Imagine how vulnerable a woman in labour feels laying on her back, naked from waist down, with legs wide open for a medical examination- all the while in pain and anxious for her baby’s well-being. For health professionals, this is a routine procedure, but for mothers, especially if they are young or first-time mothers, it can be a frightening experience.

In such settings, care and comfort are paramount for the mother’s and infant’s health and are basic rights; however, they have seldom been recognised as such. In fact, there are growing concerns about the care available to mothers in institutions in India and even the harmful practices in home births.

Mistreatment, disrespect, abuse, and dehumanised care during childbirth in the ambit of sexual and reproductive health services are termed obstetric violence (OV).

A statement by the WHO in 2015 clarifies OV as “outright physical abuse, profound humiliation and verbal abuse, coercive or unconsented medical procedures (including sterilization), lack of confidentiality, failure to get fully informed consent, refusal to give pain medications, gross violations of privacy, refusal of admission to health facilities, neglecting women during childbirth to suffer life-threatening avoidable complications and detention of women and their new-borns in facilities after childbirth due to an inability to pay”.

Several studies from across India report high rates of OV varying from 15% to 84%. This is quite a wide range and is related to the definition of OV and the settings in which the study was conducted.

What is most troubling is that these studies find that self-reported prevalence of OV is much lower than what is actually observed, which suggests under-reporting.

While the commonly reported forms of obstetric violence are verbal abuse, lack of privacy, lack of information and neglect, much more severe forms like physical and sexual abuse usually go unreported due to associated stigma and discrimination.

Being slapped on the thighs or being scolded for crying out in pain when in labour, being pinched or having your legs tied up during the labour process, are documented instances of physical and verbal violence by healthcare professionals in private and public facilities across India.

“If I complained about pain, they abused me in such vulgar language - When you slept with husband, you enjoyed - now why are you screaming, just lie down.”

On the one hand, pain relief is denied as it is considered authentic and necessary to the experience, while on the other hand, the expression of pain (shouting or crying in pain during labour) is met with abuse.

At the same time, the stereotype that women exaggerate their pain also prevails. A study quotes remarks made by healthcare workers like ‘women scream during labour not out of real pain but because of screams of other women in the ward, to join in communal screaming’.

Such contrasting responses stem from certain notions of motherhood and gender stereotypes that are found across borders.

An added dimension to this issue is the availability of pain relief. A study done in Ludhiana (urban area) found that not only are there myths surrounding epidural analgesia, but also varying levels of knowledge among physicians about this and lack of uniform availability of this service.

While physical and verbal abuse in reproductive health settings are extreme and tangible forms of obstetric violence, subtler forms go unnoticed or unreported.

“I was laying in the labour room as if I was a dead body. Many people came and examined my private parts without even asking me/telling me why they were doing and what was the result.”

Providing privacy and dignified care, providing complete information on procedures being performed and available options, and procedures of consent before, during and after labour are all basic rights in maternal care. When these are compromised, a woman’s autonomy to make decisions about her body is compromised.

Such inadequacies exist because staff’s ease is prioritised over patient choice, to apply “hospital protocols”, or because of prevailing gender stereotypes that deem a woman in labour unfit to make decisions, or simply due to indifference. Such a lack of decisional autonomy makes the expecting mother and her soon to be born child vulnerable to graver forms of abuse and neglect.

In addition to these insidious forms of OV, what is unique to the Indian context is the hesitation and even refusal of women in rural areas to approach medical facilities for childbirth. They prefer birth at home, where they can uphold certain traditional practices that are medically harmful, like removal of placenta by bare hands or fasting to stop postpartum bleeding.

Additional risk with home deliveries is in the use of unnecessary medical practices like injecting oxytocin or performing unneeded episiotomies. Hence the focus of the policy-makers has been to encourage facility births.

But research indicates that it is women who come from non-urban, marginalised backgrounds who are most affected by OV. Thus, these women are caught between two harmful trajectories.

Some health professionals believe that OV is not unique and is probably part of a larger ethos of medical practice in India, where medicine is practised in a patriarchal manner, both with women and men. Information is often not provided and human dignity not given enough priority by medical professionals.

While this might be true, one must remember that the woman who is in labour is much more vulnerable emotionally because of pain, fear and being all alone in the labour room. For many women who have faced trauma in their lives in the form of partner violence or sexual abuse, facing OV can be a severe retraumatising experience with long term mental health impact.

Such instances have come forth during the early days of the pandemic, when women in labour had to struggle to find ambulances, were shunted from one hospital to other because of lack of protocols, and further trauma was inflicted by separating mothers and infants if the mother was COVID positive.

