Gender Violence in Health Institutions as a Global Health Issue

Tiffany Nassiri-Ansari

In Conversation With, the Lancet Commission on Gender and Global Health’s seminar series, returned with a third episode on May 25th. In Gender violence in health institutions as a global health issue, Commissioner Simone Diniz revisited a topic she first explored twenty years ago in 2002’s “Violence against women in health-care institutions: An emerging problem”. Diniz, Professor of the Department of Health and Life Cycles as well as Deputy Director of School of Public Health at the University of São Paulo, was joined by two colleagues:

This webinar was co-convened with UNU-IIGH and the Gender & Health Hub. Commissioner Diniz and speakers were joined by facilitator and Commission Co-Chair Prof. Sarah Hawkes, fellow Commissioners, and livestream audiences on Zoom, Twitter, and YouTube. A recording of the hour-long webinar is publicly available on the Commission’s YouTube channel.

Setting the scene

Diniz began by noting that this webinar happened to fall on the twentieth anniversary of the abovementioned article, which was published by The Lancet in May 2002. Since then, there has been a notable increase in initiatives, responses, and particularly new terms surrounding the issue, such as the simultaneous existence of “too little too late” and “too much too soon” care often found in low- and middle-income countries.

Slide on "Essentialism, public health, and the correctional approach industry".

“This is a very intersectional form of violence,” Diniz commented on institutional gender violence, which operates upon the idea that women’s bodies are inherently defective and in need of routine correction. Experiences of obstetric violence are differentiated and exacerbated by a “hierarchy of motherhood” shaped by race, class, age, (dis)ability, gender, health history, marital status, and more.

She situated this issue within the broader movement for cognitive and epistemic justice, and highlighted activism and knowledge production within Latin America and the Caribbean since the 1990s as a key component of change. Chief among these actions has been the movement to humanise childbirth, which builds on two frameworks: human rights in health and evidence-based healthcare. Progress has been limited, however, by the idea that alliances and humanised care are “a luxury in poor settings”.

It is within this context that Latin American and global grassroots movements have been operating for decades, creating new terms, indicators, and evidence bases to identify and confront the challenge of obstetric violence. New initiatives to classify forms of violence and work across countries to conduct comparative studies are especially promising, and Diniz highlighted global progress on this front through the abundance of obstetric policies being formulated in Africa and Asia alongside Latin America.

Ultimately, the hope is to communicate the view that “women are understood not as victims of their own violent bodies, but submitted to gendered institutional violence in maternity care”, and promote respectful care through gender equity. Moving towards suggestions and solutions, Diniz identified midwives as a central figure in this fight, and stressed the need to invest power, money, and resources in women as they “fight for the rights of women, children, and communities”.

She transitioned into the panel discussion by raising a number of questions for consideration by both speakers and viewers alike, touching on the role of social movements in both the global South and the global North, the potential of educational institutions and governments to either help or hinder change, and the possibility for a ‘reverse-learning’ opportunity in which the South takes the lead on contextualising this issue within the lenses of intersectionality, coloniality, racism, and more.

Panel discussion: Naming and confronting obstetric violence

Moving into the panel discussion, Diniz introduced her colleagues and guest speakers as not just academics, but long-time activists. She invited both speakers to reflect on how knowledge itself has changed in the three decades since they first started working on this issue, how research and teaching can better harness the production of knowledge, and how international and collaborative activism can change reality.

Naming violence as violence

d’Oliveira began by noting that reflection is an important theme in healthcare, and this webinar allowed her to return to a topic she first started working on a long time ago. In 2002, when she and Diniz first published their paper with colleague Lilia Blima Schraiber, obstetric and institutional violence were just starting to be named around the world. At the University of São Paulo, colleagues felt that “it was not right that we had the space to write at such a prestigious journal as The Lancet and had chosen to expose such a bad image of Brazil”. Negative reactions to this work continued, with d’Oliveira and her fellow researchers dubbed “the violent women” for working on a WHO multi-country study on domestic violence.

Quote by Ana Flavia: "Violence is not easy to recognise, and its perpetuation is based also in this trivialisation and naturalisation".

This pushback and silencing would continue for more than a decade, as d’Oliveira and colleagues later discovered when they created the Don’t Stay Silent movement in 2014 to denounce sexual violence and abuse perpetuated by colleagues and professors within the university. Speaking out was crucial, d’Oliveira stated, as “naming violence as violence is a way to challenge its presence, its trivialisation, its naturalisation, but it may also be very threatening for those who want the issue to remain invisible”. The movement continued to speak out despite instructions not to, insisting that “a violent institution is no shelter and cannot support women experiencing domestic or sexual violence, and this is a precondition to support survivors – for the service not to be violent itself”.

Moving on to speak about the different forms of violence, d’Oliveira also touched on different experiences of violence and levels of vulnerability for different women, emphasising that “we are not just one woman. We are women in our diversity, and violence affects us all but in different ways”. She identified the medical system as a key player in the reproduction of gender, class, and race inequalities alongside perpetuating institutional violence, and called for changes in health systems, knowledge, and practice to centre women and recognise them as subjects rather than objects.

Ultimately, d’Oliveira noted that by 2002, researchers already had more than ten years of evidence that violence could occur within the health system. Twenty years later, “it is difficult to believe and it is very upsetting that in the very place of care where people are suffering and need treatment and cure, violence [remains] present”. She called for change in how health and medicine are taught and practiced, challenged the Brazilian government’s attempts to prohibit the term “obstetric violence”, and advocated for collaborative and cognitive justice to transform care “into a more pleasant, healthy, and meaningful experience for all involved”.

