Obstetric Violence in Spain (Part II): Interventionism and Medicalization during Birth

Impact of shared decision-making on women's childbirth preferences: A cluster randomised controlled trial

BACKGROUND

Midwives provide counselling for birth plans (BPs) to women during prenatal care; however, the impact of individualised BP counselling interventions based on shared decision-making (SDM) regarding women's preferences is unknown.

METHODS

This randomised cluster trial included four primary healthcare units. Midwives provided BP counselling based on SDM to women in the intervention group (IG) during prenatal care along with a handout about evidence-based recommendations. Women in the control group (CG) received standard BP counselling from midwives. The main outcome was preference changes concerning BPs.

RESULTS

A total of 461 (95.5 %) pregnant women received BP counselling (IG, n = 247; CG, n = 214). Women in the IG changed their BP preferences for 13 items compared with those in the CG. These items were: using an unique space during birth (81.1 % vs 51.6 %; p < 0.001), option for light graduation (63 % vs 44.7 %; p < 0.001), listening to music (57.3 % vs 43.6 %; p = 0.006), drinking fluids during labour (84.6 % vs 93.6 %; p = 0.005), continuous monitoring (59 % vs 37.8 %; p < 0.001); desire for natural childbirth (36.6 % vs 25 %; p = 0.014), epidural analgesia (55.1 % vs 43.6 %; p = 0.023); breathing techniques (65.2 % vs 50.5 %; p = 0.003), massage (74.9 % vs 55.3 %; p < 0.001); birthing ball use (81.9 % vs 56.9 %; p < 0.001), spontaneous pushing (49.3 % vs 28.7 %; p < 0.001), choosing birth position (69.6 % vs 41.5 %) and delayed umbilical cord clamping (67.8 % vs 44.1 %; p = 0.001).

CONCLUSION

SDM counselling, together with a handout about evidence-based recommendations on childbirth and newborn care, produced more changes in women's preferences expressed in the BP than standard counselling.

"Normal in all the rush": A phenomenological study analyzing midwifery students' views on obstetric violence

INTRODUCTION

In recent years, obstetric violence, which undermines women's dignity and autonomy, has received increased attention worldwide. Considering the importance of midwives in combating violence in the obstetric field and the significance of the discussed issue, the following question arises: How do future midwives view obstetric violence?

OBJECTIVE

This study aimed to investigate midwifery students' thoughts about obstetric violence.

DESIGN AND METHOD

This study was conducted using a phenomenological qualitative research design. This study, which adopted a descriptive approach and used typical case sampling, was conducted in the midwifery department of the Kutahya Health Sciences University. Sixteen midwifery students studying fourth-year in the 2018-2019 academic year, who had participated in childbirth during their studies, and who agreed to participate in the study were included. All students had the experience of repeated monitoring and presence in labor. They had witnessed births in different institutions. Focus group interviews were conducted using an unstructured interview guide to obtain data for the study. Data were collected through four focus group interviews with groups of four students in the classroom environment. The data were evaluated separately by two researchers using the content analysis method in MAXQDA Analytics Pro 2020. The Consolidated Criteria for Reporting Qualitative Studies guidelines were used as a guide in reporting.

RESULTS

As a result of the analysis, four main themes emerged: defining violence, causes of violence, effects of witnessing violence, and whether can violence be prevented?

CONCLUSIONS

Midwifery students have an awareness of all visible forms of obstetric violence. However, they were less aware of the invisible structural and policy drivers of obstetric violence. It is invaluable to raise awareness of obstetric violence among midwifery students, who will be the most important defenders of women in childbirth. Studies focused on education and policy will contribute to women receiving quality care at birth.