These protocols were subsequently changed based on evidence from other countries but not before several mother-infant dyads had been traumatised.

The underreporting of obstetric violence could indicate that such childbirth experiences are considered the norm, which is dangerous as it makes this deep-rooted issue difficult to shake.

In a society that makes women internalise an inferiority status, that conditions them to place the needs of others first, and places a value judgement on every step they take, women unwittingly tend to settle for less. They do not realise just when the less they are settling for starts to encroach on their basic rights.

This is even more strikingly true for women from low socioeconomic or marginalised backgrounds, whose response to violations of rights and dignity does not even find a voice.

Another important aspect that we must focus on to understand OV is that its impact is not episodic and is not limited to the immediate aftermath of childbirth. The mental health repercussions of OV are wide and long-lasting.

Postpartum depression and post-traumatic stress disorder (PTSD) are strongly associated with negative childbirth experience because of obstetric violence. Postpartum PTSD entails nightmares and flashbacks of the birth, anger, anxiety, depression for the mother, and also hampers daily living.

The mother may even develop a fear of another pregnancy which may lead to avoidance of sex. She may feel emotionally detached and distant from her infant and partner, and in the long term this may manifest as discord in the relationship with her partner and an anxious or avoidant attachment with her child.

All these difficulties have ripple effects over the lives of the larger family.

To improve childbirth experiences among Indian women in public health settings and decrease obstetric violence, the LaQshya Guidelines (Labour Room Quality Improvement Initiative) were initiated by the Ministry of Health and Family Welfare, Government of India. These are the first step forward to ensure that women get respectful maternity care and health professionals use standardised practices.

The guidelines endorse the privacy of mothers during childbirth by recommending separate rooms or at least a private cubicle during the birthing process.

They advise a birth companion during labour and freedom of choosing a birthing position.

They recommend providing beds instead of tables for labour.

Lastly, they emphasise placing the baby on the mother’s abdomen upon birth and initiating breast feeding within an hour of birth.

The guidelines condemn the practices of trying to induce labour when there are no clinical indications; physical and verbal abuse of pregnant women; separating baby from mother right after birth; and demand for gratuitous payment in celebration of the baby’s birth, among others.

The initiative has brought much-needed attention to what has long been a neglected aspect of maternity care.

There are some initial indications that these guidelines might be working at least in small pockets of care. The Vriddhi program has provided an implementation framework in the form of standard operating protocols in labour rooms and operation theatres, technical support, training to labour room staff, and periodic monitoring and review.

Under this program, as of September 2020 they reported that they were able to train 1,920 service providers in the LaQshya guidelines, and 132 maternal care units completed state certification for LaQshya, with 86 units receiving national certification across 7 states. Additionally, on several good maternal care practice indicators, there have been documented improvements since implementation through the Vrddhi program.

Although this program is a good start at introducing accountability and ensuring evidence-based medical practices in maternal care, aspects like abuse, lack of privacy, providing information and choices to the mother, asking for gratuitous payment by staff and inadequate pain relief are harder to measure and probably largely ignored in the impact. The number of service providers trained is also a small fraction in a country as large as India.

OV is a form of Gender Based Violence and needs to be recognised as such. Apart from addressing structural concerns, we must make attempts at breaking this vicious cultural and historical normalisation of gender-based violence by introducing a rights based perspective, ethical practices, and sensitive communication skills into the medical education and/or training for upcoming health professionals.

Additionally, it is necessary that there is knowledge and awareness amongst women of all ages and sections of society about what to expect and what they can ask for during institutional deliveries.

Obstetric violence has been hidden for too long, and women have not had spaces to talk about it openly. While having birth companions in the labour room may halt it to an extent, there is also a need for bystander education in which interns, medical students and nursing trainees are asked to call out any OV that they witness.

It is time that Obstetric Violence has its own #MeToo like movement. The fact that it may happen most to those without privilege means that those of us who have the voice should start discussing it.

Dr Prabha Chandra runs the Perinatal Psychiatry Services as well as the NIMHANS Centre for Well Being at the National Institute of Mental Health and Neurosciences, Bangalore, India. She is President Elect of the International Association of Women’s Mental Health, and has expertise in areas of women’s mental health, the mental health impact of partner violence and perinatal psychiatry.

Sushmita Sumant is a Research Associate at Centre for Mental Health Law & Policy (CMHLP) at Indian Law Society, Pune.

Dr. Lakshmi Shiva is a consultant psychiatrist and founder of Aasare Neuropsychiatric Centre, Bangalore. Her interests include women’s mental health, trauma-related issues, OCD and psychotherapy.