Case studies on obstetric violence : experience, analysis, and responses.
Date: 2024-05-02
Institutions: Directorate-General for Justice and Consumers
Subjects: France, Netherlands, Slovakia, Spain, access to the courts, case study, fight against crime, gynaecology, health care profession, help for victims, human rights, legislation, medical examination, report, sexual violence, social survey, women's rights

Case studies 
on obstetric 
violence: 
experience, 
analysis, and 
responses

Virginie Rozée and Clémence Schantz, 
FRANCE

Rodante van der Waal and Marit van der Pijl, 
THE NETHERLANDS

Barbora Holubová,  
SLOVAKIA

Stella Villarmea and Adela Recio Alcaide, 
SPAIN

Justice  
and Consumers

1

EUROPEAN COMMISSION

Directorate-General for Justice and Consumers
Directorate D — Equality and Non-Discrimination
Unit D.3 Gender Equality

European Commission
B-1049 Brussels

CASE STUDIES ON 
OBSTETRIC VIOLENCE: 
EXPERIENCE, ANALYSIS, 
AND RESPONSES

Virginie Rozée and Clémence Schantz,  
FRANCE

Rodante van der Waal and Marit van der Pijl,  
THE NETHERLANDS

Barbora Holubová,  
SLOVAKIA

Stella Villarmea and Adela Recio Alcaide,  
SPAIN

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Table of Contents

Introduction 

 2 FRANCE by Virginie Rozée and Clémence Schantz 

Executive summary 
Background 

Aim 

Main findings 

Summary and lessons learned  

Overview 
Definitions and references  
Data collection and evidence on obstetric violence in France 
Empirical evidence 

Relevant manifestations of obstetric violence  

1

2

2
2

2

2

3

4
7
8
8

10

12
Root causes of obstetric violence  
14
Consequences of obstetric violence  
Obstetric violence and Covid-19  
15
Achievements and challenges in collecting and monitoring data  17
18
Relevant initiatives and their impact  
18
Initiatives leading to political action 

1 

2 

2.1 
2.1.1 

2.1.2 

2.1.3 

2.1.4 

2.2 
2.3 
2.4 
2.4.1 

2.4.2 
2.5 
2.6 
2.7 
2.8 
2.9 
2.9.1 

2.9.2 

Initiatives to combat obstetric violence 

2.10  Conclusions and recommendations 
2.10.1 

Achievements and lessons 

2.10.2 

Challenges 

2.10.3 

Recommendations 

20

24
24

24

25

3 

3.1 
3.2 
3.3 
3.3.1 
3.3.2 
3.4 
3.5 
3.6 
3.7 

 THE NETHERLANDS by Rodante van der Waal and Marit  
van der Pijl 

26

Executive summary and overview 
Definitions and references 
Data collection and evidence on obstetric violence  
Empirical evidence  

Relevant manifestations  

Root causes of obstetric violence  
Consequences of obstetric violence  
Obstetric violence and Covid-19  
Achievements and challenges 

26
26
29
29

32

38
40
41
41

43
43

45

47

50

50
52
53
55
55

58

66

69

69

71

3.8 
3.8.1 
3.8.2 
3.9 

Relevant initiatives and their impact  
Initiatives leading to political action 

Initiatives to combat obstetric violence 

Conclusions and recommendations 

4 

SLOVAKIA by Barbora Holubová 

4.1 
4.2 
4.3 
4.4 
4.4.1 

4.4.2 
4.5 
4.6 
4.7 
4.8 
4.9 
4.9.1 
4.9.2 

5 

5.1 
5.2 
5.3 
5.3.1 

5.3.2 

5.4 
5.5 
5.6 
5.7 
5.8 
5.8.1 

5.8.2 

5.9 

Executive summary 
Introduction 
Definitions and references 
Data collection and evidence on obstetric violence in Slovakia 
Empirical evidence (quantitative and qualitative)  

Relevant manifestations  

60
Root causes of obstetric violence  
61
Consequences of obstetric violence  
Obstetric violence and Covid-19  
62
Achievements and challenges in collecting and monitoring data   63
63
Relevant initiatives and their impact  
63
Initiatives leading to political action 

Initiatives to combat obstetric violence  

Other relevant initiatives  

4.9.3 
4.10  Conclusions and recommendations 

SPAIN by Stella Villarmea and Adela Recio Alcaide 

71
Overview 
Definitions and references in the country 
74
Data collection and evidence on obstetric violence in the country  76
76
Empirical evidence (quantitative and qualitative)  

Relevant manifestations  

Root causes  
Consequences  
Obstetric violence and Covid-19  
Achievements and challenges  
Relevant initiatives and their impact  
Initiatives leading to political action 

Initiatives to combat obstetric violence 

Conclusions and recommendations 

79

87
90
91
93
93
93

96

98

Annex 1 - Evolution of the obstetric violence debate in Spain:  
the case of Childbirth is Ours 

102

Annex 2 - Testimonies 

106

LIST OF TABLES 

Table 1: Experiences of disrespect and abuse during labour and birth per category  

Table 2: Women giving birth with complications during childbirth 

Table 3: Development of the number of births by the method of birth (2004–2020) 

Table 4: Process and results indicators on obstetric interventions comparison to standard  
in NHS hospitals, 2012–2018 

LIST OF FIGURES

Figure1: List of milestones relating to obstetric violence in France 

Figure 2: The seven dimensions of obstetric racism  

31

56

57

77

6

35

LIST OF ACRONYMS

Acronym

AT

BE

BG

HR

CY

CZ

DK

EE

EL

ES

EC

EP

EU

FI

FR

DCC

DE

FIGO

HU

IE

IT

LV

LT

LU

MS

MT

NL

OVO

PL

PT

RO

SDG

SK

SI

SE

SRHR

UN

WHO

Country

Austria

Belgium

Bulgaria

Croatia

Cyprus

Czechia

Denmark

Estonia

Greece

Spain

European Commission

European Parliament

European Union

Finland

France

Dutch Civil Code

Germany

Federation of Gynaecology and Obstetrics

Hungary

Ireland

Italy

Latvia

Lithuania

Luxembourg

Member States

Malta

The Netherlands

Observatory of Obstetric Violence

Poland

Portugal

Romania

Sustainable Development Goal

Slovakia

Slovenia

Sweden

Sexual and Reproductive Health and Rights

United Nations

World Health Organization

8

Introduction

1  Introduction

The  four  Case  Studies  on  the  issue  of  obstetric  violence  in  this  volume  were 
prepared  to  inform  the  development  of  a  wider  study  on  the  topic,  ‘Obstetric 
violence in the European Union: Situational analysis and policy recommendations’ 
by Patrizia Quattrocchi. This wider study was developed under the aegis of the 
SAAGE network, which draws together experts in gender equality to inform and 
support European Union level policy initiatives by providing expertise and knowl-
edge  on  both  relevant  wide-ranging  political  issues  and  technical  issues.  The 
SAAGE network is coordinated by Fondazione Giacomo Brodolini S.r.l. SB (FGB SRL 
SB), an Italian independent research centre.

The general objective of the wider study is to inform the European Commission 
on the issue of obstetric violence in the European Union Member States and to 
contribute  to  the  better  understanding  of  this  phenomenon  and  of  current  re-
sponses to the issue. It was undertaken in a context of growing public awareness 
of  and  concern  about  the  issue,  an  established  imperative  for  quality  care  at 
childbirth,  and  an  understanding  of  obstetric  violence  as  a  violation  of  human 
rights and a form of gender-based violence and of institutional violence. 

Obstetrics is the medical discipline that deals with pregnancy, childbirth and the 
post-partum period. Obstetric violence has emerged as a concern in policy, re-
search and debate. The Council of Europe has defined it in terms of: inappropriate 
or non-consensual acts, such as episiotomies and vaginal palpation carried out 
without consent, fundal pressure or painful interventions without anaesthetic and 
of sexist behaviour in the course of medical consultations.1 

The case studies were undertaken in the third quarter of 2022 by national ex-
perts in France (Virginie Rozée and Clémence Schantz), the Netherlands (Rodante 
van der Waal and Marit van der Pijl), the Slovak Republic (Barbora Holubová) and 
Spain (Stella Villarmea and Adela Recio Alcaide). They were deployed to further 
inform the wider study and its recommendations. The four Member States cov-
ered by the case studies were selected for their diversity of geographical location, 
social and cultural context, obstetric practices and healthcare systems and data 
availability.

The four case studies are based on a common guideline. They provide an over-
view  of  the  issue  as  it  manifests  in  these  Member  States  and  its  causes  and 
consequences, setting out and analysing the data and evidence available. They 
further examine initiatives taken by government and other stakeholders in these 
Member  States  to  raise  awareness,  secure  consideration  of,  and  combat  this 
issue. They extract learning from these initiatives and make recommendations 
for an improved response to the issue within the Member State.

1   Council of Europe (2019).

1

2 FRANCE by Virginie Rozée and Clémence Schantz

2   FRANCE  

by Virginie Rozée and 
Clémence Schantz

2.1 

Executive summary

2.1.1  Background

In  France,  violence  in  perinatal  care  has  been  publicly  addressed  and  dis-
cussed since the 1970s. But it really became a public and political issue in 
the mid-2010s when feminists began to report violence during childbirth on the 
internet. Denunciations and criticisms of obstetric and gynaecological care were 
disseminated on social networks and by the press. This growing digital and media 
mobilisation led a government body, the High Council for Equality between 
Women and Men (HCE), to draw up a report on obstetric violence to define, 
understand and counteract it. However, there is no consensus in France about 
the concept and existence of obstetric violence, especially within the medical 
community. This absence of consensus limits initiatives to prevent and combat it.

2.1.2  Aim

The overall objective of this case study is to provide an overview of obstetric 
violence in France, based on scientific literature and grey literature from 
associations, social networks and the press. The first aim is to identify and under-
stand the empirical evidence available in France to capture and measure obstetric 
violence, its manifestations in the country and its root causes and consequences. 
The aim is then to identify existing initiatives in France from government, insti-
tutions and associations that have led to greater consideration and awareness 
of obstetric violence, both within the medical community and among the general 
population. Finally, this overview aims to formulate recommendations to better 
consider and combat obstetric violence in France.

2.1.3  Main findings

Research on the conditions and experiences of gynaecological and obstetric care 
is scarce in France and there is no statistical data measuring the obstetric vio-
lence. Its structural and subjective dimensions make it difficult to objectively de-
fine what obstetric violence is, to identify key variables relating to it and therefore 
to measure its extent. Hypothetically, all women in France may be exposed to 
violence during pregnancy and childbirth, but French healthcare is charac-
terised by inequalities and discrimination that may affect some women more 
than others. Obstetric violence has mental, physical and social consequences that 
can compromise women’s overall health. 

2

2 FRANCE by Virginie Rozée and Clémence Schantz

Obstetric violence has become more visible during the Covid-19 pandemic.

To  address  obstetric  violence,  following  two  successive  public  cases 
denouncing  violence  by  renowned  gynaecologists,  the  government  convened 
the  National  Consultative  Ethics  Committee  (CCNE)  to  provide  a  better 
framework  for  women’s  consent  during  gynaecological  and  obstetric  care. 
Other  initiatives  have  also  been  implemented,  such  as  the  Maternys  label 
of  facilities  that  respect  the  good  treatment  and  transparency  of  their 
practice during childbirth. However, the effects of such a label on women’s actual 
experiences  are  still  unknown.  Birth  centres  have  also  been  created.  But  their 
small number prevent them from meeting the social demand. In civil society, two 
main  associations  act  against  obstetric  violence:  StopVOG,  which  increases 
the  public  visibility  of  this  violence  by  publishing  testimonies  on  their  social 
networks;  and  CIANE,  which  has  become  the  most  important  association  to 
support women and families who have experienced violence, including through 
legal proceedings. There are few initiatives to train and raise awareness among 
health professionals in France. Deconstructing the obstetric paradigm based on 
the  notion  of  risk  is  very  difficult.  French  obstetrics  is  highly  medicalised  and 
medical  training  is  based  on  the  assumption  that  childbirth  is  a  risky  medical 
event. Thus, in this context, this case study report recommends more scientific 
studies  on  obstetric  violence,  better  support  for  associations,  national 
information campaigns on women’s rights during gynaecological and obstetric 
care, an increase in the number of birthing centres and a constructive debate on 
other birthing alternatives such as home births.

2.1.4  Summary and lessons learned 

Obstetric  violence  is  now  a  visible  issue  in  the  French  public  arena,  mainly 
because of social networks and the media, as well as the ongoing mobilisation of 
collectives like StopVOG. However, it is a struggle for this violence to be recognised 
as a public health problem and to enter the political and legal agenda. To date, 
there is no law on the subject and there have been few condemnations. 

However,  initiatives  have  been  put  in  place  by  the  government,  starting  with 
the HCE report in 2018 which for the first time addressed obstetric violence 
and  made  recommendations.  Other  initiatives  have  also  been  implemented  to 
improve the conditions of gynaecological and obstetric care and avoid compli-
cations  linked  to  a  negative  experience  of  childbirth:  birth  plans,  early  postna-
tal interviews, birth centres and the Maternys label. But their impacts and 
effects  seem  limited.  Professional  groups  such  as  the  French  National  College 
of Midwives (Collège National des Sages-Femmes, CNSF) and associations such 
as the CIANE are also developing initiatives to better consider, understand and 
therefore combat this violence. One initiative is establishing indicators to meas-
ure the extent of obstetric violence.

Nevertheless,  the  challenges  are  still  significant.  The  healthcare  system 
in France is in crisis, with “medical deserts” in particular. The closure of many 
maternity  units  limits  women’s  choice  and  autonomy.  And  the  current  difficult 
working conditions of health professionals are not always compatible with effi-
cient and quality gynaecological and obstetric care, both on a human and medical 
level. The lack of time in particular makes it difficult for health professionals to 
obtain  the  explicit  consent  of  their  patients,  as  explicitly  required  by  the  law. 
Beyond consent, the word ‘violence’ is often interpreted as having an intentional 
dimension, which is refuted by many health professionals. As a result, obstetric 

3

2 FRANCE by Virginie Rozée and Clémence Schantz

violence is constantly questioned in French society, especially within the medical 
community. This limits actions and initiatives to combat it. 

2.2 

Overview

In France, violence in perinatal care has been an underlying social and political 
issue since the 1970s.2 Indeed, the obstetrician Frederic Leboyer developed 
the concept of painless births for the wellbeing of the child, i.e. to reduce the 
supposed  ‘trauma  of  birth’.3  Dr  Michel  Odent  decided  to  put  Leboyer’s  recom-
mendations into practice and offered births with as little medical intervention as 
possible in her maternity hospital les Pithiviers. But this medical care of painless 
childbirth has been highly criticised by the ‘defenders of scientific obstet-
rics’4  as  being  unrealistic  and  too  dangerous  and  by  some  feminists  as  being 
child-centred only (criticisms which will make Michel Odent leave les Pithiviers 
in 1985 and move to England). These initial controversies prevented the prac-
tice from developing further. In 2005, Michel Briex, gynaecologist-obstetrician, 
and the midwives of the maternity service of the Libourne hospital published in 
‘Chronicles of motherhood, the beautiful evil and the art of being born’,5 some 
women’s narratives collected on the Gyneweb mailing list who reported aggres-
sive behaviour, infantilisation and violence during childbirth. However, the testi-
monies have gone almost unnoticed by general public.

