classify obstetric and gynaecological violence as a form of institutional gender-based violence at both national and EU levels.
Adopt policies grounded in respect for informed consent and create independent reporting systems for victims.
Collect national and EU-level data to inform policymaking and establish national observatories on obstetric violence.
Train healthcare professionals in gender-sensitive, patient-centred approaches aligned with WHO guidelines.
Raise societal awareness about obstetric and gynaecological violence and inform women and pregnant individuals about their rights and how to exercise them.

Addressing obstetric and gynaecological violence is not only a public health issue but also a fundamental matter of human rights.

Additional Context: The Call for an EU Recommendation on Harmful Practices

Civil society organisations, healthcare professionals, and academics advocating for women’s and LGBTIQ+ rights have expressed concern over the delay in publishing the European Commission’s Recommendation on Preventing Harmful Practices. This Recommendation is a crucial step under the Gender Equality Strategy 2020-2025 and the LGBTIQ Equality Strategy 2020-2025, providing guidance to Member States on tackling harmful practices, including obstetric and gynaecological violence.

The Recommendation complements the recently adopted Directive on Combating Violence Against Women and Domestic Violence, addressing gaps in legal frameworks concerning practices such as female genital mutilation, intersex genital mutilation, and obstetric violence. Stakeholders have actively contributed to the drafting process, emphasising international human rights and public health standards. Its adoption is critical to ensuring comprehensive and harmonised measures across Europe.

Joint Call to the European Commission for Adopting the Recommendation on Harmful Practices