Obstetric violence in the United States and other high-income countries: an integrative review

Obstetric violence has been documented throughout the world, yet this human rights issue has mostly been investigated in middle- and low-income countries where the intensity and brutality of abuse and mistreatment is more easily recognised as problematic. This integrative review aimed to analyse sources about obstetric violence in high-income countries with the objective of identifying gaps in the research, challenges to the study of obstetric violence, and solutions to framing research that meets those challenges. A systematic search was conducted using the PubMed and CINAHL databases from February to June 2022. Empirical and non-empirical sources, published in English, with no date restrictions, were retrieved. Citation searching was also done. Forty-six sources were included. Identified gaps in the research were: (a) scarce attention to obstetric violence in most high-income countries; (b) most US sources are non-scientific and from outside the healthcare disciplines; (c) inconsistencies in terminology; (d) most studies were conducted with samples of women who had given birth, with scant research about healthcare providers and obstetric violence, and (e) the association between obstetric violence and traumatic birth was under-recognised. Identified challenges to the study of obstetric violence were: (1) factors that enable and perpetuate obstetric violence are multilevel and nonlinear; (2) the phenomenon is contextually complex; and (3) blind spots from routinised harmful practices and normalised mistreatment can prevent healthcare providers and birthing people from recognising obstetric violence. A systems approach and complexity theory are guiding frameworks recommended as solutions to the challenges of studying and correcting obstetric violence.

Cultural Adaptation, Validation and Evaluation of the Psychometric Properties of an Obstetric Violence Scale in the Spanish Context

Obstetric violence refers to dehumanized or derogative treatment of women in their pregnancy, childbirth or postpartum periods and may be manifested in different ways. Currently, there is no tool validated in Spain to measure women's perception of obstetric violence. The objective of this study was to carry out the cultural adaptation and validation of an existing 14-item obstetric violence scale in the Spanish context and to evaluate its psychometric properties. The research was conducted in two phases: first, a methodological study designed to evaluate content validity, through assessments by eight experts (calculating the Aiken V coefficient) and face validity in a sample of 20 women; second, a cross-sectional study to evaluate construct validity (through confirmatory factor analysis and Rasch analysis), divergent validity against a scale of birth satisfaction, known-groups validity and, finally, reliability. In Phase 1, Aiken V values higher than 0.71 were obtained for all items. Phase 2 was conducted on a sample of 256 women and the fit values for the unidimensional model were RMSEA: 0.070 (95% CI: 0.059-0.105) and GFI: 0.982 (95% CI: 0.823-0.990). The Rasch analysis indicated poor performance of item 2, which was removed. The Omega and Cronbach's Alpha coefficients were 0.863 and 0.860, respectively. A final 13-item version of the Obstetric Violence Scale was produced, with a total score ranging from 0 (no obstetric violence perception) to 52 (maximum obstetric violence perception). The Obstetric Violence Scale is a reliable and useful tool to measure women's perception of obstetric violence. This study was not registered.

Predictors of childbirth experience: Prospective observational study in eastern Spain

BACKGROUND

In recent years, birth experience has been highlighted by national and international organisations as a relevant value in measuring maternal health care quality. According to a standardised tool, we aimed to assess which clinical indicators had the most significant influence on the birth experience.

METHODS

This prospective observational study was carried out in fourteen hospitals in eastern Spain. 749 women consented to the collection of birth variables at discharge, and subsequently, at 1-4 months, data were collected on the birth experience as measured by the Spanish version of the Childbirth Experience Questionnaire. Next, a linear regression analysis was performed to determine which clinical birth indicators greatly influence the birth experience measure.

RESULT

The study sample (n = 749) was predominantly Spanish and primipara, with 19.5% vaginal births. The predictors that emerged in the linear regression model were to have a birth companion (B = 0.250, p = 0.028), drink fluids during labour (B = 0.249, p < 0.001), have early skin-to-skin contact (B = 0.213, p < 0.001) and being transferred to a specialised room for the second stage of labour (B = 0.098, p = 0.016). The episiotomy (B = -0.100, p < 0.015) and having an operative birth (B = -0.128, p < 0.008) showed a negative influence.

CONCLUSION

Our study supports that intrapartum interventions recommended according to clinical practice guidelines positively influence the mother's birth experience. Episiotomy and operative birth should not be used routinely as they negatively influence the birth experience.