While in the 2000s, obstetric violence was already the subject of cam-
paigns,  scientific  studies  and  even  laws  in  some  countries,  mostly  in 
Latin  America,6  it  did  not  become  a  public  and  political  issue  in  France 
until the mid-2010s. The issue of obstetric violence first appeared in feminist 
activist circles7 and then was disseminated through social networks. In 2013, Ma-
rie-Hélène Lahaye, a Belgian feminist and jurist famous in France, launched her 
blog ‘Marie accouche-là’ (Mary, gives birth there / now) to denounce the conditions 
of childbirth. Public claims then appeared on social networks, through in particu-
lar the hashtag #PayeTonUtérus. Launched on 19 November 2014, this hashtag 
collected 7 000 comments in 24 hours.8 That same year, Agnès Ledig, author and 
midwife, publicly denounced a practice called ‘le point du mari’ (the husband’s 
stitch),9 a practice which consists, during the suture of a torn perineum or an epi-
siotomy, in making an additional stitch to tighten the entrance of the vagina and 
to supposedly allow the man more pleasure during penetration; its prevalence is 
unknown and women are not aware of this practice which is performed without 
their  consent.  Then,  in  2015,  some  50  doctors,  journalists  and  feminists 
published an opinion piece revealing and denouncing the practice of non-con-
sensual  vaginal  and  anal  touching  of  patients  under  anaesthesia  for 
a medical procedure.10 These revelations provoked indignation and numerous 
testimonies on social networks, including those used to denounce mistreatment 
during gynaecological and obstetric care like #PayeTonUterus, #PayeTonGyneco, 

2   Topçu (2021).
3   Leboyer (1974).
4   Topçu (2021).
5   https://www.cairn.info/revue-spirale-2005-2-page-208.htm 
6   Quattrocchi (2019).
7   Azcué and Tain (2021).
8   Bousquet et al. (2018).
9   https://www.isabelle-alonso.com/articles-1/le-point-du-mari-195 
10   https://blogs.mediapart.fr/edition/les-invites-de-mediapart/article/060215/le-consentement-point-aveugle-
de-la-formation-des-medecins.

4

2 FRANCE by Virginie Rozée and Clémence Schantz

#PayeTonAccouchement,  #ViolencesObstétricales  and  #MonPost-partum.11  The 
progressive liberation of women’s voices must have contributed to the visibility 
of violence.12

At  the  same  time,  we  observe  a  certain  distancing  of  women13  from  the 
medicalisation of their childbirth. According to the National Perinatal Survey 
(see below), the choice to use non-medical methods for pain relief doubled from 
14.3% in 2010 to 35.5% in 2016.14 This period also corresponds to the beginning 
in France of the ‘Pill Crisis’15 which exacerbates the more general questioning of 
the medicalisation of bodies and the lack of autonomy and control by women 
over their reproductive bodies.

These  denunciations  and  the  public  debates  were  taken  up  by  journalists 
and  revived  in  the  following  years  by  the  broadcasting  of  radio  programmes16 
and documentaries on the subject,17 as well as by the publication of comic strips 
and  popular  books.18  Indeed,  cultural  products  on  obstetric  violence  or  related 
issues  have  emerged.  In  March  2016,  blogger  and  illustrator  Emma  published 
L’histoire de ma copine Cécile (The story of my friend Cécile), in which she de-
scribes in detail, with drawings, the conditions of her friend’s childbirth, including 
the episiotomy that she had refused.19 In 2017, the journalist Mélanie Déchalotte 
published Le livre noir de la gynécologie (The black book of gynaecology);20 one 
year later, Marie-Hélène Lahaye published her book Accouchement, les femmes 
méritent  mieux  (Childbirth,  women  deserve  better).21  Later,  documentaries  and 
short films were also produced, such as Ovidie’s ‘Tu enfanteras dans la douleur’ 
(You will give birth in pain) in 2019 and Nils Tavernier’s ‘Et si on s’écoutait’ (Let’s 
listen to each other) in 2021. 

All these mobilisations from 2013 onwards led to the State taking up the 
issue. In 2017, an observatory of gynaecological and obstetric violence22 (IRASF) 
was created and Marlène Schiappa, then Secretary of State for Equality between 
Women and Men, commissioned a report from the French High Council for Equal-
ity between Women and Men (Haut Conseil à l’Égalité entre les femmes et les 
hommes, HCE) on gynaecological and obstetric violence. The report of 164 pages, 
giving a lot of space to women’s voices (with many quotes from interviews), was 
published in 2018. Two months later, the French National Academy of Medicine 
produced a 22-page report on the same issue.23 

However,  despite  the  fact  that  it  has  become  a  public  and  political  issue  (see 
Figure 12), there is no consensus on obstetric violence in France and it 

11   Salles (2021).
12   Michel & Squires (2018).
13   This case study uses the term ‘women’ as an inclusive term, also considering transgender men and other 
people who self-identify as non-binary who are going to or have given birth.
14   Blondel et al. (2017).
15   Bajos et al. (2014).

16   For instance: ‘Maltraitrance gynécologique’ [Internet]. France Culture. https://www.franceculture.fr/emis-

sions/sur-les-docks/collection-temoignages-maltraitance-gynecologique.

17   Salles (2021.)
18    Déchalotte (2017); Lahaye (2018).
19   https://emmaclit.com/2016/06/10/lhistoire-de-ma-copine-cecile/. 
20   Déchalotte (2017).

21   Lahaye (2018).
22   This report focuses on obstetric violence. But it will also frequently mention gynaecological violence be-
cause some documents consider both gynaecological and obstetric violence as inextricably linked. 

23  Bousquet et al. (2018) and Academie de Medicine (2019).

5

2 FRANCE by Virginie Rozée and Clémence Schantz

continues  to  generate  controversy  and  debate,  particularly  within  the 
medical  community.  Two  main  elements  are  at  the  heart  of  the  controver-
sy:  consent  and  intentionality.  The  issue  of  consent  came  to  the  fore  in  2022 
when  a  member  of  the  government,  a  former  gynaecologist  and  obstetrician, 
was  accused  of  rape  by  civil  society  for  having  carried  out  gynaecological  ex-
aminations without asking for the explicit consent of patients. These claims rely 
on the Kouchner law of 4 March 2002,24 according to which free and informed 
consent must be obtained for any medical act by the health professional and this 
consent can be withdrawn at any time. In France, gynaecological consultations 
are short in duration and consent is therefore often taken for granted as soon as 
the woman enters the consulting room. The notion of intentionality is also the 
subject of debates between health professionals and women. The Study Circle of 
Obstetrician Gynaecologists of Ile de France (Cercle d’Etudes des Gynécologues 
Obstétriciens d’Ile de France, CEGORIF) wrote that ‘this term of violence induces 
a notion of intentionality and it is to us, the health professionals, that it causes 
violence’.25 However, the HCE report states that obstetric violence is carried out 
by women and men who do not necessarily intend to be abusive. 

Figure1: List of milestones relating to obstetric violence in France

Date
July 2003
September 2013
March 2014
November 2014
February 2015
March 2016
July 2017
October 2017
End of 2017
January 2018
June 2018
July 2019
December 2019
February 2020
Spring 2020
Autumn 2021
June 2022
June 2022

Events
Creation of CIANE
Launch of the blog "Marie accouche là" by Marie-Hélène Lahaye
Denunciation of "Point du mari" by Agnès Ledig
Emergence of #PayYourUterus; #PayYourGyneco on social networks
Controversy on vaginal and rectal touching of patients under anaesthesia (Faculty of Medicine Lyon-Sud)
Publication of L'histoire de ma copine Cécile  by the blogger and illustrator Emma
Commissioning of a report to the HCE by the Secretary of State for Gender Equality
Publication of the Livre noir de la gynécologie  by Mélanie Déchalotte 
Creation of the collective "All Against Obstetrical and Gynecological Violence" (now StopVoG)
Publication of Accouchement, les femmes méritent mieux  by Marie-Hélène Lahaye 
Publication of the HCE Report on Gynaecological and Obstetric Violence
French documentary "Tu enfanteras dans la douleur" by Ovidie
First scientific conference on obstetric violence in France (INED, Paris)
Launch of Nils Tavernier's short films with the Maison des femmes and the CEGORIF
Controversy over the wearing of masks during expulsive efforts in the context of the COVID pandemic19
Media coverage of the "Darai Affair" on gynaecological violence at Tenon Hospital (Paris)
Media coverage of complaints of gynaecological violence against State Secretary Chrysoula Zacharopoulou
Prime Minister convenes CCNE to advise on consent for gynaecological examinations

24   Law n°2002-303 of 4 March 2002 on the rights of patients and the quality of the health system.

25   Hatem-Gantzer (2020:179). Translation by the authors of ‘ce terme de violence induit une notion d’inten-

tionnalité et nous fait, à nous soignants, violence’.

6

2 FRANCE by Virginie Rozée and Clémence Schantz

2.3 

Definitions and references 

In France, two institutional reports are references in the field of obstetric violence: 
the HCE report26 and the report of the French National Academy of Medicine,27 
both  published  in  2018,  following  the  growing  public  and  media  mobilisation 
on the subject. These two reports address obstetric violence but approach this 
violence from a different epistemological position.

The HCE report defines gynaecological and obstetric violence as ‘the most se-
rious  sexist  acts  that  can  occur  in  the  context  of  women’s  gynaecological  and 
obstetric care. Sexist acts during gynaecological and obstetric care are gestures, 
words, practices and behaviours carried out or omitted by one or more members 
of the medical staff on a patient during gynaecological and obstetric care (…). It 
can take many forms, from the most seemingly innocuous to the most serious’.28 
Based on this definition, the HCE identifies six types of sexist acts: (1) Fail-
ure to take into account the patient’s discomfort, linked to the intimate nature 
of  the  consultation;  (2)  Judgemental  comments  about  sexuality,  dress,  weight 
and whether or not she wants to have a child, which refer to sexist injunctions; 
(3)  Sexist  insults;  (4)  Acts  (medical  intervention,  prescription,  etc.)  carried  out 
without consent or without respecting the patient’s choice or voice; (5) Acts or 
refusal of acts that are not medically justified; and (6) Sexual violence: sexual 
harassment,  sexual  assault  and  rape.29  It  is  this  definition  of  the  HCE  that  is 
mostly taken up by associations like StopVOG.

Entitled ‘De la bientraitance en obstétrique. La réalité du fonctionnement des ma-
ternités’ (On benevolence in obstetrics. The reality of the functioning of maternity 
wards), the report of the French National Academy of Medicine states that 
‘the  term  “obstetric  violence”  covers  any  medical  act,  posture  or  interven-
tion  that  is  inappropriate  or  non-consensual.  It  therefore  covers  not  only 
acts that do not comply with the recommendations for clinical practice but also 
medically justified acts performed without prior information and/or without the 
patient’s  consent  or  with  apparent  brutality.  Finally,  attitudes,  behaviours  and 
comments that do not respect women’s dignity, decency and intimacy are also 
cited under this term and are linked to the failure to take pain into account during 
and after childbirth’.30

As  can  be  seen,  the  HCE  explicitly  uses  the  term  ‘obstetric  violence’  to 
highlight its structural dimension, while the French National Academy of Medicine 
focuses on benevolence (bientraitance) to highlight its shortcomings. In France, 
the term ‘obstetric violence’ is rarely used by health professionals, who more 

26   Bousquet. et al. (2018).

27   Académie de médecine;  (2018).

28   Bousquet et al. (2018: 3). Translation by the authors of ‘les actes sexistes les plus graves qui peuvent se 

produire dans le cadre du suivi gynécologique et obstétrical des femmes. Les actes sexistes durant le suivi 

gynécologique et obstétrical sont des gestes, propos, pratiques et comportements exercés ou omis par une ou 

plusieurs membres du personnel soignant sur une patiente au cours du suivi gynécologique et obstétrical (…). 

Ils peuvent prendre des formes très diverses, des plus anodines en apparence aux plus graves’.

29  Bousquet et al. (2018).

30  Académie de médecine (2018 ::3). Translation by the authors of ‘le vocable de ‘Violences obstétricales’ re-

groupe tout acte médical, posture, intervention non approprié ou non consenti. Il recouvre donc, non seulement 

des actes non conformes aux recommandations pour la pratique clinique mais aussi des actes médicalement 

justifiés réalisés sans information préalable et/ou sans le consentement de la patiente ou avec une apparente 

brutalité. Enfin, les attitudes, comportements, commentaires ne respectant pas la dignité, la pudeur et l’inti-

mité des femmes sont également cités sous ce terme et rapprochés de la non-prise en compte de la douleur 

pendant et après l’accouchement’.

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2 FRANCE by Virginie Rozée and Clémence Schantz

often use the term ‘benevolence’ proposed by the Academy of Medicine, or the 
term ‘inappropriate acts’.31 On the other hand, the term ‘obstetric violence’ is 
used by militant associations32 and by some academic scholars.33

While  these  two  recognised  institutes  address  obstetric  violence  and 
make recommendations, it should be noted that there is no legal defi-
nition  and  no  specific  law  as  in  some  Latin  American  countries.  In  the 
absence of a legal framework, the observation and denunciation of such violence 
does  not  automatically  lead  to  a  trial  or  even  condemnation.  For  example,  in 
2021, Professor Emile Darai, an endometriosis specialist practising in one of the 
main Parisian hospitals, was the subject of several complaints of sexual assault 
and rape, which allegedly took place during gynaecological consultations. How-
ever,  although  this  professor  is  the  subject  of  a  judicial  investigation  and  has 
been removed from his responsibilities as head of department, he has not been 
suspended and continues to practise and carry out gynaecological examinations 
(pending the outcome of the investigation)34.

