by Alisha Bjerregaard and Christina Zampas

On October 4, 2019, the UN Special Rapporteur on violence against women, its causes and consequences, Dubravka Šimonović, presented her latest report, “A human rights-based approach to mistreatment and violence against women in reproductive health services, with a focus on childbirth and obstetric violence.”  The first U.N. report of its kind, it addresses human rights abuses experienced by women during facility-based childbirth “as part of a continuum of the violations that occur in the wider context of structural inequality, discrimination and patriarchy.”   The report states unequivocally that: “Women’s human rights include their right to receive dignified and respectful reproductive health-care services and obstetric care, free from discrimination and any violence, including sexism and psychological violence, torture, inhuman and degrading treatment and coercion.”

Women and girls have long experienced mistreatment or even violence when delivering children in healthcare facilities around the world; however, these abuses have been shrouded in silence and stigma and rarely framed as human rights violations.  As the report underscores, this is partly due to harmful gender stereotypes about “women’s decision-making competence, women’s natural role in society and motherhood[, which] limit women’s autonomy and agency,” and how such stereotypes are “further justified by the belief that childbirth is an event that requires suffering on the part of the woman.”  Essentially, her “physical and emotional health is not valued.”

Although human rights bodies have denounced some of the abusive practices in the context of childbirth as violations of human rights, their decisions and statements have often been limited to specific abuses, such as forced sterilization and the shackling of incarcerated women, leaving many types of mistreatment “unaddressed or inadequately analyzed under international human rights law” (Khosla, Zampas et al., p. 132).  They have not articulated the rights violations as part of a wide range of abuses within the context of childbirth, nor the role of intersectional discrimination.

Human rights violations addressed in the report include: physical and verbal abuse; over-medicalization, including the overuse of caesarian delivery, episiotomy and oxytocin when not medically justified; symphysiotomy; forced sterilization; forced abortion; shackling of women; failure to respect privacy and confidentiality; procedures without anesthesia; a lack of autonomy and decision-making; and the post-childbirth detention of women for inability to pay their hospital bills.  This list is not exhaustive, the report notes, nor does it include violations outside healthcare facilities.

The report frames some of these abuses in the context of “violence against women,” as defined under international human rights law, while recognizing that not all mistreatment during childbirth constitutes violence against women.  Such assessment must be done on a case-by-case basis.  The report further acknowledges that some forms of mistreatment may constitute violence and may violate other human rights, such as rights to health, privacy, freedom from discrimination and freedom from inhuman and degrading treatment.

Recognizing that mistreatment and violence against women during childbirth denies women autonomy and agency, the report places special emphasis on informed consent to medical treatment as “a human right and a safeguard against such violence.” It calls upon states to “respect women’s autonomy, integrity and their capacity to make informed decisions about their reproductive health.”  The International Federation for Gynecology and Obstetrics (FIGO’s) ethical guidelines (pp. 22-24) on informed consent are used in defining the appropriate human rights standard.

The report examines the root causes of mistreatment, identifying harmful gender stereotypes, discriminatory laws and practices, asymmetrical power dynamics in the provider-patient relationship, and health systems conditions and constraints, including poor working conditions, inadequate training, and failure to prioritize women’s health care in budgetary allocations, as underlying factors driving these abuses.  The report calls attention to FIGO’s guidelines (pp. 40-43) on “Harmful stereotyping of women in health care” as a key resource for providers.

The report also importantly acknowledges the significant role that intersectional discrimination plays in exacerbating abuse, noting that women and girls with intersectional identities, including socioeconomically disadvantaged, minority and indigenous women, and women with disabilities, are at higher risk of discrimination and abuse in the context of reproductive health care.

The report builds on a growing body of work in this area.  The evidence has been mounting that these abuses against women during childbirth are widespread and systematic, with fact-finding reports and public health studies documenting rights violations around the globe.  The World Health Organization issued a groundbreaking statement on the prevention and elimination of disrespect and abuse during facility-based childbirth in 2014, devoting resources to empirical research to the issue, and publishing global guidelines on intrapartum care for a positive birth experience in 2018.  As the new UN report highlights, social movements and social media have helped to further break the silence and stigma around these abuses, providing women with a platform to share their stories and push for accountability.

To address these violations, the report recommends that states develop national strategies to ensure respectful treatment during childbirth and other reproductive health service provision.  In particular, states should: guarantee women’s right to birth companions of their choice and remedy the lack of pain relief; ensure robust protections for informed consent; address the underlying structural problems that drive this mistreatment and abuse; and establish human rights-based accountability mechanisms.  Recognizing the broader continuum of reproductive health abuses, the report also calls for a review of laws that discriminate against women and perpetuate harmful gender stereotypes, including third-party consent laws and those that criminalize abortion and miscarriage, with an emphasis on addressing intersectional discrimination.

By shedding light on the rights violations experienced by women during facility-based childbirth, and the drivers of this mistreatment and violence, we hope that this report spurs states to prevent and redress these abuses.  We also hope that human rights bodies engage in robust analyses of abuses that women experience during childbirth, the context in which they occur, and the inherent discrimination of these practices, as well as the intersectional nature of the discrimination that many women face.