Experiences with obstetric violence among healthcare professionals and students in Spain: A constructivist grounded theory study

BACKGROUND

Obstetric violence appears to be a worldwide concern and is defined as a type of gender-based violence perpetrated by health professionals. This violence undermines and harms women's autonomy. In Spain, 38.3 % of women have identified themselves as victims of this type of violence.

AIM

To explore current information and knowledge about obstetric violence within the Spanish healthcare context, as well as to develop a theoretical model to explain the concept of obstetric violence, based on the experiences of healthcare professionals (midwives, registered nurses, gynaecologists and paediatricians) and nursing students.

METHODS

A constructivist grounded theory study was conducted at Jaume I University in Spain between May and July 2021, including concurrent data collection and interpretation through constant comparison analysis. An inductive analysis was carried out using the ATLAS.ti 9.0 software to organise and analyse the data.

RESULTS

Twenty in-depth interviews were conducted, which revealed that healthcare professionals and students considered obstetric violence a violation of human rights and a serious public health issue. The interviews allowed them to describe certain characteristics and propose preventive strategies. Three main categories were identified from the data analysis: (i) characteristics of obstetric violence in the daily routine, (ii) defining the problem of obstetric violence and (iii) strategies for addressing obstetric violence. Participants identified obstetric violence as structural gender-based violence and emphasised the importance of understanding its characteristics. Our results indicate how participants' experiences influence their process of connecting new information to prior knowledge, and they provide a connection to specific micro- and macro-level strategic plans.

DISCUSSION

Despite the lack of consensus, this study resonates with the established principles of women and childbirth care, but also generates a new theoretical model for healthcare students and professionals to identify and manage obstetric violence based on contextual factors. The term 'obstetric violence' offers a distinct contribution to the growing awareness of violence against women, helps to regulate it through national policy and legislation, and involves both structural and interpersonal gender-based abuse, rather than assigning blame only to care providers.

CONCLUSIONS

Obstetric violence is the most accurate term to describe disrespect and mistreatment as forms of interpersonal and structural violence that contribute to gender and social inequality, and the definition of this term contributes to the ongoing awareness of violence against women, which may help to regulate it through national policy and legislation.

Perceptions of the Brazilian obstetrics physicians about the term obstetric violence: a cross-sectional study

INTRODUCTION

We observe a growing global discussion about the practices considered "obstetric violence" against women during pregnancy and childbirth. Otherwise, the indiscriminate subjective and lay interpretation of the term "obstetric violence" can lead to a misunderstanding among medical professionals.

OBJECTIVE

This study aimed to describe the obstetrician's perceptions about the term "obstetric violence" and the medical groups affected negatively by the topic.

METHODS

A cross-sectional study applied to Brazilian obstetrics physicians regarding their perceptions of "obstetric violence."

RESULTS

From January to April 2022, we sent about 14,000 direct mail nationwide. A total of 506 participants responded. We observed that 374 (73.9%) participants consider the term obstetric violence nocive or harmful to professional practice. Furthermore, after Poisson regression, we described that the respondents who graduated before 2000 and from a private institution were significant and independent groups for the full or partial agreement that the term is nocive for the obstetricians in Brazil.

CONCLUSION

We observed that almost three in four obstetrician participants consider the term "obstetric violence" nocive or harmful to professional practice, particularly in those who graduated before 2000 and from a private institution. The findings are relevant to propose further debates and strategies to mitigate the possible harms caused to the obstetrician team by the indiscriminate use of the term obstetric violence.

Individual and country-level variables associated with the medicalization of birth: Multilevel analyses of IMAgiNE EURO data from 15 countries in the WHO European region

OBJECTIVE

To investigate potential associations between individual and country-level factors and medicalization of birth in 15 European countries during the COVID-19 pandemic.

METHODS

Online anonymous survey of women who gave birth in 2020-2021. Multivariable multilevel logistic regression models estimating associations between indicators of medicalization (cesarean, instrumental vaginal birth [IVB], episiotomy, fundal pressure) and proxy variables related to care culture and contextual factors at the individual and country level.