Finally, it is important to note that at the institutional level, as here with the French 
National  Academy  of  Medicine  report,  women’s  voices  are  often  silenced, 
while scientific studies emphasise that violence is subjective and therefore de-
pends on the histories and feelings of each individual.35 It is essential to take into 
account women’s experiences of obstetric care in order to better understand and 
define  obstetric  violence.  Since  2022,  Lucile  Faivre-Pierret,  a  doctoral  student 
at the University of Paris 1 and INED, is working on this reality-based definition 
by  collecting  in  France  the  discourse  and  experiences  of  women  who  consider 
themselves to have experienced obstetric violence.36

2.4 

Data collection and evidence on obstetric violence in France

2.4.1  Empirical evidence

In France, there is a large body of research in medicine, public health and social 
sciences  on  reproductive  and  sexual  health.  But  studies  on  the  conditions 
and experiences of women during gynaecological and obstetric care and 
during childbirth are scarcer. The analytical approaches used very rarely focus 
on violence, but they show that gynaecological consultations can be a place of 
violence, particularly around contraceptive injunctions.37 The first social scientific 
conference  on  the  subject  in  France  only  took  place  in  December  201938.  This 
conference was remarkable in its ability to bring together researchers, health pro-
fessionals and associations. Contributions, using mainly a qualitative approach, 
were made on obstetric violence in different regions of the world: Europe, Latin 
America,  the  Middle  East,  Asia  and  sub-Saharan  Africa.  The  participants  were 

31   Le Ray et al. (2021).

32   Bisch et al. (2020); Evrard (2020); Evrard et al. (2021).
33   Rozée & Schantz (2021); Schantz et al. (2021).
34   In France, medical acts, even without explicit consent, are not condemned because it is difficult to prove 
sexual abuse or coercion by the health professional.
35   Académie de médecine (2018); Lévesque et al. (2018); Michel & Squires (2018).
36   Ph.D thesis tentatively entitled ‘Derrière la notion contestée de ‘violences gynéco-obstétricales’, objectiver 

les mauvaises expériences de soin en gynéco-obstétrique. Pour une définition sociologique issue des expé-

riences profanes’ (https://www.ined.fr/fr/recherche/chercheurs/Faivre-Pierret+Lucile). 
37   Fonquerne (2021).
38    https://www.ined.fr/fr/actualites/rencontres-scientifiques/seminaires-colloques-ined/violences-obstetricales/

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numerous, but it should be noted that among the health professionals, midwives 
were much more numerous than obstetricians. All the papers pointed out that 
more research is needed on the subject.

In  France,  there  is  no  statistical  data  measuring  the  extent  of  obstet-
ric violence. However, since 1995, a National Perinatal Survey39 has been 
regularly conducted (1995, 1998, 2003, 2010, 2016, 2021) and its results are 
referenced in the European Perinatal Health report. The latest National Perinatal 
Survey carried out in 2021 in all 480 French maternity hospitals (France metro-
politan and overseas), including 6 birth centres, involved 13 404 women.40 For the 
first time, women were contacted again two months after giving birth. For 
those women who agreed, this follow-up was carried out by telephone or internet. 
Also for the first time, this latest survey looked at women’s mental health and 
addressed a few questions on obstetric violence. It introduced the concept 
of ‘inappropriate care’. This notion can be used as a ‘proxy’ for the measurement 
of obstetric violence. But it should be noted that the term ‘obstetric violence’ is 
only mentioned once in the report to refer to the current context of the debate on 
this subject in France and is not adopted by the authors in the rest of the report. 
The word “consent”, which is at the centre of obstetric violence’s debate in France, 
is  also  absent,  although  the  questionnaire  addresses  the  issue  of  ‘agreement’ 
before a medical act.

The  2021  EPN  survey  showed  that  15.5  %  of  the  women  experienced  a 
difficult or very difficult pregnancy and 11.7 % had a bad or very bad ex-
perience of childbirth.41 Women’s reaction to the discovery of their pregnancy 
is positive in most cases and no different from the situation of women in 2016. 
However, their psychological state during pregnancy seems to have deteriorated 
without  it  being  possible  to  define  with  the  data  from  the  ENP  2021  and  the 
proportion linked to the pandemic context. The share of women having consulted 
a health professional for psychological difficulties during pregnancy is increasing 
(8.9 % in 2021 compared to 6.4 % in 2016).42 We do not know whether or not this 
slight increase is related to difficult experiences of obstetrical care.

Concerning the use of technology in childbirth, apart from induction of labour, 
of which the frequency is increasing (25.8 % compared with 22 % in 2016), the 
survey highlights a decrease in the use of medical interventions aimed at 
accelerating labour: fewer artificial ruptures of the membranes (33.2 % among 
women in spontaneous labour compared with 41.4 % in 2016) and fewer oxy-
tocin administrations (30 % among women in spontaneous labour compared with 
44.4 % in 2016), in line with national recommendations. The caesarean section 
rate has been stable since the 2000s in France with a rate of 21.4 % in 2021. 
Having given birth by caesarean section in a previous childbirth remains the main 
risk factor for a caesarean section. The rate of instrumental vaginal childbirth 
remains  stable  at  around  12  %.  Midwives  perform  88.6  %  of  deliveries  by 
spontaneous vaginal childbirth, a rate that is stable compared to 2016 (87.5 %). 
The episiotomy  rate, which had already been declining for several decades, 
has fallen sharply from 20.1 % in 2016 to 8.3 % in 2021, in line with national 
recommendations.43

39   Enquête Périnatale Nationale, EPN.
40   Le Ray et al. (2021). In 2021, France recorded over 740 000 births.
41   Le Ray et al. (2021).
42   Le Ray et al. (2021).
43   Le Ray et al. (2021).

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2.4.2  Relevant manifestations of obstetric violence 

The 2021 EPN survey conducted two months after childbirth showed that about 
10 % of women reported having been exposed sometimes or often during their 
pregnancy, childbirth or stay in the maternity facility to inappropriate words or 
attitudes  from  health  professionals  and  about  7  %  to  inappropriate  gestures. 
These occur in all contexts (consultation, ultrasound, emergency, delivery room, 
epidural), but are more frequent during the stay in the maternity department.44

Based  on  the  testimonies  of  women  and  couples,  Anne  Evrard,  vice-president 
of  CIANE  (Collectif  InterAssociatif  autour  de  la  NaissancE),  reported  a  similar 
situation: infantilising, sexist, humiliating, denigrating and even threatening and 
intimidating  comments.  Here  are  some  of  the  specific  feelings  she  collected 
from  women  who  claim  to  have  experienced  obstetric  violence:  the  disruption 
of contact and dialogue with the health professionals; the loss of the woman’s 
place as interlocutor and a key actor; a loss of confidence in the team and great 
loneliness;  a  feeling  of  devaluation,  humiliation  and  infantilisation;  the  failure 
to take account of specific feelings, the denial of her ability to make legitimate 
choices considered essential; a feeling of dispossession of her role, her body, her 
baby or, conversely, of being reduced to a mere body; an experience of isolation 
and abandonment and, in an emergency, the absence of a person dedicated to 
explaining or even simply contacting her; and the emergence of fear and the risk 
of death without it being possible to express it openly.45

In the 2021 EPN, women also reported that health professionals did not al-
ways ask for their consent before performing a medical procedure (e.g. 
vaginal touching during pregnancy) or intervention (e.g. administering oxytocin, 
performing an episiotomy or emergency caesarean section during childbirth). In-
deed, for 4.2 % of the women, the health professional(s) never asked for consent 
before  performing  a  vaginal  touch  during  pregnancy;  for  11  %  of  the  women, 
consent  was  sometimes  requested;  and  for  78  %,  consent  was  systematically 
requested. During labour and childbirth, in almost 20 % of cases women report 
that their agreement was not sought for the administration of oxytocin during 
labour, in 51.8 % of cases for the performance of an episiotomy and in 34.5 % 
of  cases  for  the  performance  of  an  emergency  caesarean  section  (for  women 
exposed to these interventions).46

According to associations, the media and scientific literature, all women are likely 
to experience violence during pregnancy and childbirth.47 Nevertheless, some em-
pirical and scientific data lead to the hypothesis that women who are already dis-
criminated in their daily lives because of their colour, disability, living conditions, 
legal status, addiction, etc.,48 may be in France more exposed to obstetric violence 
than others. The Trajectoires & Origines survey, conducted by the French National 
Institute for Demographic Studies (INED) and the National Institute of Statistics 
and Economic Studies (INSEE) in France in 2008–2009 showed significant in-
equality  and  discrimination  in  healthcare  in  France  and  identified  the 
main factors as structuring discrimination in the field of health: being 
a woman, being an immigrant from Africa and the French overseas, and 

44   Le Ray et al (2021).
45   Evrard (2020).
46   Le Ray et al. 2021).
47   Schantz et al. (2021).
48   Lévesque et al. (2018:232).

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2 FRANCE by Virginie Rozée and Clémence Schantz

being Muslim.49

Similarly,  the  work  of  Priscille  Sauvegrain  has  shown  the  social  inequalities  of 
access  and  care  in  maternal  health:  differentiated  access  to  birth  preparation 
according to women’s socio-demographic characteristics,50 a higher risk of ma-
ternal  mortality  among  immigrant  women  in  France,  especially  those  born  in 
sub-Saharan Africa51 and a different care and treatment of black women during 
childbirth.52 She has also reported a higher caesarean section rate among women 
from sub-Saharan Africa. The healthcare teams justify this practice for several 
reasons:  the  poorer  health  of  African  women  and  the  anatomical  characteris-
tics of their pelvis, which is smaller and anthropoid in shape.53 All the studies 
have therefore shown that some women receive lower-quality obstetric 
care in France than other women. Among the various reasons, it is important 
to remember that the prejudice of the Mediterranean syndrome persists in 
Europe, including in France. The ‘Mediterranean syndrome’ designates ‘a form of 
exaggeration  of  the  pain  of  patients  from  Mediterranean  cultures and 
especially from North Africa, who are judged to be more anxious, complaining 
and soft and for whom it would therefore be a matter of following up their com-
plaints less’.54 On this matter, the French press published an article in September 
2022 entitled ‘Childbirth: the “Mediterranean syndrome” invites itself to the de-
livery room’.55

Racialised women may also be perceived and discriminated in relation to 
other social differentiation factors, in particular their social background, level of 
education, income, living place or deviation from the ‘healthy weight’ norm. Their 
deviation from the ‘reproductive norm’ that in France socially defines when and 
with whom to have children56 could be another factor that increases exposure 
to obstetric violence: women considered too young or too old to have children, 
those  considered  to  have  ‘too  many’  children,  same-sex  couples,  transgender 
men, people who are not in relationships, etc.

The Academy of Medicine considers that socially and psychologically ‘frag-
ile’  women are more  likely  to  experience  obstetric  violence. It states: ‘It 
is  important  to  pay  particular  attention  to  the  screening  of  particularly  fragile 
patients (psychiatric history, patients who have been victims of sexual or conjugal 
violence) in order to allow for appropriate care, which is the only way to limit the 
risk of psychological trauma during childbirth’.57

According to the HCE report, all the violence described here is carried out 
by both men and women, whatever their speciality, i.e. gynaecologists, obste-
tricians, midwives, anaesthetists, nurses and any other health professionals who 

49   Rivenbark & Ichou (2020).
50   Sauvegrain (2008).
51   Sauvegrain et al. (2017).
52   Sauvegrain (2012).
53   Sauvegrain (2013).
54   Loriol et al. (2010), cited in Lambert et al. (2022).
55   https://www.mediapart.fr/journal/france/120922/accouchement-le-syndrome-mediterraneen-s-in-

vite-en-salle-de-naissance
56   Bajos & Ferrand (2006).
57   Académie de médecine (2018:14). Translation by the authors of ‘Il est important d’accorder une attention 
toute particulière au dépistage des patientes particulièrement fragiles (antécédents psychiatriques, patientes 

victimes de violences sexuelles ou conjugales) afin de permettre une prise en charge adaptée qui, seule, per-

mettra de limiter le risque de traumatisme psychologique lors de l’accouchement.’

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work in the field of obstetrics and gynaecology.58

2.5 

Root causes of obstetric violence 

The use of the concept of ‘obstetric violence’ by the HCE report is signif-
icant. Using this concept allows the structural dimension of this violence to be 
made visible59 and to be included in the continuum of gender-based violence.60 
Moreover, the report explicitly makes the link between sexism and vio-
lence  during  gynaecological  and  obstetric  care  in  the  title.  It  states  that 
‘sexist acts during gynaecological and obstetric care (...) are part of the history of 
gynaecological and obstetric medicine, which is marked by the desire to control 
women’s bodies (sexuality and capacity to give birth)’.61

According to Marie-Hélène Lahaye, the Belgian lawyer who was the first in France 
to highlight the concept of obstetric violence through her blog ‘Marie accouche-là’, 
obstetric violence is the sum of two types of violence: institutional violence and 
gender violence.62 Obstetric violence in France is part of the history of gynaecol-
ogy, which produces, reproduces and even accentuates gender norms; and of the 
organisation of the healthcare system, which leaves little room for both humane 
and effective medical care.

Whereas at the beginning of the last century almost all births took place at home, 
today 99 % of births take place in hospitals in France,63 while in 2020 only 
92 births took place in the six birth centres in metropolitan France. But a process 
of institutionalising birth was put in place at the end of the World War II in order 
to better supervise and make childbirth safer. This ‘major move’64 has led to pro-
found changes in maternity care, perinatal healthcare and childbirth techniques. 
In France, the closure of small maternity hospitals, hospital mergers and 
partnerships and public–private cooperation have led to the closure of 
more than half of all maternity hospitals since 1975 (a reduction in the 
total number of maternity units from 1 369 in 1975 to 483 in 2021). Moreover, 
the childbirth in France is characterised by the homogenisation of the care of-
fered and a concentration of the births in hospitals. While home birth is almost 
impossible65  and  even  considered  ‘a  deviant  practice’,66  giving  birth  in  a  birth 
centre (maison de naissance) remains a laborious and difficult undertaking. This 
leaves individuals and couples with little freedom to choose where to give birth. 

Moreover, French obstetrics is one of the most medicalised in Europe.67 
As in the rest of the world, the medicalisation of maternal health in France has 
led  to  a  significant  reduction  in  complications  during  pregnancy  and  childbirth 
and in maternal and infant mortality. However, with the gradual introduction of 
standardised  places  and  practices  mobilising  technical,  surgical  and  medicinal 

58   Bousquet et al. (2018: 3)
59   Sadler et al. (2016).
60  Delage et al. (2019).
61   Bousquet et al. (2018:3). Translation by the authors of ‘Les actes sexistes durant le suivi gynécologique 
et obstétrical (…) s’inscrivent dans l’histoire de la médecine gynécologique et obstétricale, traversée par la 

volonté de contrôler le corps des femmes (sexualité et capacité à enfanter)’.

62   Lahaye (2018).
63   National Perinatal Survey (2016).

64   Thébaud (2010).

65   Pruvost (2016).
66   Cardi et al. (2016).
67   Pruvost (2018).

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2 FRANCE by Virginie Rozée and Clémence Schantz

objects,  this  medicalisation  has  been  accompanied  by  a  hypertechnicalisation 
of birth, leaving women with little decision-making power and autonomy during 
childbirth.68 Today in France, childbirth is governed by the notions of risk and sur-
veillance and by the increased use of technosciences.69 In 2021, three practices 
characterise  obstetrics  in  France:  a  high  use  of  epidural  analgesia  (82.7  %  of 
deliveries), a high use of oxytocin (a hormone used to increase the frequency and/
or intensity of uterine contractions – 30 % of women in spontaneous labour were 
given this hormone) and a quasi-systematic use of the gynaecological position 
(93.9 %). Nevertheless, caesarean section rates have been stable since the early 
2000s (around 20 %) and episiotomy rates are gradually decreasing as already 
mentioned.70

Some health professionals, particularly midwives, question their working condi-
tions (lack of staff in hospitals, budgetary restrictions) and deplore the application 
of a series of medico-technical and protocol-based gestures71 which no longer 
allow them to adopt a caring, listening and supportive attitude.72 Gynaecolog-
ical  and  obstetric  violence  is  part  of  this  new  context  of  pressure  on 
the French healthcare system. Poor working conditions, lack of quality 
services and facilities, lack of adequate training, the profit motive applied 
to health facilities, and the constraints imposed on health professionals are fac-
tors that favour the occurrence of gynaecological and obstetric violence.73 These 
conditions and constraints are no longer compatible with humane medical care 
and the explicit collection of informed consent.

