Introduction

In this post, members of the Obstetric Violence Reading Group reflect on Paola Sesia’s chapter titled “Naming, framing and shaming through obstetric violence: A critical approach to judicialisation of maternal health rights violations in Mexico” in Gamlin, J et al (eds) Critical Medical Anthropology: Perspectives in and from Latin America (2020) 222-247. In this piece, Sesia discusses litigation on obstetric violence in Mexico, considering the judicialisation of maternal health rights violations through the lens of critical medical anthropology, and highlighting structural determinants and power relations in healthcare settings. Our reflections explore the opportunities that arise from naming and framing obstetric violence as a structural issue and how this characterisation shapes our understanding of potential remedies. 

Structural violence as the impossibility of another world

Structural violence emerges in Sesia’s account not only as a backdrop to individual violations, but as a system that forecloses the possibility of alternatives. The routine denial of care, the stereotyping of indigenous women, and the chronic under-resourcing of maternal health services in Mexico expose how obstetric violence is normalised within institutional arrangements that reproduce inequality. Sesia reveals that these conditions are sustained as if they were inevitable, leaving little room to imagine healthcare otherwise. Even when strategic litigation secures remedies in emblematic cases, the deeper structures that entrench racism, poverty, and gendered subordination remain largely untouched. This is the power of structural violence: it harms women in the present and goes on to constrain the very possibility of envisioning another world of alternative care models. Further, because it is naturalised or normalised as the ordinary functioning of the system, people often fail to see these harms as violence at all, or do not recognise themselves as subjects of violence.

Sesia’s characterisation of obstetric violence and implications for law

Sesia conceptualises obstetric violence broadly, allowing the term to draw together a “community of survivors”. Experiences which seem disconnected are united by their similar markers of gender-based violence and institutional deficiency. In this way, obstetric violence is expanded to encompass more than simply interpersonal harms, which risk being mistaken for individualised misunderstandings. She situates this within a broader culture of judicialisation in Latin America, which has existed since the 1990s. In such cases, the courts have seen a growing reliance on the individual right to health. Yet, certainly in the Mexican context, this judicial protection has failed to translate into broader, structural reforms, to proactively address the growing problems in maternity care. For law, through a broader definition of obstetric violence, there becomes greater urgency to act on this pressing, widespread, and clearly gendered issue. Thus, Sesia’s work lays the foundations for shifting the blame from individuals to institutions, and demanding far higher recourse for these systemic issues than is currently being seen.

Remedies

Our final reflection relates to Sesia’s discussion of remedies: once structural and institutional violence that violates fundamental rights has been identified, how should the state respond? For example, having identified the problem of institutionalised obstetric violence as primarily structural (rather than requiring individual punitive measures), GIRE – a Mexican feminist NGO leading the movement against obstetric violence – has been faced with several challenges relating to identifying, monitoring, and enforcing structural reforms. Sesia raises the following pertinent questions: “how, through which mechanisms, in how much time and who can verify satisfactory compliance…? And what does ‘satisfactory compliance’ mean for the different parties involved?”

Sesia’s chapter inspires deeper consideration of the various issues that arise in relation to structural remedies and institutional reforms. One is the challenge of identifying specific reforms that are likely to address the cultural crisis at the heart of institutionalised obstetric violence. Harmful cultural norms include discriminatory attitudes; hierarchical and disciplinarian approaches to health care delivery; and entrenched norms around the role of healthcare professionals and birthing people. It is likely that interventions would be needed at various levels (individual, institutional, and cultural) to effectively bring about change.

Another issue relates to the usefulness of litigation, given challenges in monitoring and enforcement of remedies and reforms. In this regard, we reflected on the role of supervised structural remedies, which have now been employed by the Mexican Supreme Court (‘SCJN’). In the seminal case on obstetric violence in Mexico, the SCJN required the responsible state authority to adopt monitoring and training reforms, and to report to a district judge on their compliance. In South Africa, court-appointed agents have been used to supervise state compliance in cases involving systemic rights violations. A similar supervisory approach might be useful in addressing obstetric violence. 

Conclusion

Our reflections on Sesia’s article contemplate some of the implications of obstetric violence as an institutional and structural phenomenon, and particularly the potential for legal responses through the lens of health rights. Institutions in which abuse is normalised are also embedded in harmful social structures, and institutional remedies should thus seek also to address harmful cultural norms. The concept of obstetric violence holds significant potential for joint action to demand this kind of institutional and structural change, by bringing together a “community of survivors”. However, Sesia offers examples from the Mexican context that highlight the challenges of identifying, monitoring, and enforcing structural remedies. Our reflections thus highlight both the benefits and limitations of the judicialisation of health rights. While judicialisation holds potential for engagement with health authorities regarding their obligations to monitor and prevent obstetric violence, meaningful reform requires multifaceted responses and significant cooperation from health authorities.

• Caitlin Daly, PhD candidate, University of Leeds
• Simone Gray, Lecturer and PhD candidate at the School of Law, University of KwaZulu-Natal.
• Frances Hand, DPhil in Law candidate at St Edmund Hall College, University of Oxford.
• Patricia San Juan, PhD student at Andalusian Interuniversity Institute of Criminology (Malaga Section), University of Malaga.
• Camilla Pickles, Associate Professor of Biolaw, Durham University.
• Georgia Speechly, DPhil in Law candidate at Exeter College, University of Oxford.