RESULTS

Among 27 173 women, 24.4% (n = 6650) had a cesarean and 8.8% (n = 2380) an IVB. Among women with IVB, 41.9% (n = 998) reported receiving fundal pressure. Among women with spontaneous vaginal births, 22.3% (n = 4048) had an episiotomy. Less respectful care, as perceived by the women, was associated with higher levels of medicalization. For example, women who reported having a cesarean, IVB, or episiotomy reported not feeling treated with dignity more frequently than women who did not have those interventions (odds ratio [OR] 1.37; OR 1.61; OR 1.51, respectively; all: P < 0.001). Country-level variables contributed to explaining some of the variance between countries.

CONCLUSION

We recommend a greater emphasis in health policies on promotion of respectful and patient-centered care approaches to birth to enhance women's experiences of care, and the development of a European-level indicator to monitor medicalization of reproductive care.

Breastfeeding and Obstetric Violence during the SARS-CoV-2 Pandemic in Spain: Maternal Perceptions

Catalan legislation, a pioneer in Europe, has defined obstetric violence (OV) as "preventing or hindering access to truthful information, necessary for autonomous and informed decision-making". The definition also states that OV can affect physical and mental health, as well as sexual and reproductive health. Some authors have expressed concern about an increase in OV during the SARS-CoV-2 pandemic. During the pandemic, recommendations were also openly offered on the non-establishment and/or early abandonment of breastfeeding without scientific evidence to support them. Experiencing a traumatic childbirth can influence breastfeeding outcomes. Here, we conducted a cross-sectional study using a self-administered online questionnaire. The sample consisted of women who gave birth in Spain between March 2020 and April 2021. The mean age was 34.41 (±4.23) years. Of the women, 73% were employed, 78.2% had a university education, and almost all were Caucasian. Among the subjects, 3.3% were diagnosed with SARS-CoV-2 during pregnancy and 1% were diagnosed during delivery. Some of the women (1.6%) were advised to stop breastfeeding in order to be vaccinated. Women diagnosed with SARS-CoV-2 during delivery (p = 0.048), belonging to a low social class (p = 0.031), with secondary education (p = 0.029), or who suffered obstetric violence (p < 0.001) perceived less support and that the health care providers were less inclined to resolve doubts and difficulties about breastfeeding. Breastfeeding has been significantly challenged during the pandemic. In addition to all the variables to be considered that make breastfeeding support difficult, we now probably need to add SARS-CoV-2 diagnosis and OV.

Obstetric violence in a group of Italian women: socio-demographic predictors and effects on mental health

This study had two aims: (1) to explore the types and incidence of obstetric violence (OV) in a group of Italian women, as well as associated socio-demographic factors; and (2) to assess whether OV affects women's mental health (e.g. psychological distress and post-traumatic stress). A web-based cross-sectional study was conducted with 282 Italian women. Women answered questions on socio-demographic factors, childbirth characteristics, OV and mental health. Multiple linear regression analyses assessing the predictive role of socio-demographic and childbirth characteristics on OV were conducted. Additionally, hierarchical multiple linear regression analyses assessing whether OV affected women's mental health were also carried out. More than three quarters of the sample (78.4%) had experienced at least one type of OV (55.5% of non-consented care and 66.4% of abuse and violence). The factors most associated with OV were younger age, low educational level, not having attended a prenatal childbirth preparedness course, and having given birth naturally. The form of OV that most affected women's mental health was that linked to abuse and violence rather than non-consented care. Study findings shed light into addressing OV from a multidimensional perspective.

Obstetric violence and associated factors among women during facility based childbirth at Gedeo Zone, South Ethiopia

Introduction

Obstetric violence is a specific form of violence against women that violates their human rights. Conducted by obstetric care providers regarding the body and reproductive processes of the woman, being characterized by dehumanized assistance, abuse of interventionist actions, medicalization, and reversion of the process from natural to pathological.

Objective

To assess the magnitude of obstetric violence and associated factors among women during childbirth in Gedeo Zone, South Ethiopia.