Anne Evrard, vice-president of CIANE, based on the testimonies of women and 
health  professionals,  argues  that  most  often  it  is  the  absence  of  satisfactory 
communication between health professionals and women that signals the onset 
of obstetric violence.74 Yet the impact of the behaviour and attitudes of health 
professionals on the immediate and longer-term experiences of women or cou-
ples is crucial. 

68   Bousquet et al. (2018).

69   Carricaburu (2007); Clarke et al. (2003).
70   Le Ray et al. (2021).
71   Morel (2007-2008).
72   Coulm (2013).
73   Lévesque et al. (2018).
74   Evrard (2020).

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2.6 

Consequences of obstetric violence 

In France, as elsewhere, violence has consequences for women’s mental 
health,  but  also  for  their  physical  and  social  health.  The  physical  and 
psychological damage is serious and long-lasting, putting the woman’s 
overall health at risk. 

The main consequences of obstetric violence include depressive symptoms and 
post-traumatic stress disorder. The report of the Academy of Medicine acknowl-
edges that ‘all these defects in the quality of care, whether real or felt by the 
patients, can lead to major psychological disturbances similar to post-traumatic 
stress disorder (PTSD), which will require complex psychosomatic treatment. This 
PTSD, which affects nearly 5 % of patients, may be secondary to a life-threaten-
ing emergency situation, which is rightly distressing, but is most often the con-
sequence  of  daily  obstetric  practices,  which  are  technically  irreproachable,  but 
humanly deficient’.75 The 2021 EPN survey showed that 16.7 % of women had 
major depressive symptoms at two months post-partum.76 

Evrard lists all the interrelated consequences that CIANE has observed as a result 
of  obstetric  violence.77  On  a  psychological  level,  she  notes  loss  of  sleep,  loss 
of  appetite,  nightmares,  bad  memories,  repetitive  flashes  of  the  most  difficult 
moments,  major  anxiety  and  frequent  crying.  She  observes  that  obstetric  vio-
lence even affects women’s self-esteem, leading to a degraded self-image, guilt 
and anger. On a physical level, obstetric violence can lead to diffuse body pain 
and persistent perineal pain, even in the absence of injury or episiotomy. On a 
social  level,  isolation  from  family  and  friends  for  fear  of  being  misunderstood 
and an inward-looking attitude were observed, as well as an inability to return to 
work because of obsession with the events, sadness, discouragement and intense 
physical and psychological fatigue. Difficulties in the relationship with the child 
were also observed, as well as a severely impaired or non-existent sexuality, and 
even marital crises. This violence can also lead to a loss of confidence in health 
professionals, to the non-use or under-use of health services and even to seeking 
medical services elsewhere for fear of being confronted with this violence again.

Finally, while it is not possible to establish a direct link with obstetric violence ex-
perienced by women, it is important to point out that in France, suicide is current-
ly the leading cause of maternal mortality (along with cardiovascular disease).78

75   Académie de médecine (2018:13). Translation by the authors of ‘Tous ces défauts dans la qualité de la 

prise en charge, bien réels ou ressentis par les patientes peuvent entrainer des perturbations psychologiques 

majeures analogues à un état de stress post-traumatique (SPT) qui nécessitera une prise en charge psycho-

somatique complexe. Ce SPT, qui toucherait près de 5 % des patientes, peut-être secondaire à une situation 
d’urgence vitale, angoissante à juste titre, mais s’avère le plus souvent la conséquence de pratiques obstétri-

cales au quotidien, techniquement irréprochables, mais humainement défaillantes’.

76   Le Ray et al. (2021).

77   Evrard (2020).
78   Inserm and Santé Publique France (2021).

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2 FRANCE by Virginie Rozée and Clémence Schantz

2.7 

Obstetric violence and Covid-19 

In France, as everywhere, the Covid-19 pandemic forced the reorganisation 
of care, including in maternity facilities, sometimes in a hurry and without clear 
institutional instructions. It also increased the difficulties of access to care 
(due to the successive lockdowns) and also the stress and uncertainty of health 
professionals and women. 

In France, two practices drew the attention of associations and health users from 
the start of the pandemic, were relayed on social networks and led to the re-emer-
gence in the spring of 2020 of debates on obstetric violence: the imposition in 
some facilities of the wearing of masks during labour; and the refusal, in 
some maternities, to allow patients to be accompanied during childbirth. 
On  this  point,  beyond  the  right  of  women  to  be  accompanied  by  a  person  of 
their  choice  during  childbirth,  studies  show  the  positive  health  impacts  of  this 
accompaniment: it increases the probability of a spontaneous childbirth (without 
caesarean  section)  and  reduces  the  time  of  childbirth,  the  use  of  instruments 
and analgesia and negative perceptions of childbirth (and therefore post-partum 
depression).79 These conditions gave rise, among other things, to a blog post by 
Marie-Hélène Lahaye, entitled ‘When you’re at war, you don’t give birth at 
the front’ (Quand on est en guerre, on n’accouche pas sur le front), posted on 
29 March 2020.80

Faced with these new constraints around hospital childbirth, a sizeable share of 
women (25.8 %) in France said they were considering giving birth at home during 
the pandemic without prior preparation. This was reported in the results of the 
survey of the collective StopVOG, a French collective created in 2017 to 
denounce  obstetric  violence.81  StopVOG  conducted  an  online  survey  in  May 
2020 to report on women’s experiences, the protocols put in place and respect for 
women’s rights and human rights during this period of crisis. This survey collected 
2 727 responses from women who gave birth between 15 February and 31 May 
2020. It reported that 25 % of respondents had an induced childbirth (compared 
to 22 % in the 2016 EPN survey); that 46 % had to wear a mask during childbirth 
and, of the 8.4 % who had an episiotomy, 71.4 % stated that their consent was 
not sought. It also reports that 75 % of respondents showed at least three signs 
of  depression  and  PTSD.  This  report  was  accompanied  by  several  extracts  of 
testimonies as well as a mapping of France of these testimonies. This report 
warned,  from  the  very  first  months  of  the  pandemic,  that  the  health 
crisis context has aggravated obstetric violence. 

At the same time, a scientific European survey (IMAgiNE EURO – Improving 
MAternal NEwborn care in the EUROpean region), coordinated by the SS WHO 
Collaborating Centre IRCCS Burlo Trieste, was carried out on the conditions 
of childbirth in different European countries, from the point of view of women 
who have given birth and of health professionals working in perinatal and obstet-
ric care services.82 Regarding the scores of quality of maternal and new-born care 
(QMNC) defined by the World Health Organization, France has higher scores than 
its European neighbours during the Covid-19 pandemic. However, women who 
gave birth in France reported difficult conditions of childbirth. 

79   Bohren et al. (2017).

80   https://blogs.mediapart.fr/marie-helene-lahaye/blog/290320/quand-est-en-guerre-n-accouche-pas-sur-

le-front.
81   Bisch et al. (2020).
82   https://www.burlo.trieste.it/ricerca/imagine-euro-improving-maternal-newborn-care-euro-region. 

15

2 FRANCE by Virginie Rozée and Clémence Schantz

Among  respondents  who  underwent  labour  (497  individuals),  11.5  %  declared 
having  had  fundal  pressure83  (for  instrumental  vaginal  birth,  IVB),  32.4  %  re-
ceived no pain relief after a caesarean session, 47.7 % of respondents declared 
that they had no choice of birth position, 62.5 % that no consent has been re-
quested (for IVB), 34.6 % that they were not involved in choices, 50.9 % that their 
companionship was not allowed, 23.1 % reported not having been treated with 
dignity and 18.5 % declared abuse (physical, verbal and emotional).84 Although 
these two voluntary surveys have obvious biases (more women with a particular 
experience  may  have  responded),  they  provide  interesting  and  quite  alarming 
indicators of the conditions of childbirth during the crisis in France.

The qualitative research, Mater-Covid1985, conducted in 2021 and 2022, com-
plements  these  quantitative  surveys.  Funded  by  the  French  National  Research 
Agency, it aims to document the experiences of women who gave birth during 
the pandemic in the Paris region and on Reunion Island. The question of obstetric 
violence was at the centre of this research, questioning whether the health crisis 
context had exacerbated this violence. The 55 interviews conducted with women 
who had given birth during three key periods of the pandemic showed women at 
the end of their pregnancy had a strong apprehension of giving birth ‘alone’. The 
large discrepancy between what the women feared and the actual conditions of 
their childbirth meant that they declared that ‘everything went well’, or even that 
they were ‘lucky’. Nevertheless, few of them had anticipated the difficul-
ties of being alone with a newborn in the post-partum period. Thus, the 
pandemic created a great deal of loneliness among the women, accentuated by 
a feeling of ‘stolen motherhood’. The majority of women overall did not describe 
a positive experience of childbirth, although they did not link this to the notion of 
obstetric violence. The degree of intensity of this experience is related to wom-
en’s perceptions of motherhood and medicine, as well as to their personal and 
family history.86

This research also included 34 interviews with health professionals who accom-
panied women in childbirth during the pandemic. These experiences were marked 
by  a  polarisation  of  feelings,  with  some  experiencing  great  ‘excitement’  while 
others’  daily  lives  were  strongly  marked  by  fear.  The  health  crisis  undermined 
the mental wellbeing of many of them; it may have been indicative of a more 
general malaise and the re-emergence of controversies about obstetric violence 
reinforced their malaise.87

83   This practice has been discouraged by the French National Authority for Health (Haute Autorité de la 

Santé, HAS) since 2007 because it is considered traumatic for women and can lead to complications. 
84   Lazzerini et al. (2021).
85   https://www.mater-covid19.org/ 

86   Rozée and Schantz (2023).

87   Schantz &  Ferrere (2022).

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2.8 

Achievements and challenges in collecting and monitoring data

As this report points out, obstetric violence has a systemic dimension,88 i.e. here 
linked to the current weaknesses of the French health care system but also to 
gender, social class and racial inequalities, which are prevalent in French soci-
ety.89 It also has a subjective dimension,90 i.e. it is linked to the personal, social 
and  medical  history  of  each  individual.  This  subjective  dimension  means  that 
the same act or behaviour will have different consequences for different people. 
These  systemic  and  subjective  dimensions  make  it  difficult  to  identify 
and  therefore  report  violence.  Moreover,  many  women  who,  for  instance, 
have been badly spoken to, who have been subjected to an unjustified medical 
procedure or whose pain has not been taken into account and relieved, will not 
systematically identify these acts and behaviour as violence. The same patterns 
can be observed for all gender-based violence. 

All this makes it difficult to understand obstetric violence and in particu-
lar to measure its prevalence, from the perspective of women in France. 
Conducting such research from women’s perspective and experience is 
an  urgent  and  necessary  challenge,  including  with  socially  vulnerable 
and marginalised women.91 The StopVOG collective also advocates that sys-
tematic studies be conducted. In particular, it proposes adding specific questions 
to the National Perinatal Survey on obstetric violence, on women’s satisfaction 
during their medical care, and on their free and informed consent. It also proposed 
that these questions be asked at the end of the maternity ward (as is the case 
today) and then again one year later (in the new version, women are consulted 
two months later, as mentioned above). For the StopVOG collective, ‘it does not 
seem possible to experience and analyse events at the same time. Sometimes 
it is necessary to step back to understand what really happened and to grasp all 
the dimensions and impacts.’92

Similarly, the French National College of Midwives93 published in 2023 a com-
mentary which proposes a set of standardised questions adapted to the French 
context, with the women’s point of view as a starting point. The CNSF proposes 
that this set of questions could be used in surveys like the next National Perinatal 
Survey, to find out the percentage of women who report having been exposed to 
obstetric violence.94

Another important challenge is ensuring and raising awareness and commitment 
of health professionals, who need to take a more critical view of their practices 
to ensure quality care.95 Their training is thus at the heart of this challenge as 
the HCE report mentions that the prevention of obstetric violence requires the 
training of health professionals.96 This is also what emerges from Master’s re-
search  on  gynaecological  and  obstetric  follow-ups  carried  out  with  22  women 
interviewed, for whom obstetric violence is the result of a lack of awareness and 

88   Sadler et al. (2016).

89   Lévesque and Ferron-Parayre (2021); Lévesque et al. (2018).

90   Lévesque & Ferron-Parayre (2021); Michel & Squires (2018).

91   Lévesque et al. (2018).
92   (Bisch et al. 2020: :51). Translation by the authors of ‘il ne paraît pas possible de vivre les événements et 
de les analyser en même temps. Un recul est parfois nécessaire pour comprendre ce qui est réellement arrivé 

et en saisir toutes les dimensions et impacts’ p.51. 

93   Collège National des Sages-Femmes, CNSF
94   Sauvegrain et al. (2023).
95   Lévesque & Ferron-Parayre (2021).
96   Bousquet et al. (2018).

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therefore of training of health professionals.97

2.9 

Relevant initiatives and their impact 

2.9.1 

Initiatives leading to political action

Relevance of the topic in political and institutional debate

As described at the beginning of this case study, the scale of civil society mobili-
sation from the mid-2010s in France led to the creation of a specific Observatory 
and the publication of a government report presenting recommendations to com-
bat obstetric and gynaecological violence. 

More recently, in 2021 and 2022, two significant public and publicised 
cases led to the consideration of obstetric violence issues within the gov-
ernment. The first one concerns the Professor Emile Daraï (see above), who was 
the subject of 190 testimonies of violence and 28 complaints of rape, including 
on minors (#NousToutes 2022). The second concerns a member of the govern-
ment. In June 2022, an investigation was opened against Chrysoula Zacharopou-
lou,  Secretary  of  State  and  former  gynaecologist,  accused  of  rape  and  sexual 
assault by two patients and violence by another. Faced with the growing number 
of charges and complaints, Prime Minister Elisabeth Borne decided to refer the 
matter to the National Consultative Ethics Committee (CCNE) on 6 July 2022.98 
The committee then organised hearings with health professionals, collectives and 
associations such as StopVOG and CIANE and other experts. It was expected to 
give  its  opinion  on  the  notion  of  consent  during  gynaecological  examinations 
and make recommendations by the end of 2022. These recommendations will 
provide a framework for collecting consent and clarifying expectations of health 
professionals during gynaecological examinations. 99

Degree of recognition of the topic by healthcare providers

Within the healthcare community, the positions regarding public denunciations of 
obstetric violence are not homogeneous. In other words, there is no consen-
sus on obstetric violence in the medical community, and the debate over 
the use of terms to qualify it (violence vs lack of benevolence or abuse) 
is revealing.

