Obstetric Violence in the United States:
A Systematic Review of Quantitative and Qualitative Evidence 1 2 Alexandra Boubour, MSc and Martine Hackett, PhD, MPH 1Donald and Barbara Zucker School of Medicine at Hofstra/Northwell 2Department of Public Health, Hofstra University
1. BACKGROUND • •
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Reproductive justice upholds that access to safe, respectful obstetric care is a basic human right that must be universally available to all birthing persons.1.2 Obstetric violence denies this human right.3 Obstetric violence is abuse, disrespect, mistreatment of a pregnant person during pregnancy, parturition, or the immediate puerperal period by a healthcare worker (Fig 1). It is an attempt to control the birthing person’s body and decisions, violating their autonomy and dignity. Obstetric violence disproportionally affects Black Indigenous People of Color (BIPOC) in the United States (US), with 37% of birthing BIPOC reporting mistreatment during maternity care.3-9 Obstetric violence drives significant racial and ethnic disparities in maternal and infant perinatal outcomes, including mistrust in health institutions.3-8 BIPOC in the US experience the highest rates of pregnancy-related deaths, of which approximately 80% are preventable.9 While the term, “obstetric violence,” has gained increasing media coverage in recent years, patient experiences with obstetric violence remain a nascent area of study with numerous literature gaps remaining. No studies have collectively analyzed qualitative and/or quantitative data on experiences with obstetric violence in the US.
5. CONCLUSIONS
4. RESULTS A total of 858 articles were screened and 16 were deemed eligible for inclusion (Fig 2). Included studies reported 2219 participants in total, with 185 in qualitative studies, 1827 in quantitative studies, and 207 in the mixed-methods study. Qualitative evidence was grouped into seven second-order themes: lack of agency, abuse, discrimination, threats and blaming, health systems constraints, poor provider rapport, and failure to meet standards of care (Fig 3).
This is the first study to collectively analyze qualitative and quantitative data on experiences with obstetric violence in the US. Convergent results-based synthesis revealed seven second-order themes highlighting the types of obstetric violence experienced by birthing people: physical abuse, verbal abuse, sexual abuse, stigma and discrimination, failure to meet professional standards of care, poor rapport between birthing person and healthcare provider, and health systems conditions and constraints. Experiences with obstetric violence may be underreported due to mistrust, fear of stigma and discrimination, and/or fear of retaliation. Our findings illuminate critical problems with perinatal care provision. Birthing people throughout the US were regularly subject to traumatic, dehumanizing care and reported experiences at odds with human rights, anti-racist praxis, and the ethical pillars of healthcare provision. There is an urgent need to address human rights violations for all birthing people with particular attention to those who identify as BIPOC.
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6. IMPLICATIONS • Figure 2. PRISMA flowchart.
• Figure 3. Visual network of qualitative themes.
Quantitative evidence was categorized into ten types of obstetric violence experiences. BIPOC most frequently reported experiencing lack of respect (N=1758, 86.43%), provider-centered care (N=1521, 74.78%), and discrimination (N=1382, 67.94%) (Table 1). Of experiences included in the meta-analysis, BIPOC had the highest odds of reporting an experience with forced or coerced Cesarian birth (OR=27.58; 95% CI: 5.29-48.36) (Fig 4). Convergent results-based synthesis of qualitative and quantitative evidence generated seven second-order themes classified per evidence-based typology (Fig 5).
Figure 1. Examples of obstetric violence.
2. RESEARCH QUESTION
Type of Obstetric Violence Experienced Physical abuse Verbal abuse Sexual abuse Discrimination Lack of respect Neglect Non-consented intervention Provider-centered care Poor communication Lack of redress
What are Black Indigenous People of Color’s (BIPOC) experiences with obstetric violence in US-based hospital settings?
3. METHODS • •
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Design: We performed a mixed studies systematic review to enhance generalizability, interpretation, and the rationale for policy change.10,11 Strategy and Selection Criteria: MEDLINE, Embase, and Web of Science were searched using set inclusion and exclusion criteria. Resources were imported to Covidence, which removed duplicates automatically. Title and abstract screening and full text review were performed by a single reviewer (AB) in Covidence. Critical Appraisal: Risk of bias was assessed with validated tools for each study design.12-14 Data Extraction: The Cochrane Standard Data Collection Form was adapted to extract relevant criteria, including implications and recommendations, and piloted on a subset of 10% of included studies.15 Data were obtained from study authors as needed. Data Analysis: Convergent results-based synthesis design was employed.10 Thematic synthesis was used to analyze all qualitative data.16 DerSimonian-Laird random-effects model with reciprocal transformation was used to perform a meta-analysis of quantitative data; experiences with inconsistent operational definitions were excluded from the meta-analysis. Heterogeneity was quantified with I2 and τ2.17
Ibrahim et al. 2022 N = 207
Ibrahim & Kozhimannil 2022 N = 207
Logan et al. 2022 N = 839
Vedam et al. 2019 N = 572
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Obstetric violence, including discrimination and abuse, directly contributes to pregnancy-related deaths.9 Improving respectful care is key to reduce maternal and infant mortality. Most current approaches to addressing obstetric violence center organizations complicit in the perpetuation of obstetric violence to generate solutions. Our research highlights the urgent need to uplift BIPOC voices and resilience pathways in pursuit of birth equity and the elimination of obstetric violence in the US. Fig 6 summarizes recommendations from the literature and original proposals to mitigate obstetric violence.4,5,18-47 Elimination of obstetric violence will require persistent multilevel interventions and an unwavering demand for structural change.
Total N = 2034
Zhuang et al. 2023 N = 209
N 12 81 2 66 129 16
% 5.80 39.13 0.97 31.88 62.32 7.73
N 35 97 1 72 195 15
% 16.91 46.81 0.48 34.78 94.20 7.25
N 105 488 9 572 736 64
% 12.51 58.16 1.07 68.18 87.72 7.63
N 58 303 4 530 511 51
% 10.14 52.97 0.70 92.66 89.34 8.92
N 28 105 1 142 187 13
% 13.40 50.24 0.48 67.94 89.47 6.22
N 238 1074 17 1382 1758 159
% 11.70 52.80 0.84 67.94 86.43 7.82
81
39.13
63
30.43
390
46.48
278
48.60
101
48.33
913
44.89
145 98 15
70.05 47.34 7.25
152 100 18
73.43 48.31 8.70
625 461 92
74.49 54.95 10.97
439 318 72
76.75 55.59 12.59
160 157 28
76.56 75.12 13.40
1521 1134 225
74.78 55.75 11.06
Table 1. Frequency of categorized obstetric violence experiences.
Figure 6. Summary of recommendations and proposed interventions to aid in eliminating obstetric violence in the US.
7. RESOURCES Figure 5. Typology of themes derived from convergent results-based synthesis.
References, additional tables and figures, acknowledgements, local advocacy, and additional multimedia are linked in the QR code above. Figure 4. Odds of experiencing various obstetric violence types.