Motors of change

Picking up on d’Oliveira’s call for change, Rattner identified “two big motors of change” in her reflections on the past two decades of activism and progress in the movement for humanised care: international organisations and grassroots movements. She noted that the World Health Organization first started writing about appropriate technologies for birth and women’s right to proper prenatal care in 1985, and yet this remains an issue to this very day.

Quote from Daphne Rattner: "Every women has the right to proper prenatal care, and has a central role in all aspects of this care".

However, more actors have since joined the call for change, such as the International MotherBaby Childbirth Organization, the International Federation of Gynecology and Obstetrics, and the White Ribbon Alliance. Working together as a movement, these international organisations emphasise that “woman-centred care, childbirth care, pregnancy care, and postnatal care should become a positive experience for women”, and play a key role in bringing knowledge and guidelines to this space.

Their work unfolds in parallel with the activism of grassroots organisations such as the Brazilian Network for the Humanization of Childbirth (ReHuNa), which Rattner has been involved with since its establishment in 1993. ReHuNa organised the first International Conference on the Humanization of Childbirth in 2000, and has been working ever since to “give visibility to this violence” through policy influencing, advocacy, international convenings, diffusion of information, and more. The three speakers and other colleagues published a paper based on this work in 2018, titled “Disrespect and abuse in childbirth in Brazil: Social activism, public policies and providers’ training”.

Rattner ended with an assessment of the current situation in Brazil and contemporary challenges. In 2011, the Stork Network proposed the establishment to 250 new birth centres to change the childbirth care paradigm in Brazil; as of today, only 50 of those centres have been created, making it “very difficult to change the environment of childbirth care”. ReHuNa has identified an additional 50 birth centres not included in the network’s list, and is calling for “more training, more schools of midwifery,” and more investment in prenatal care.

However, the situation is complicated by government pushback as mentioned by d’Oliveira. Rattner pointed out that medical councils are also “one of the centres of resistance”, with some going so far as to issue resolutions against humanised care and women’s bodily autonomy. The COVID-19 pandemic has further exacerbated this situation by reversing the clock on maternal mortality, with Brazil now reporting numbers comparable to those from the 1990s, due in part to the government’s failure to produce timely guidelines for vaccinating pregnant women. Ending her grim assessment of the current situation, Rattner branded these failures to prevent avoidable deaths as “a kind of institutional violence”.

Audience Q&A: Defining and classifying forms of violence

Hawkes returned to thank the speakers for sharing a “rich set of ideas, experiences, and solutions” before segueing into the audience Q&A session, which covered two questions on definitions and classification.

“You mentioned the different terms relating to obstetric violence – how do you think that the use of different terms and the multitude of terms affects the reporting and understanding of the issue?”

Diniz reflected on both the advantages and disadvantages of working with multiple terms. She stated that the multiplicity of terms allows for many approaches and different perspectives, and that this captures the richness and diversity of the issue and allows for the customisation of the problem to local cultures and languages.

“There is an advantage in the openness,” she said, but at the same time there is a disadvantage as “we need something that’s relatively comparable for us to create indicators that could be used in different settings”. Common indicators for comparative analyses are crucial, and Diniz pondered on the ways in which the Commission might play a role in “trying to figure out what would be the commonalities for international, global collaborative research and action”.

Slide on obstetric violence as a frontier object with many terms.

“To what extent can we classify the omission of services as obstetric violence? Is it obstetric violence when countries remove the right to legal and safe abortions?”

This question on classification elicited a small debate among speakers. Diniz felt strongly that the denial of abortion services is in fact a form of obstetric violence, and Rattner added that there are different levels of violence to be considered, from the individual to the systemic. At the societal level, she opined that the “absence of laws to guarantee women’s rights can be called some form of violence too”. Crucially, Rattner reminded everyone that “things at the social level can seep into the interpersonal level, as they interact and intersect”.

However, d’Oliveira raised a question about definitional limits, and asked whether there is a line between gender-based violence and gender inequalities and discrimination. She pointed to the existence of terms such as reproductive justice and reproductive coercion which might be more relevant to the issue of abortion rights and laws, and recommended that the term ‘obstetric violence’ be reserved for instances of humiliation and abuse. d’Oliveira highlighted a WHO multi-country study on intimate partner violence as a relevant example in terms of how ‘violence’ was defined as a fixed set of actions, and suggested that “we need a set of acts that we call violence, and a set of unfair distributions of healthcare that we call gender-based inequalities”. In summary, she acknowledged that the lack of safe abortion is a cause of maternal mortality around the world, but urged audiences to think strategically and consider: “How much do we gain or lose by putting everything under the umbrella of obstetric violence?”

Final thoughts and moving forward: From the individual to the structural

Clockwise: Daphne Rattner, Ana Flavia d'Oliveira, Simone Diniz, and Sarah Hawkes.

Due to time constraints, a number of audience questions were unfortunately left unaddressed. Hawkes identified key themes from these questions, which touched on individual experiences of violence, systemic and structural determinants, and the complex overlaps between obstetric violence and reproductive justice.

She linked these themes to a topic that the Commission as a whole is grappling with: “Situating inequalities not just as an individual experience, but also as something that is embedded within the systems and structures that we all operate within”. In closing, Hawkes stressed that in order for progress to take place, systems and structures will have to change just as much as individuals and practices.


About the Author

Tiffany Nassiri-Ansari sits on the Secretariat of the Commission and serves as a Research Assistant at UNU-IIGH.