These debates were observed during the hearings held prior to the drafting of 
the HCE report in 2017 and then regarding its content. Various midwifery profes-
sional organisations responded to requests for hearings. Then, the CNSF issued a 
reserved opinion on the HCE report, but welcomed its publication for the impor-
tant questions it raised in public debate. Conversely, the French National College 
of  Obstetricians  and  Gynaecologists  (Collège  National  des  Gynécologues  Ob-
stétriciens Français, CNGOF) did not wish to participate in the working groups and 
criticised the report when it came out. The organisation refuted the conclusions, 

97   Désétables (2022).
98  https://www.elle.fr/Societe/News/Violences-gynecologiques-Elisabeth-Borne-saisit-le-Conseil-national-d-

ethique-sur-le-consentement-4034668.
99   At the time of writing, the CCNE report was not published yet 

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saying they did not take sufficient account of the very hard working conditions of 
health professionals in the field of perinatal care. This led the then-president of 
the CNGOF to declare that obstetricians-gynaecologists were the victims in this 
debate. Some health professionals denounced this ‘gyneco bashing’.100 

However, in October 2021 (in the midst of the highly publicised ‘Darai’ affair de-
scribed above), the CNGOF published on its official website that ‘Professionals are 
perfectly aware of the particularity of the gynaecology or obstetrics consultation, 
which touches on the psychic and physical intimacy of women. This consultation 
requires a listening, an attitude, a dialogue and a physical examination in a spirit 
of benevolence and mutual respect.’101 They suggest that practitioners in France 
adhere to ‘the gynaecology and obstetrics consultation charter’ and display it in 
their waiting rooms, so that each woman can read it before the consultation. This 
charter recalls the objectives and purposes of gynaecological examinations, as 
well as the rights of patients (their privacy and intimacy must be respected, their 
consent must be obtained and it can be withdrawn at any time). Once again, the 
CNGOF uses the term benevolence in this official statement.

The  lack  of  acceptance  of  the  term  ‘violence’  is  mainly  based  on  the  lack  of 
consideration  of  the  working  conditions  of  professionals.  But  it  mainly  comes 
as well from the fact that many professionals consider that the idea of inten-
tionality underlies the concept (which the HCE report refutes). In this regard, the 
report  of  the  French  Academy  of  Medicine  considers  that  the  sometimes  viru-
lent criticisms of practices and attitudes described as ‘obstetrical violence’ have 
tainted healthcare relationships, in particular the mutual trust between patients 
and health professionals, which is essential for serene and quality medical care. 
Moreover, according to this report, these criticisms do not take into account the 
real  advances  in  birth  safety,  of  which  health  professionals  can  be  proud,  and 
which do not deserve a global, outrageous and unfair questioning of these same 
professionals.102

Despite  these  disagreements,  as  described  above,  the  CNSF  has  just 
published a commentary which emphasises the importance of recognis-
ing and measuring the extent of obstetric violence and the need to look 
at it from the women’s perspective.103 Similarly, in 2022, the French Society 
of Perinatal Medicine (Société Française de Médecine Périnatale) is setting up a 
working group on benevolence in perinatal health; this group is supposed to start 
working in 2023. 

Degree of recognition of the topic by the general public and women

In France, there have been no media campaigns on obstetric violence and it is 
therefore difficult to measure the degree of awareness and acceptance of women 
and the public on this issue.

100   Sauvegrain et al. (2023)
101   Translation by the authors of ‘Les professionnels ont parfaitement conscience de la particularité de la 
consultation de gynécologie ou d’obstétrique qui touche à l’intimité psychique et physique des femmes. Cette 

consultation nécessite une écoute, une attitude, un dialogue et un examen physique dans un esprit de bien-

veillance et de respect mutuel’.
102   Académie de médecine (2018:18).
103   Sauvegrain et al. (2023).

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2.9.2 

Initiatives to combat obstetric violence

Relevant initiatives to address the topic to general public

The Collective Stop VOG is very present in the media, on social networks 
and  strongly  participates  in  the  public  dissemination  of  information 
on  obstetric  violence  in  France,  including  during  the  Covid-19  crisis,  when 
they ran an awareness campaign on changes in childbirth protocols during the 
pandemic. The collective was created at the end of 2017, ‘to end the taboo of 
obstetric violence’. In 2022, Sonia Bisch, the founder of and spokeswoman for the 
collective, declared that the collective received more than 200 testimonies per 
month, of which excerpts are made visible through #StopOmerta104. Sonia Bisch’s 
media career is representative of the progressive awareness of civil society. She 
gave birth to her first child in 2015, a childbirth that she experienced very badly. 
She testified for the first time in August 2017, in a report by the news channel 
BFM TV accompanying the announcement of the commissioning of the HCE re-
port on obstetric and gynaecological violence.105 She is filmed at home, blurred, 
from behind and in silhouette, under a changed first name. But she then testified 
with  her  face  uncovered  on  the  occasion  of  the  first  demonstration  in  France 
against gynaecological and obstetric violence, on 25 November 2017.

Sonia  Bisch  also  provided  testimonial  in  the  first  French-language  feature 
documentary  on  obstetric  violence,  Tu  enfanteras  dans  la  douleur,  directed 
by  Ovidie.106  This  documentary,  broadcast  on  a  national  public  channel  (Arte, 
broadcast  on  16  July  2019),  also  marked  a  turning  point  in  the  visibility  and 
denunciation of obstetric violence.107 For the first time, the testimonies were made 
openly, showing that the shame should be shifted from victims to perpetrators 
and that the taboos on the subject must be lifted. While the open testimonials 
were important, just as important was the content: the women recounted their 
childbirth  with  sometimes  very  strong  terms  such  as  ‘massacres’;  they  also 
explained the consequences, the trauma left by the experience, and that it was far 
from being ‘the best day of their lives’. The documentary even carried testimony 
of the then Secretary of State for Equality between Women and Men, Marlène 
Schiappa, who narrated how she experienced obstetric violence during her last 
childbirth.

The French local and national media continue to publish information and 
mobilise around obstetric violence. A recent article on the issue appeared in 
Le Monde, one of France’s leading daily newspapers, entitled ‘Can you advise me 
how to find a non-violent gynaecologist: faced with the fears of some patients, 
the embarrassment of practitioners’.108 The article demonstrated the new impor-
tance of the subject in the public space, while also describing the gap between 
women and some health professionals.

104   See the testimonies collected on @StopVOG twitter account: https://twitter.com/StopVOGfr?ref_src=tws-

rc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Eauthor

105   BFM TV. Violences obstétricales : ‘J’ai eu des douleurs immenses’, témoigne une mère. BFM TV [Internet]. 

3 August 2017.See: https://www.bfmtv.com/sante/violences-obstetricales-j-ai-eu-des-douleurs-immenses-
temoigne-une-mere_VN-201708030099.html. 

106   Ovidie (2019).

107   Salles (2021).
108   https://www.lemonde.fr/societe/article/2022/10/12/paroles-de-gynecologues-obstetriciens-sur-leurs-pra-
tiques-si-la-defiance-s-installe-avec-les-patientes-ce-sera-du-perdant-perdant_6145397_3224.html.

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Relevant  initiatives  to  involve  and  train  health  professionals  in  recognising, 
understanding and preventing obstetric violence

There are few initiatives to train health professionals in France. These 
include the original production in 2020 of three short training films entitled ‘Et 
si on s’écoutait?’ (Why don’t we listen to each other?) by the French actor and di-
rector Nils Tavernier, in collaboration with CIANE, the Maison des Femmes (a care 
centre, attached to the Delafontaine hospital, for women in difficulty or victims 
of violence)109 and the CEGORIF110. Based on testimonies collected by CIANE, they 
portray ‘ordinary’ obstetric violence. Three situations are described: a consultation 
in a private gynaecological practice to obtain information on abortion, a childbirth 
and a consultation in an obstetric emergency room for a miscarriage. The films 
show the distress of women faced with a lack of time and attention from health 
professionals and the inappropriate and infantilising words used by some pro-
fessionals.  However,  the  violence  committed  does  not  seem  to  be  intentional. 
This is seen through the portrayal of the difficult working conditions of the health 
professionals: exhausting hours, few holidays, many patients to take care of and 
lack  of  staff.111  These  short  films,  available  online,  were  made  to  be  screened 
and discussed in training courses for health professionals intending to work in 
perinatal and obstetric care, within the departments or in discussion groups with 
patients. The Maison des Femmes states that the aim of this mini-series was to 
open up dialogue between patients and health professionals to enable a better 
understanding of the expectations of some and the difficulties of others, with a 
view to improving overall care practices.
With the same objective, CIANE and social science researchers are increasingly 
present in midwifery schools and medical courses to raise awareness and train 
health professionals on the issue of obstetric violence. An inter-university diploma 
entitled ‘Taking charge of violence against women towards good treatment’ (Prise 
en charge des violences faites aux femmes vers la bientraitance)112 includes a 
module entirely dedicated to ethical reflection on care and more particularly on 
consent to care and violence in care. This diploma is coordinated by an obstetrician 
gynaecologist, Dr Perrine Millet. 

Relevant initiatives to support women in the exercise of their reproductive rights 

Created in 2003, CIANE (Collectif InterAssociatif autour de la NaissancE) 
is the leading patient association in the field of perinatal health. It is a 
group of some 30 parents’ associations. Some are generalist, others deal more 
specifically  with  caesarean  sections,  breastfeeding,  home  birth,  pre-eclampsia 
or hyperemesis gravidarum. CIANE members participate in working groups with-
in HAS and the CNGOF, communicate at conferences and also publish scientific 
articles on obstetric violence.113 It has now become one of the main active 
associations that supports women and families who have experienced 
obstetric violence, by helping them to denounce these practices, to get answers 
to  their  questions  about  the  poor  medical  treatment  they  may  have  suffered, 
and by accompanying them during hearings with health professionals and even 

109   https://www.lamaisondesfemmes.fr/.
110  https://www.terrafemina.com/article/violences-obstetricales-ces-trois-courts-metrages-de-nils-tavernier-
denoncent_a352606/1.

111  Salles (2021).

112   https://formations.univ-grenoble-alpes.fr/fr/catalogue-2021/du-diplome-d-universite-DU/diplome-inter-

universitaire-prise-en-charge-des-violences-faites-aux-femmes-vers-la-bientraitance-ITZR6SOW.html 

113   Evrard (2020); Evrard et al. (2021).

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during legal proceedings. 

CIANE  is  at  the  forefront  of  the  initiative  to  set  up  birth  centres  in 
France. Following demands to find alternatives to highly technical and medical-
ised hospital birth delivery, the French government set up birth centres in 2016 
(Law 2013-1118 of 6 December 2013), the aim of which is to offer alternative 
reception facilities for women with a physiological birth as well as overall support 
at birth. There are eight birth centres in France: six in continental France and two 
in  the  French  overseas  territories  (Guadeloupe  and  Reunion  Island).  In  October 
2020, the French Social Security Financing Bill extended the piloting of these 8 
birth centres and authorised the opening of 12 additional birth centres in 2022. 
Birth centres provide a space where women who wish to do so, whose pregnancy 
is not considered to be at risk, can regain control, autonomy and decision-making 
power over their body and their birth and give birth as ‘naturally’ as possible (i.e. 
without  medication  or  instruments).  But  despite  the  creation  and  development 
of these centres, they remain insufficient to meet the growing demand. In 2018, 
only  506  women  (0.07  %)  in  2018  gave  birth  in  one  of  the  then  eight  birth 
centres in France.114

In contrast to other European countries, the possibility of experiencing 
childbirth outside hospitals remains very limited115 and is still perceived 
as dangerous and irresponsible. It is almost impossible to find insurance for 
midwives  wishing  to  perform  home  births,  making  this  mode  of  practice  ex-
tremely difficult. Several midwives have recently been banned from the Council 
of the Order of Midwives (Conseil de l’Ordre des Sages-Femmes) as a result of 
this poorly regulated practice in France.116 While according to a February 2020 
opinion poll, the public fully supports birth alternatives such as birthing 
centres,117 there is no consensus among health professionals.118 Some profes-
sionals argue that it is preferable, safer and easier to label hospital maternity 
units that respect and promote women’s autonomy and choice during childbirth 
(where ‘label’ in English is more equivalent to the idea of ‘accreditation’ or ‘ap-
proval’). In 2019, the CNGOF proposed labelling maternity hospitals that respect 
the good treatment and transparency of their practice during childbirth, and the 
label Maternys was therefore created.119 On a voluntary basis, maternity facilities 
that apply for this label are committed to the benevolence and transparency of 
their service by following the 12 recommendations made by the CNGOF. On the 
first webpage of initiative, Professor Joelle Belaisch-Allart, President of the Label 
Committee, states ‘Labelling maternity units that place benevolence at the centre 
of their concerns is more necessary than ever. The objective is to entrust part 
of the quality control to the women themselves; taking into account the words 
of  women  to  improve  our  practices  is  our  collective  ambition’.120  However,  the 
effects of such a label on women’s actual experiences are still unknown.

114   Chantry et al. (2019).

115   In France, less than 1% of births take place outside a health facility in 2016 (Insee, civil status statis-

tics, 2016).

116   Sestito (2017).

117   https://www.ipsos.com/fr-fr/les-maisons-de-naissance-plebiscitees-par-9-francaises-sur-10. 

118   See the communication of the CNGOF ‘Generalization of the Birth Centres or more means for the mater-

nities? The CNGOF’s response to the Senate’, published on 9 March 2020.
119   https://www.maternys.com/label-cngof-maternys/. 
120   Translation by the authors of ‘labelliser les maternités qui mettent la bientraitance au centre de leurs 

préoccupations s’avère plus que jamais nécessaire. L’objectif est de confier désormais une partie du contrôle 

qualité aux femmes elles-mêmes ; tenir compte de la parole des femmes pour améliorer nos pratiques, telle 

est notre ambition collective’.

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As  part  of  the  2005–2007  French  perinatal  plan,  the  concept  of  the 
‘birth plan’ was established. Produced in the first trimester of pregnancy, the 
birth plan is a document to be filled in by the future parents, to declare 
their wishes concerning the childbirth (for instance, whether or not they ac-
cept a medication or refuse a medical procedure). However, the few studies that 
collect this information and the informal discussions between people who have 
given birth show that this plan is not always followed. Although the proportion 
of women who have drawn up a birth plan has tripled between 2016 and 2021, 
they are still few in number to take this step, 10.2 % in 2021. Of the women 
who expressed written or oral requests, 92.5 % were able to express them to the 
team; the most frequent requests were to be able to have skin-to-skin contact 
with their baby (67.3 % of women expressing requests), to be able to walk or 
change position (60.1 %) or to limit medical procedures (52.2 %). The proportion 
of women declaring that they had ‘no particular requests’ for childbirth was high 
(70.1  %),  although  it  is  not  clear  whether  this  result  reflects  confidence  in  the 
healthcare team or, on the contrary, the fact that women do not dare to express 
requests, or even that they are unaware of this possibility.121 In the same vein, 
the early postnatal interview (EPNP) has become a mandatory step in 
the care of post-partum women in France since July 2022 (Article L2122-1 
of the Public Health Code). The introduction of this interview follows numerous 
requests from perinatal professionals and user representatives to deal with de-
pression, suicide and post-traumatic syndromes. It is part of the ‘First 1000 Days’ 
programme  launched  by  UNICEF  and  taken  up  by  the  French  government.  Al-
though it is not directly related to obstetric violence, it is a sign of the awareness 
of the need to consider women’s mental health after childbirth.