Method

Community based cross-sectional study was conducted among randomly selected 661 mothers in Gedeo Zone, South Ethiopia, from May 1 to May 30 2020. Multi-stage sampling technique was used to get a total of 661 mothers from their kebeles. Data was collected by using face-to--to-face interview with a structured questionnaire and in-depth interview was also employed. Data entry and analysis was done by Epi data version 3.1 and SPSS 23.0 statistical software. Bivariate and multivariable logistic regression models were used to determine the important predictors of obstetric violence. Association between outcome and independent variables was presented by adjusted odds ratio with 95% CI.

Results

From the total of 661 mothers, about 79.7% (527) of mothers experienced obstetric violence with 95% CI (76.9–82.8). educational status (AOR = 2.2573, 95%CI = 1.44,3.54), ANC utilization (AOR = 2.365, 95%CI = 1.62–3.21), duration of stay (AOR = 0.5367,95%CI = 0.28,0.86)), and facing complication during labor and delivery (AOR = 3.1382, 95%CI = 2.34,5.17) were the major factors associated with obstetric violence.

Conclusion

The magnitude of obstetric violence was high. Non dignified care and non-consented care was the most common form of obstetric violence which may lead a woman to choose for home delivery instead of health facility care, this in turn leads to a great increase in maternal morbidity and mortality as supported by qualitative approach of the study.

TheMidwifery Student’s Observations about the Implementation of International Guidelines and Protocols in Greek Maternity Hospitals

Background: Childbirth is a unique experience ina woman’s life and always remains indelibly engraved in her memory. For this reason, it is necessary to ensure appropriate conditions to have a positive birth experience. Thus, guidelines and protocols have been developed by major international organizations that aim to promote normal labor and better care for the mother and fetus without unnecessary interventions. The aim of this study is to investigate whether the international guidelines and protocols are observed in Greek maternity hospitals. Methods: The study involved 124 male and female students from the three departments of Midwifery: University of West Attica, International Hellenic University and University Western Macedonia, which completed an equal number of self-report questionnaires with their socio-demographic data and were then asked to answer questions posed by instructions for normal childbirth. Results: It was observed that many of the guidelines are not followed, such as grooming and enema, prohibition of feeding and fluid intake, application of pressure on the bottom of the uterus, frequent vaginal examination, prohibition in the presence of sessions, continuous cardiotocographic follow-up in low-risk pregnancies, termination of delivery only in a supine gynecological position, routine perineotomy and immediate ligation of the umbilical cord. Conclusions: The purpose of the guidelines is to maintain the natural course of childbirth by avoiding a series of unnecessary acts that alter the naturalness and undermine the rights of women in childbirth.

Validation and Psychometric Properties of the Spanish Version of the Fear of Childbirth Questionnaire (CFQ-e)

The fear of childbirth is a topical concern, yet the issue has barely been studied in Spain, and only one fear of childbirth measurement instrument has been validated in the country. The aim of this study was to translate, adapt and validate the Fear of Childbirth Questionnaire (CFQ) for use in Spain, as well as to describe and evaluate the psychometric properties of the Spanish version of this instrument. In a first phase, a methodological study was carried out (translation–backtranslation and cross-cultural adaptation), and pilot study was carried out in the target population. In addition, content validation of the instrument was obtained (CFQ-e) from 10 experts. In the second phase, a cross-sectional study was carried out at several centres in Gran Canaria Island to obtain a validation sample. The evaluation of the psychometric properties of the CFQ-e, including construct validity through exploratory factor analysis and confirmatory factor analysis, the calculation of reliability via factor consistency using the ORION coefficients as well as alpha and omega coefficients were carried out. The CFQ-e showed evidence of content validity, adequate construct validity and reliability. The CFQ-e is composed of 37 items distributed in four subscales or dimensions: “fear of medical interventions”; “fear of harm and dying”; “fear of pain” and “fears relating to sexual aspects and embarrassment”. The CFQ-e constitutes a valid and reliable tool to measure the fear of childbirth in the Spanish pregnant population.