Relevant  initiatives  to  deconstruct  general  assumptions  on  childbirth,  (over)
medicalisation of reproductive health, gender and other stereotypes, naturalised 
behaviours, beliefs, practices, power dynamics, etc. 

Deconstructing the obstetric paradigm based on the notion of risk is dif-
ficult in France, particularly because of the health professionals whose 
medical training is based on the belief that childbirth is a risky event, 
that must be medically and technically supervised by a competent and equipped 
medical team. Some social science studies contribute to deconstructing childbirth 
as  a  risky  medical  event.  Similarly,  there  is  social  demand,  as  birthing  centres 
have to turn down many requests every year. But dialogue with some health pro-
fessionals, especially obstetrician-gynaecologists, is often difficult; this disagree-
ment on the concept of obstetric violence prevents the possibility of discussion. 

Birth centres could contribute to changing this vision of childbirth, that 
risk is inherent, and to open up discussions and changing the paradigm 
of a science of obstetrics based on risk. But these birthing centres are 
controversial  in  France.  They  give  rise  to  passionate  debate  and  this  issue 
of giving birth without the presence of an obstetrician and a medical team and 
without technology remains taboo in France.

121   Le Ray et al. (2021).

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2.10  Conclusions and recommendations

2.10.1  Achievements and lessons

1. 

2. 

3. 

Feminist activist circles and social networks have played a key role 
in reporting obstetric violence and raising awareness in the general 
population.
Two  institutional  reports  were  published  in  2018  following  the 
growing public and media mobilisation on the issue and are signifi-
cant references in the field of obstetric violence: the HCE report and the 
report of the French National Academy of Medicine.
Two associations play a central role in denouncing obstetric vi-
olence  and  supporting  women  and  families  who  have  experienced  it: 
CIANE, created in 2003, the leading patient association in the field of 
perinatal health; and the collective StopVOG, created in 2017. They have 
contributed to putting pressure on institutions to define obstetric violence 
and on the government to widen the options of locations for delivery for 
women, e.g. by opening birthing centres.

2.10.2  Challenges

1. 

2. 

3. 

4. 

5. 

6. 

7. 

There is no consensus on obstetric violence in France and the topic 
generates controversy and debate, particularly within the medical com-
munity.
There is no legal definition and no specific law in France on obstetric 
violence.
Research on the conditions and experiences during gynaecological and 
obstetric care and during childbirth are scarce and there is no sta-
tistical data measuring the extent of obstetric violence in France. 
Conducting such research from the perspective and experience of women 
is an urgent and necessary challenge, including with socially vulnerable 
and marginalised women.
In contrast to other European countries, the possibility of experienc-
ing  childbirth  outside  the  institution  of  hospitals  remains  very 
limited and is still perceived as dangerous and irresponsible.
There are few initiatives to raise awareness and train health pro-
fessionals in France.
Deconstructing the obstetric paradigm based on the notion of risk 
is very difficult in France, particularly because of disagreements over 
the concept of obstetric violence within the medical community.
Birth  centres  could  have  contributed  to  changing  this  vision 
of  childbirth, that risk is inherent, and to  open  up  discussions  and 
changing  the  paradigm  of  a  science  of  obstetrics  based  on  risk  (in 
addition to giving more choice and autonomy to women). But these birth 
centres are very controversial in France, where obstetrics is highly medi-
calised.

24

2 FRANCE by Virginie Rozée and Clémence Schantz

2.10.3  Recommendations

1. 

2. 

3. 

4. 

5. 

6. 

Support  associations  that  address  obstetric  violence,  as  they  play  a 
central role in lobbying the government and institutions and contribute 
greatly to the recognition of this issue as a public health problem.
Implement a national media campaign to better inform women of 
their sexual and reproductive rights, including during gynaecological 
consultations and during childbirth and especially on free informed con-
sent.
Support  academic  research  on  obstetric  violence,  including  sta-
tistical surveys on women’s experiences during obstetric care and 
childbirth and qualitative research to better understand obstetric violence 
from the perspective of women. Such research will make it possible to 
better define and frame obstetric violence, taking into account its subjec-
tive dimension. 
Bring the issue of obstetric violence (and more broadly of gynae-
cological violence) into the legal domain by setting a legal frame-
work and providing a legal definition of this violence; and consider penal 
solutions  when,  during  gynaecological  care  and  delivery,  consent  has 
not  been  sought  and  when  the  patient’s  choice  and  integrity  have  not 
been respected.
Expand the range of birthing options by opening more birthing cen-
tres throughout France and in the overseas departments. 
Open a debate on home birth, bringing together midwives, including 
those  who  perform  home  births,  obstetrician-gynaecologists  and  re-
searchers, in order to better assess the risks and possible alternatives to 
the current technicalisation and medicalisation of childbirth, in line with 
social demands. 

25

3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

3   THE NETHERLANDS 

 by Rodante van der Waal 
and Marit van der Pijl

3.1 

Executive summary and overview

Dutch maternity care is organised in a different way than in other countries. 
The system is divided into primary  midwife-led  care  and  obstetrician-led 
care. In the case of a low-risk pregnancy, women receive midwife-led care 
in the community by a primary care midwife. People can choose to give birth 
either at home, in a birth centre or in a hospital with the primary care 
midwife as the responsible care provider. Primary care midwives are therefore 
a strong independent professional group in the Netherlands. In case of risk fac-
tors or complications during pregnancy or labour, women are referred to 
obstetrician-led care, where they are taken care of by nurses, hospital-based 
midwifes, obstetric residents and obstetricians or obstetric registrars. This makes 
the Netherlands a unique setting to study obstetric violence through a 
range of maternity care practices. 

Obstetric  violence  exists  in  both  midwifery  and  obstetric  care.  Since 
2020, the number of publications on obstetric violence in the Netherlands 
is increasing. Five studies are included in this report; one quantitative and four 
qualitative studies. There is one important activist organisation in the Nether-
lands that focuses on obstetric violence: the Birth movement (Geboortebeweg-
ing). On the basis of this case study report, five recommendations are made: 
to  make  decentralised  autonomous  midwifery  care  possible  to  give  pregnant 
people control over their care; to make sure a guideline on care outside of the 
normal guidelines is developed to ensure people’s freedom to design their own 
care plan; to address and tackle the problems of obstetric violence and obstetric 
racism at the same time; to teach all birth professionals extensively about ob-
stetric violence and obstetric racism; and to create awareness on multiple levels 
of the obstetric system. 

3.2 

Definitions and references

Obstetric  violence  (translated:  Obstetrisch  geweld)  is  not  a  common  term 
in the Dutch context. The Royal Dutch Organisation of Midwives (KNOV) and the 
Dutch Society for Obstetrics and Gynaecology (NVOG) both do not mention the 
term nor synonyms of the term within their official documents, statements, or 
guidelines. 

Before  2020,  scientific  articles  covering  Dutch  people’s  traumatic  birth  ex-
periences  had  already  acknowledged  the  existence  of  obstetric  violence. 
Factors such as a lack of informed consent, lack of communication and unilateral 
decision-making are reported. However, neither the term obstetric violence nor a 

26

 
3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

synonym was mentioned.122 Recent and forthcoming articles on the occurrence 
of obstetric violence in the Dutch context do mention the term or the synonym 
‘disrespect and abuse’ (D&A).123 

There are two important independent  foundations that use  the  term  ‘ob-
stetric violence’. The Birth Movement (Geboortebeweging) are the main ac-
tivists fighting for birth rights in the Netherlands and use the term as a regular 
part of their discourse to describe injustice in childbirth.124 They use the term on 
their website and on their active Facebook page. Furthermore, they use the term 
in their actions and they teach classes in midwifery and medical schools on ‘care 
outside of regular guidelines and respectful maternity care’, in which the term 
‘obstetric  violence’  is  also  mentioned.  In  2016,  the  Birth  Movement  initiated  a 
campaign in which women were asked to share their experiences with maternity 
care in the Netherlands on social media. This campaign is also known as #ros-
esrevolution or #breakthesilence, previously initiated in several other countries. 
The Dutch campaign evoked public and media attention, as a large number of 
women shared their stories.125 Another important foundation is the Foundation 
for  Birth  Trauma (Stichting Bevallingstrauma), which is the most well-known 
organisation on birth trauma in the Netherlands and has a long entry on obstetric 
violence as a cause of traumatic birth on their website.126 

The term ‘obstetric violence’ has also appeared in several media channels, 
for  instance  in  the  Dutch  newspaper  the  General  Daily  (Algemeen  Dagblad)127 
and on Dutch public radio channel 1 (NPO1).128 Brainwash, a well-known cultural 
platform, has an article on obstetric violence on their website and is making a 
short  informative  documentary  on  the  term  (forthcoming).129  The  website  VICE 
published  an  article  mentioning  the  term.130  The  midwifery  platform,  The  Wise 
Voice (Het Vroede geluid), has a ‘long read’ on obstetric violence and published 
an informative video on the term.131 The magazine, Baby on the Way (Baby op 
komst), for pregnant people made by midwives has a webpage on obstetric vi-
olence  on  their  website.132  The  magazine  for  professional  birth  workers,  Early 
(vakblad Vroeg), has an article on obstetric violence as well.133 However, there are 
also several media items in which clearly topics related to obstetric violence are 
discussed, but the term is not mentioned, for example an item of RTL news.134

122   Hollander et al. (2017); Fontein, et al. (2018a, 2018b).
123   van der Pijl et al. (2021, 2022); van der Waal (2021, 2022a, 2022b); van Nistelrooij & van der Waal 
(2019); van Hassel et al. (2023); van der Waal (forthcoming a, forthcoming b).

124   https://www.geboortebeweging.nl 

125  https://www.facebook.com/search/photos/?q=geboortebeweging&__tsid__=0.6421076819347953&__

epa__=SERP_TAB&__eps__=SERP_PHOTOS_TAB.

126   https://stichtingbevallingstrauma.nl/obstetrisch-geweld-2-0/.

127   https://www.ad.nl/gezin/geen-knip-geen-meting-geen-inwendig-onderzoek-nee-zeggen-tijdens-je-beval-

ling-mag~a16281ab/?referrer=https %3A %2F %2Fwww.google.com %2F.

128   https://open.spotify.com/episode/2lmwGTpRq68WHPgKE622Ny.

129   https://www.brainwash.nl/programmas/brainwash-zomerradio/seizoen-2022/rodante-van-der-waal.html.

130   https://www.vice.com/nl/article/gydv94/hoe-vrouwenrechten-grof-geschonden-worden-in-de-nederland-

se-verloskamers.

131   https://vimeo.com/640933816.

132   https://babyopkomst.nl/news/obstetrisch-geweld/.

133   https://www.vakbladvroeg.nl/omgaan-met-geweld-tijdens-de-bevalling/.

134   https://www.rtlnieuws.nl/lifestyle/artikel/5201166/genoeggewegen2020-vrouwen-delen-hun-bevalling-

strauma-ik-riep-hou-op-ik.

27

3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

Based on the personal experience of the authors in the professional context of 
primary  care  midwives  and  doulas,  the  term  obstetric  violence  is  more 
common and well-known than in the professional environment of obste-
trician-led  care.  The  discourse,  vocabularies  and  understanding  of  the 
process of birth and its cultural context remains quite distinct between the 
two. 

There has been discussion on the term in the Netherlands for two reasons. The 
first is the same as practically everywhere else: birth workers tend to react defen-
sively and the term is considered provocative. Therefore, some choose to stick 
with the phrasing of WHO: ‘disrespect and abuse’ or ‘mistreatment’.135 
The second one is more context-specific and has to do with the translation. In the 
Netherlands, the word ‘verloskunde’ is used as the more common word for ob-
stetrics, although a literal translation of obstetrics (‘obstetrie’) does exist. This is 
confusing, because ‘verloskundige’ is also the newer gender-neutral term for mid-
wife – ‘vroedvrouw’ is the traditional word. Since midwives still have a strong and 
leading position in the Netherlands, there are very few doctors who only special-
ise in obstetrics. Most specialised doctors involved in pregnancy and childbirth are 
gynaecologists, with obstetrics belonging to their specialisation. This is different 
than in most other countries. Since it is not a separate specialisation, ‘obstetrics’ 
is hence not a commonly used word in the Netherlands. Since the Dutch maternity 
care system is divided between primary care and secondary care, primary care is 
mostly characterised as ‘verloskundige zorg’ (midwifery care) and secondary care 
as ‘gynaecologische zorg’ (gynaecological care). Five years ago, there were hence 
discussions in activist circles if they should call obstetric violence ‘verloskundig 
geweld’ (midwifery violence), ‘gynaecologisch geweld’ (gynaecological violence), 
or  ‘obstetrisch  geweld’  (obstetric  violence).  Because  gynaecological  violence  is 
already indicative of another kind of violence and because ‘verloskundig geweld’ 
(midwifery violence) implies that it only happens within independent midwifery, 
while it actually happens less in independent midwifery.136 Therefore the activists 
from  the  birth  movement  stuck  to  the  term  obstetrisch  geweld  (obstetric  vio-
lence) – also to be understood better internationally.

The term ‘obstetric racism’ or ‘racism in maternity care’, an important 
counterpart of obstetric violence, has appeared in several media. In the 
renowned journal, Free Netherlands (Vrij Nederland), and on Dutch public radio 
channel 1, interviews with midwife Bahareh Goodarzi were recently published on 
obstetric racism and structural inequality in Dutch maternity care.137 Goodarzi’s 
academic  research  also  contributes  to  greater  awareness  of  inequity  in  Dutch 
maternity care, both professionally and publicly.138 Midwife Pia Qreb shared her 
experiences on the acclaimed feminist podcast platform, Sauce (Dipsaus), and in 

135   Please see See van der Waal et al. (2022b) for a more thorough discussion on this problem with the 

terminology. 

136   There is no data yet to support this claim. However, this is the experience of the first author of the case 

study, who was trained in both contexts, and this conclusion has come out of her PhD research, a qualitative 

study with 30 participants. A Dutch study does show that women who give birth at home in midwife-led care 

experience more respect, privacy, communication and autonomy during labour and birth (Van der Pijl et al., 

2021). Currently, analysis is being performed to investigate the occurrence of obstetric violence in midwife-led 
care and obstetrician-led care. Here, it is important to consider that in midwife-led care, labour and birth are 

more often uncomplicated compared to in obstetrician-led settings.

137   https://www.vn.nl/geboortezorg-gelijk/.

138   https://www.medischcontact.nl/nieuws/laatste-nieuws/artikel/ras-en-etniciteit-registreren-in-de-zorg-

een-precaire-kwestie.htm.

28

3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

the journal Lovel.139, 140

3.3 

Data collection and evidence on obstetric violence 

3.3.1  Empirical evidence 

Qualitative evidence 

Four distinct qualitative studies that specifically use the term ‘obstetric 
violence’  were  done  in  the  Netherlands,  all  in  recent  years:  a  qualitative 
content  analysis141  of  an  activist  campaign  on  obstetric  violence;  a  cross-cul-
tural thematic analysis between the Netherlands and South Africa on the effect 
of  obstetric  violence  on  student  midwives  and  doctors;142  a  thematic  analysis 
(conducted in 2020–2021) of 31 in-depth interviews and 12 focus groups with 
mothers, midwives, midwives in training and doulas on obstetric violence;143 and 
an auto-ethnography (conducted in 2021–2022) on the epistemic nature of ob-
stetric violence.144 

In  2020,  a  qualitative  content  analysis  was  performed  to  investigate  the 
stories  women  shared  in  the  #breakthesilence  campaign  of  the  Birth 
Movement (as described above).145 The study aimed to determine what types 
of  disrespect  and  abuse  were  described  in  the  stories,  based  on  the  existing 
typology of Bohren et al. (2015) and to gain a more detailed understanding of 
the experiences. In total, 438 stories were investigated. Situations of ineffective 
communication, loss of autonomy and lack of informed consent and confidenti-
ality were the most commonly mentioned. The more detailed analysis revealed 
five main themes: ‘Lack of informed consent’; ‘Not being taken seriously and 
not  being  listened  to’;  ‘lack  of  compassion’;  ‘the  use  of  force’;  and  ‘short  and 
long-term consequences’. These situations were often described in combination 
with feelings such as a lack of or losing control, fear, being objectified and being 
humiliated. ‘Left powerless’ was identified as the overarching theme: women felt 
that power was taken away from them, or they experienced difficulties maintain-
ing control due to situations that occurred.146

In 2020–2021, a cross-cultural thematic analysis was done on the effect of 
obstetric violence and obstetric racism in the training of midwives and 
doctors  in  the  Netherlands  and  South  Africa.  Students’  curricular  encounters 
in two colonially related geopolitical spaces, South Africa and the Netherlands, 
were  amplified  to  highlight  global  systemic  tendencies  that  push  students  to 
cross ethical, social and political boundaries in relation to the mother they are 
trained  to  care  for.  Obstetric  violence  was  understood  as  a  fundamental  part 
of students’ rite of passage to become professionals. It was asserted that the 
embedment of obstetric violence in their rite of passage ensures the reproduction 

139   https://www.dipsaus.org/exclusives-posts/2020/7/18/institutioneel-racisme-in-de-geboortezorg.

140   https://tijdschriftlover.nl/english/inequity_in_dutch_healthcare_a_series; https://tijdschriftlover.nl/english/
inequity_in_maternity_care; https://tijdschriftlover.nl/english/inequity_in_preventive_care. 
141   van der Pijl et al. (2020).
142   van der Waal et al. (2021).

143   van der Waal et al. (forthcoming b).

144   van Hassel et al. (2023).
145   van der Pijl et al. (2020).
146   van der Pijl et al. (2020).

29

3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

of the modern obstetric subject, the racialised mother and institutionalised vio-
lence worldwide. Drawing on Davis-Floyd’s definition of the rite of passage, the 
same characterisation of the three stages of the rite of passage were used. The 
following violent instances within the rite of passage were identified that 
eventually lead to the reproduction of obstetric violence: in the stage of 
separation: 1) emotional isolation; and 2) having to adapt the goals, norms and 
values of the obstetric institution that instrumentalise the mother; in the stage 
of transition: 3) establishing subjectivity through assertiveness, competition and 
learning at the cost of mothers; 4) colluding in explicit obstetric violence, obstetric 
racism  and  sexual  violence;  and  5)  traumatic  experiences;  and  in  the  stage  of 
integration: 6) complicity: balancing guilt with numbness; and 7) responsibility at 
the cost of mothers.147

In 2020 and 2021, a qualitative study on obstetric violence was conducted to 
get a better sense of the root causes of and ways of resistance to obstetric 
violence in the Netherlands based on the epistemic standpoints of those directly 
involved; 31 participants were included: 10 mothers, 11 midwives, 5 midwives in 
training and 5 doulas. Data was collected in three rounds: individual interviews, 
homogenous  focus  groups  and  heterogenous  focus  groups.  The  data  analysis 
was done through Thematic Analysis, informed by Care Ethics, Abolition Feminism 
and Critical Midwifery Studies. Two main themes were established. The first 
was ‘institutionalised separation’ with the subtheme’s ‘expropriation’, ‘carcerality’ 
and ‘violence’. Institutionalised separation was understood to be the separation 
of multiple relations of the pregnant person, i.e. with a partner, a community of 
care,  their  midwives  and  a  consequent  experience  of  isolation  and  loneliness. 
The  second  main  theme  indicated  the  strategy  of  the  participants  affected  by 
obstetric violence, hence also professionals, to resist it and was coined ‘under-
commoning childbirth’ with subthemes ‘fugitive planning’, ‘anarchic relationality’ 
and ‘abolition’. ‘Undercommoning’ means the formation of an underground com-
mons of knowledge, mutual aid and radical care. The aim of the second theme is 
to reconstitute or ‘heal’ the relationality that was broken through institutionalised 
obstetric violence and thus to resolve the experience of isolation.148 

In 2022, an auto-ethnographic study was done to investigate the epistemic 
component of obstetric violence. This is the first study on obstetric violence 
in the Netherlands that specifically centres epistemic injustice as a major part of 
obstetric violence. Through a narrative analysis of four auto-ethnographic 
experiences  with  birth  and  miscarriages  in  the  Netherlands,  four  forms 
of epistemic injustice in Dutch reproductive care were laid bare and analysed 
through  the  international  theoretical  literature  on  the  subject:  1)  hermeneutic 
injustice;  2)  testimonial  injustice;  3)  wilful  hermeneutic  ignorance;  and  4)  gas-
lighting.149 

Quantitative evidence 

One quantitative study on obstetric violence was conducted in the Neth-
erlands.150 In order to obtain more information on the prevalence, a survey study 
was performed in 2020 to investigate: (1) how often women experience disre-

147   van der Waal et al. (2021).

148   van der Waal et al. (forthcoming b).

149   van Hassel et al. (2023).

150   van der Pijl et al. (2022).

30

3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

spect and abuse during labour and birth in the Netherlands; (2) how frequently 
they  consider  such  experiences  upsetting;  (3)  which  respondent  characteristics 
are associated with those experiences of disrespect and abuse that are upsetting; 
and (4) the associations between upsetting experiences of disrespect and abuse 
and  women’s  overall  labour  and  birth  experiences.  The  survey  consisted  of  37 
questions divided over 7 categories based on existing literature and the local con-
text. The second part of the survey specifically focused on informed consent for 
different procedures during labour and birth (discussed below in Section 7.3.2). 
Over 13 000 women participated in the survey, of which 12 239 were suitable to 
be included in the data analysis. The results are reported in terms of the relevant 
aim of the study: 

(1)  How  often  do  women  experience  disrespect  and  abuse  during  labour 
and birth in the Netherlands?

54.4 % of respondents reported at least one form of disrespect and abuse. ‘Lack 
of  choices’  (39.8  %)  was  reported  most,  followed  by  ‘lack  of  communication’ 
(29.9 %), ‘lack of support’ (21.3 %) and ‘harsh or rough treatment/physical vio-
lence’ (21.1 %). The table below gives an overview of the prevalence per category. 

(2) How frequently do they consider such experiences upsetting?

36.3 % reported at least one form of upsetting disrespect and abuse. Wide var-
iation was found in how frequently certain types of disrespect and abuse were 
considered upsetting, ranging between 25 % and 100 % per situation. The table 
below gives an overview of how often different categories were referred to as 
‘upsetting’. 

Table 1: Experiences of disrespect and abuse during labour and birth 
per category 

Not experienced

Experienced

n (% of total)

Total 
experienced,
n (% of total)

Not upsetting,
n (% of 
experienced)

Upsetting,
n (% of 
experienced)

Emotional pressure

11 870 (97.0)

369 (3.0)

50 (13.6)

319 (86.4)

Unkindness/verbal 
abuse

Harsh or rough 
treatment/physical 
violence

10 941 (89.9)

1 226 (10.1)

193 (15.7)

1 033 (84.3)

9 648 (79.9)

2 429 (21.1)

872 (35.9)

1 557 (64.1)

Lack of communication

8 350 (70.1)

3 562 (29.9)

1 024 (28.7)

2 538 (71.3)

Lack of support

9 260 (78.7)

2 498 (21.3)

362 (14.5)

2 136 (85.5)

Lack of choices

6 957 (60.2)

4 602 (39.8)

2 355 (51.2)

2 247 (48.8)

Discrimination

11 426 (99.2)

94 (0.8)

11 (11.7)

83 (88.3)

Source: van der Pijl et al. 2022.

31

3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

(3)  Which  respondent  characteristics  (age,  ethnicity,  educational  level  and 
primiparity) are associated with those experiences of disrespect and abuse that 
are upsetting?

Primiparity and a migrant background were risk factors for experiencing upset-
ting disrespect and abuse in all seven categories. Higher age decreased the risk 
of  disrespect  and  abuse  in  the  categories  ‘Harsh  or  rough  treatment/physical 
violence’,  ‘lack  of  communication’  and  ‘lack  of  choices’.  Women  with  a  higher 
education level had a higher chance of experiencing a lack of choices.

(4) What is the association between upsetting experiences of disrespect and 
abuse and women’s overall labour and birth experiences?

In total, 79.1 % of respondents reported a positive or very positive experience, 
11.9 % a negative and 9 % a very negative or traumatic birth experience. Up-
setting  disrespect  and  abuse  was  found  to  have  a  strong  impact  on  the  over-
all  labour  and  birth  experience.  With  every  additional  category  of  experiencing 
upsetting disrespect and abuse, the number of (very) positive labour and birth 
experiences decreases and the number of very negative ones increases.

The groups of women most affected, whether different groups experience differ-
ent forms of obstetric violence and different prevalence rates

All the above studies indicate that marginalised people, mainly migrants, 
people of colour, people with a migration background and people with a 
language barrier suffer more often and more severe forms of obstetric 
violence. Apart from the cross-cultural study on obstetric violence and obstetric 
racism in students’ training,151 none has specifically focused on obstetric violence 
and the intersection with racism. The 2022 quantitative study determined that 
having a migration background is a risk factor for obstetric violence.152 A distinct 
form of obstetric violence, ‘obstetric racism’, is frequently reported by people of 
colour, mostly by Black people.153 Obstetric racism can be understood as being 
located at the intersection of what is commonly understood as obstetric violence 
and medical racism.154 The work of Bahareh Goodarzi and Pia Qreb (see Section 
7.2)  lays  bare  structural,  institutional,  obstetric  racism  in  the  Netherlands  and 
new  numbers  indicate  that  people  with  a  migration  background  suffer  higher 
numbers of maternal and neonatal mortality and morbidity – indicating severe 
diagnostic lapses and other forms of obstetric racism (see below for more infor-
mation). 

3.3.2  Relevant manifestations 

The quantitative study on obstetric violence in the Netherlands showed that the 
category ‘lack of choices’ (39.8 %) was reported by the highest share 
of women, followed by ‘lack of communication’ (29.9 %) and ‘lack of support’ 
(21.3 %) (see the table above).155 In terms of specific situations, ‘Not being free 
to decide the position to give birth in’ (lack of choices) was the situation indicated 
by the most women (25.3 %), followed by ‘feeling like necessary information was 

151   van der Waal et al. (2021).

152   van der Pijl et al. (2022).

153   van der Waal et al. (2021); van der Waal (forthcoming a, b).

154   Davis et al. (2022).

155   van der Pijl et al. (2022).

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3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

not provided’ (lack of communication, 20.9 %). 

The  qualitative  2020–2021  thematic  analysis  of  interviews  and  focus  groups 
with mothers, independent midwives, midwives in training and doulas reported 
the types of obstetric violence most often experienced as 1) unconsented 
and/or unwarranted and/or unwanted vaginal examinations; 2) epistemic 
injustice,  mainly  epistemic  manipulation  in  the  form  of  playing  the  dead 
baby card (a form of shroud waving where the risk to the baby’s life is exag-
gerated when a pregnant person does not consent to a procedure); 3) physical 
violence, consisting of interventions without consent; 4) penetrative violence, 
i.e. violence that is linked to, or reminiscent of, rape or sexual assault, such as 
(mostly listed) episiotomies, pelvic floor support (or ‘pelvic massage’) and vag-
inal  examinations;  5)  forced  interventions  that  are  indirectly  physical,  such 
as a transfer to the hospital without consent or knowledge of other options, or 
directed pushing against one’s will; forced interventions that are physical, such 
as CTG monitoring, oxytocin injection after birth, the baby having a foetal scalp 
electrode, breaking of the amniotic sac without knowledge, lying on one’s back; 
and 6) obstetric racism (see below for a description of obstetric racism in the 
Netherlands).156

The 2021 study on the effect of obstetric violence on students’ training reported 
the  types  of  obstetric  violence  most  often  experienced  as:  lack  of  informed 
consent,  specifically  regarding  students’  participation  in  the  care  for 
birth and forced interventions/physical abuse (mostly vaginal examinations, 
episiotomies and pelvic floor support), and verbal abuse (mostly racist and pater-
nalising remarks).157 

The analysis of the #breakthesilence campaign showed that in almost half the 
stories women report being ignored and not being taken seriously. For exam-
ple, women reported caregivers not talking to but about them while being in the 
room. A lack of compassion was also mentioned in half of the stories, mostly 
in situations where women expressed pain or exhaustion to the care providers. 
Lack of informed consent was also an important theme: in over a quarter of the 
stories, women reported at least one act taking place without their consent. 
In some cases, the act was only announced by the care providers, while in others, 
the act took place without any comment or consultation. In around a fifth of the 
stories, a form of use of force was described, mostly during the active stage of 
labour and in relation to interventions being carried out.158 

Lack  of  consultation  or  consent  is  a  reoccurring  subject  regarding  ob-
stetric violence in the Netherlands. The quantitative survey showed that 11.8 % 
of  the  respondents  reported  a  (medical)  intervention  being  performed  without 
clear permission in advance, while 3 % experienced a medical intervention that 
was continued despite requesting for it to be stopped.159 The second part of the 
quantitative  survey  specifically  focused  on  informed  consent,  investigating  10 
common  procedures  during  labour  and  birth,  asking  for  each  procedure  if  the 
respondents underwent the procedure, if they were asked for consent, if the in-
formation they received was sufficient and, if they did not give consent, whether 
they found this upsetting.160 

156   van der Waal (forthcoming b).
157   van der Waal et al. (2021).
158   van der Pijl et al. (2020).

159   van der Pijl et al. (2022).

160   van der Pijl et al. (forthcoming).