Assessment of Medicalization of Pregnancy and Childbirth in Low-risk Pregnancies: A Cross-sectional Study

BACKGROUND

Medicalization may lead to over-testing during pregnancy and increased cesarean section (CS). This study investigated the medicalization of low-risk pregnancies and childbirths in Rasht, Iran.

METHODS

In this cross-sectional study, 337 postpartum women completed a demographic questionnaire and the Medicalized Pregnancy and Childbirth checklist. In this study, medicalization indicators were the source of providing prenatal care, prenatal screening for aneuploidy, number of received care, hospitalization before the onset of labor, intrapartum drug use, and CS. Demographic data were reported using descriptive statistics. Chi-square or Fisher's exact and Man-Whitney tests were used for comparison purposes. Logistic regression was run to determine the medicalization indicators associated with the mode of childbirth.

RESULTS

Of the participants, 82.2% received prenatal care from obstetricians, 85.8% had undergone prenatal screening tests. There was a significant difference between the median number of ultrasound examinations (P=0.006), prenatal screening for aneuploidy (P=0.002), and multivitamin/mineral supplements use (P<0.001), according to the source of providing prenatal care. Of the participants, 67.1% had CS. Women who received prenatal care from obstetricians had about 2.3 times more odds of CS (OR=2.23, P=0.019). Furthermore, with the increased number of ultrasounds, the odds of CS augmented by 25% (OR=1.25, P=0.013). Finally, 26.4% of the participants were hospitalized before the onset of labor; the intervention increased the odds of CS more than twice (OR=2.08, P=0.026).

CONCLUSION

The study showed a picture of medicalization in low-risk pregnancies. Of the medicalization indicators, the source of providing prenatal care, time of admission, and use of ultrasounds were associated with CS. Midwife-led care could diminish medicalization.

Obstetric Violence as an Infringement on Basic Bioethical Principles. Reflections Inspired by Focus Groups with Midwives

Background: obstetric violence is still far too invisible; the word “violence” generates rejection and obstetric violence is complex to define and typify, as it is a subjective experience. It has been widely analyzed from legal, sociological, and clinical perspectives, but not equally so from the bioethical point of view. This article sets out to take a more in-depth look at the experiences of midwives in order to describe the ethical perspectives of obstetric violence. We intend to describe the effects that malpractice and violence within obstetric care have on American and European bioethical principles. Methodology: A qualitative methodology of the phenomenological tradition was used: 24 midwives participated in three focus groups. Results and Discussion: four categories were arrived at; they are “the maleficence of forgetting my vulnerability”, “beneficence requires respect for my integrity and dignity”, “my autonomy is being removed from me” and “a problem of social justice towards us, women”. Conclusion: obstetric violence infringes on the main bioethical principles (non-maleficence, beneficence, autonomy, justice, vulnerability, dignity, and integrity). Beyond whether it is called violence or not, what matters from an ethical perspective is that, as long as women have such negative experiences during pregnancy and childbirth, obstetric care needs better humanizing.

Obstetric Violence in Spain (Part III): Healthcare Professionals, Times, and Areas

BACKGROUND

Obstetric violence is a worldwide public health problem, which seems greater in Spain. As no studies were found that identify the most representative healthcare professionals, times, and areas involved in obstetric violence, the objective of this work was to study at what time of maternity, with which professionals, and in what areas women identified obstetric violence.

METHODS

This descriptive, retrospective, and cross-sectional study was performed from January 2018 to June 2019. The main variables were the area (hospital, primary care, both), the time (pregnancy, birth, puerperium), and the professionals attending to women.

RESULTS

Our sample comprised 17,541 participants. The area identified with the most obstetric violence for the different studied variables was hospitals. Women identified more obstetric violence at time of birth. Findings such as lack of information and informed consent (74.2%), and criticism of infantile behavior and treatment (87.6%), stood out. The main identified healthcare professionals were midwives and gynecologists, and "other" professionals repeatedly appeared.

CONCLUSIONS

Having identified the professionals, times, and areas of most obstetric violence in Spain, it seems necessary to reflect on not only the Spanish National Health System's structure and management but also on healthcare professionals' training.