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The auto-ethnography on epistemic injustice reports hermeneutic and testi-
monial injustice, as well as gaslighting and wilful hermeneutic ignorance. Herme-
neutic injustice is when a pregnant person does not have the right knowl-
edge or discourse to understand and explain the obstetric violence being 
done to them. Testimonial injustice is when a pregnant person is not believed 
or not taken seriously with regards to the violence done to them. Gaslighting is 
when the knowledge of the pregnant person is doubted in such a way that it is 
insinuated that the pregnant person is crazy or a bad mother, until they start to 
doubt themselves. Wilful hermeneutic ignorance is when facts and options are 
wilfully kept from a pregnant person.161 

Timing of obstetric violence

The  qualitative  2020–2021  thematic  analysis  of  interviews  and  focus  groups 
with  mothers,  midwives,  midwives  in  training  and  doulas  shows  that  although 
the  most  severe  and  traumatic  forms  of  obstetric  violence  happen  during 
childbirth, such violence is almost never an isolated incident. The partic-
ipants have difficulty describing when obstetric violence begins and ends, as it 
often builds up during pregnancy – in authoritative discussion on care, epistemic 
injustice,  not  being  taken  seriously,  a  lack  of  choices  in  preparation  for  birth, 
etc.  –  to  ‘culminate’  during  labour  and  persist  post-partum.  162The  same  was 
found in the 2021 study on the effect of obstetric violence on students’ training, 
which found that the hierarchical, authoritative structure of the obstetric system 
in combination with many incidents of obstetric violence or disrespect eventually 
culminate into a more traumatic experience during childbirth.163 

With regards to epistemic injustice, obstetric violence seems to happen as 
much during as before or after labour. Examples from the auto-ethnographic 
study are an episiotomy without knowing during birth, lack of knowledge of other 
options of treatment during miscarriage, playing the dead baby card before birth 
and  not  believing  the  amount  of  pain  someone  is  in  after  miscarriage.  Almost 
all  the  stories  shared  in  the  #genoeggezwegen  campaign  covered  experiences 
during labour and birth or the post-partum period. A combination of situations 
(e.g.  a  moment  during  pregnancy  and  a  moment  during  labour  and  birth)  also 
occurred.164 

The quantitative study on obstetric violence covered situations during labour and 
birth, defined as from the onset of labour until one hour after the birth of 
the placenta. However, questions were also asked about information provision, 
which could be interpreted as receiving enough information about a certain topic 
related to labour and birth.165 

Obstetric racism 

There are seven dimensions (see the figure below) of obstetric racism: 1) di-
agnostic lapses; 2) neglect, dismissiveness or disrespect; 3) intentionally causing 
pain; 4) coercion; 5) ceremonies of degradation; 6) medical abuse; and 7) racial 

161   van Hassel (2023).
162   van der Waal et al. (forthcoming b).
163   van der Waal et al. (2021).

164   van der Pijl et al. (2021).

165   van der Pijl et al. (2022).

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reconnaissance.166 Obstetric racism contributes both to the frequency and severi-
ty of obstetric violence, and also affects birth outcomes. In the Netherlands, peo-
ple belonging to an ethnic minority have a significantly increased risk of perinatal 
mortality.167 All forms of obstetric racism are documented in the Netherlands. 

Figure 2: The seven dimensions of obstetric racism 

The cross-cultural study on obstetric violence in students’ training clearly shows 
that  people  of  colour  suffer  from  obstetric  violence  more  often  and  more  se-
verely, specifically in the form of obstetric racism.168 Regarding the dimensions 
of  obstetric  racism,  students  report  medical  abuse,  that  they  are  more  often 
allowed to practice on people of colour, that people of colour are less often asked 
for consent for internal vaginal examinations, and that they are not informed that 
the one who conducts the examination or procedure is a student. The study also 
reports  coercion,  mostly  overlapping  with  general  forms  of  obstetric  violence 
such as vaginal examinations without consent, but with the additional harmful 

166  Davis et al. (2022).
167   Achterberg et al. (2020).
168   van der Waal et al. (2021).

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aspect of a woman having a language barrier and hence not understanding what 
is happening.169 

The  qualitative  2020–2021  thematic  analysis  of  interviews  and  focus  groups 
with  mothers,  midwives,  midwives  in  training  and  doulas  reports  diagnostic 
lapses when it comes to Black women, in the form of a lack of knowledge about 
pregnant and birthing bodies apart from white people’s bodies and in the form 
of the determination of care plans based on racial bias (either due to personal 
prejudices  or  due  to  prejudices  embedded  in  protocols).  It  furthermore  reports 
coercion in the form of using medical instruments (such as bigger-sized needles 
and specula) when the pregnant woman specifically indicates she needs a small-
er size. It also reports neglect, dismissiveness and disrespect in situations 
where white midwives speak to the white at-home maternity nurse, rather than 
to the Afro-Dutch mother. Both Black mothers and care workers have a hypervig-
ilant attitude regarding their own care and the care of their clients, attesting to 
the efforts of racial reconnaissance.170 

Qreb’s  thesis  on  obstetric  racism  shows  discrimination  against  both  pregnant 
people and care workers of colour. Care workers of colour reported having been 
refused to be allowed to care for people and being treated with a negative atti-
tude by pregnant people. Pregnant people of colour were treated with assump-
tions,  prejudice,  systemic  discrimination,  negative  communication  and  getting 
inferior care.171 Qreb also shared her own experiences with obstetric racism on 
Twitter, which recounted172 care workers intentionally causing pain in the form 
of refusal of pain medication, prioritising white women above Black women in 
administering pain medication. Qreb also reports ceremonies of degradation 
in the form of the many racist and paternalising remarks.173 

In the study on #breakthesilence, 7 of the 438 stories were classified as discrim-
ination based on sociodemographic characteristics, which includes discrimination 
based  on  ethnicity,  race  or  religion.174  Although  this  number  is  low,  it  is  likely 
that  #breakthesilence  had  an  underrepresentation  of  people  with  a  migration 
background.175 

The quantitative study shows that 0.3 % of the respondents experienced discrim-
ination based on race, ethnicity, cultural background or language. Although this 
number is low, the study also had an underrepresentation of respondents with a 
migration background. The survey was available in English and Dutch, which made 
it  difficult  for  non-English  and  non-Dutch  speakers  to  participate.  Furthermore, 
when  compared  to  respondents  who  themselves  and  both  their  parents  were 
born in the Netherlands, it was seen that respondents with a migrant background 
had  higher  odds  of  experiencing  obstetric  violence  in  all  categories.  The  odds 
ratios for experiencing discrimination were 3.4 and 5.9. For all other categories, 
odds ratios ranged from 1.2 to 2.1 (a few of them not reaching significance).176

Manifestation  in  different  healthcare  settings  (i.e.  hospital,  clinics,  homebirth, 

169   van der Waal et al. (2021).
170   van der Waal et al. (forthcoming b).

171   Qreb (2021).
172   https://www.thebestsocial.media/nl/kraamzorg-racisme-twitter/ 
173   Qreb (2021).
174  Bohren et al. (2015).

175   van der Pijl et al. (2020).

176   van der Pijl et al. (2022).

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maternity home); different health professionals (i.e. midwives or gynaecologist), 
other.

The qualitative analysis of the #breakthesilence campaign showed that different 
care providers were mentioned in the stories.177 Midwives and obstetricians 
were mentioned by women in roughly equal numbers, indicating that wom-
en experience disrespect and abuse throughout the Dutch maternity care system. 
Based on our personal experience (the first author is trained in the Dutch obstet-
ric system) and on the basis of scientific indications, we believe, however, that 
obstetric violence is more severe and widespread in secondary obstet-
ric-led care, by midwives, nurses and doctors. 

The occurrence of disrespect and abuse per healthcare setting based on the data 
of  the  survey  study178  is  currently  being  investigated.  Results  are  expected  in 
2023. However, a study on experienced interaction between client and care pro-
vider during labour and birth in the Netherlands showed that women who give 
birth with a community midwife at home experience more optimal respect, com-
munication, autonomy and confidentiality in the interaction compared to women 
who  give  birth  at  the  hospital  with  a  (resident)  obstetrician  or  hospital-based 
midwife.179 

While  midwifery-led  care  is  internationally  often  seen  as  a  solution  to 
obstetric violence, we see in the Netherlands that this only counts for truly in-
dependent midwives who have the time to care for their clients and do not suffer 
under  the  same  institutionalisation  of  maternity  care  as  obstetric  institutions. 
Although  there  is  a  big  division  between  midwifery-led  and  obstetric-led  care 
and obstetric violence does occur less in the former care, there is again a major 
difference  between  truly  alternative  caseload  midwives  who  put  the  needs  of 
pregnant people first and bigger group practices that are part of the ‘regular care’ 
system in the Netherlands. 

In  the  qualitative  2020–2021  study,  most  mothers  and  midwives  had  ex-
periences  with  obstetric  violence  in  either  ‘regular’  midwifery  care  or 
in the hospital, after which they looked for more alternative midwives for their 
second pregnancy (even when these women did not consider themselves to be 
‘alternative’).180 Midwives regularly burn out in regular midwifery care practices 
and then start more alternative small-scale continuity of care practices.181 While 
midwifery-led  care  thus  certainly  works  to  prevent  the  occurrence  of 
obstetric violence, at this moment in time regular bigger midwifery practices 
are so integrated in the obstetric system that it does not fully protect against 
obstetric violence. It is therefore of the utmost importance that we design mid-
wifery-led  care  in  such  a  way  that  it  truly  adheres  to  a  midwifery  philosophy, 
namely one of relationality and continuity of care. If the time is not granted to 
truly be with women, the organisation is still too similar to obstetric care, with the 
only difference that it is carried out by midwives and the reproduction of obstetric 
violence will not be resisted. 

177   van der Pijl et al. (2020).

178   van der Pijl et al. (2020).

179   van der Pijl et al. (2021.)

180   van der Waal et al. (forthcoming b).

181   van der Waal et al. (forthcoming b).

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3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

3.4 

Root causes of obstetric violence 

Professionals 

It  is  important  to  note  that  occurrences  of  obstetric  violence  should  not 
be mistaken for the prevalence of their intent: on the basis of personal 
experience,  we  believe  that  in  the  overwhelming  majority  of  situations,  care 
providers do not intend to harm their patients. Although less researched, a root 
cause of obstetric violence is neoliberal capitalism that leads to a lack of capacity 
in midwifery and obstetrics, burned-out care workers and care workers who do 
not have the time and the support to process their own trauma. Care providers 
work hard under very stressful conditions to have positive health outcomes for 
both mother and baby. They are often not aware that their acts can be interpreted 
as upsetting and aim to do their best, in the cases of nurses and midwives, for 
little  pay  for  a  job  with  a  high  workload  involving  weekend,  holiday  and  night 
shifts with a high level of responsibility in a system that is suffering under lack of 
capacity and staffing problems. 

There  are  major  differences  in  the  perspectives  of  care  providers  and 
pregnant people. In relation to informed consent, for instance, a study on per-
forming  episiotomies  showed  that  care  providers  do  value  women’s  autonomy 
but  think  that  ultimately  the  decision  for  the  episiotomy  is  made  by  the  care 
provider.  Care  providers  see  the  trustful  relationship  between  them  and  their 
patient as the basis of informed consent and consent is mostly based on opting 
out. Care providers also say that informed consent in the second stage of labour 
can be difficult to obtain.182 

Currently, the perspectives and experiences of care providers in terms of obstetric 
violence is not researched enough and requires more attention. We understand 
obstetric violence to not be a problem of healthcare professionals as individu-
als but institutionalised violence which is facilitated by the obstetric system. At 
the same time, care providers generally decide when interventions are needed, 
leading to a lack of information for and involvement by women who give birth. 
Informed consent is still not a daily routine process and there is a lack of educa-
tion on the subject. Lack of awareness about obstetric violence, resistance again 
critical inquiry into it and the negative attitude of care providers working within 
the obstetric system remain major causes of obstetric violence. There is some 
improvement,  however,  with  increasing  emphasis  on  patient-centred  care  and 
shared decision-making.

The Dutch obstetric system

Within  Dutch  maternity  care,  gynaecologists  are  the  ultimate  authorities. 
Even though there is a strong system of autonomous midwifery care, their care 
if  still  often  defined  by  a  top-down  hierarchical  system  in  which  doctors 
ultimately  decide  when  someone  should  be  referred  to  the  hospital.  If 
a midwife does not refer someone to the hospital when the hospital thinks they 
should, midwives get criticised. As often with hierarchical cultures in maternity 
care, pregnant people find themselves at the bottom of the hierarchy. 

Overall, the system can be described as very risk averse. There is a difference 
of  opinion  on  which  professional  decides  on  risk  selection.  This  often  leads  to 

182   Seijmonsbergen-Schermers et al. (2021).

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3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

debate between doctors and midwives or a lack of clarity in various protocols. For 
pregnant people this can be very confusing: one moment they are in midwifery 
care and the next moment they have been taken over by obstetric care – and they 
have limited control over these referral policies, especially when they do not have 
much social privilege.183 Consequently, any pregnant person wishing to take more 
risks than is recommended in the official protocols is seen as a problem. 

The study into students’ experiences with obstetric violence shows that a root 
cause  of  obstetric  violence  is  its  own  reproduction  through  its  strong 
embedment in students’ training. If students train within a system that is vi-
olent and they can only graduate if they are complicit, then the violence logically 
reproduces  itself  through  the  violation  and  traumatisation  of  the  student.  It  is 
important to recognise that the damaging of students through obstetric violence 
is an essential part of the normalisation and hence the functioning of obstetric 
violence within the obstetric system-184

Underlying structures of institutionalised obstetric violence 

Research  in  the  Netherlands  uncovers  underlying  suppressive  structures 
within  the  obstetric  institution  which  are  similar  to  most  countries.  In  the 
Netherlands, sexism and misogyny are also underlying causes for obstetric vi-
olence, as has been advanced in international scholarship on obstetric violence 
and in the Netherlands most specifically in the auto-ethnography on epistemic 
injustice wherein epistemic injustice is understood as a gendered form of exclu-
sion and discrimination wherein women, especially mothers, are not considered 
rational.185

In the Netherlands, the ultimate justification of obstetric violence is the 
safety of the unborn child, whether it is really in danger or not, making the 
life of the child the prima causa, or first principle, of the system of obstetrics that 
becomes almost impossible to challenge: the primacy of the child over the moth-
er. This leads to the authoritative risk aversion and epistemic injustice towards 
mothers, most notably to the playing of the dead baby.186

Less researched underlying suppressive structures that give rise to obstetric vio-
lence within the obstetric institution have become manifest as well. The qualita-
tive 2020–2021 thematic analysis of interviews and focus groups with mothers, 
midwives, midwives in training and doulas, bring to the fore as root causes the 
‘carceral logic’ of the obstetric institution, consisting of the expropriation of preg-
nant people’s knowledge and bodily capacities, their isolation and traumatisation, 
the fear of punishment and authority located with care providers. For both moth-
ers, as well as midwives, doulas and midwives in training, the institution feels 
less like a safe space of care and more like a place wherein they get captured 
through discipline, governance, protocols and punishment. Care workers fear le-
gal repercussions as well as social ones. This forces them to be complicit to the 
institution and hence disciplines them. Consequently, the relationality within the 
institution is characterised by mothers as assumed ownership over their bodies, 
circumscription of agency, regulation of movement, violation of privacy, mistrust, 
neglect, lack of relationality, lack of trust and enmity. They describe that obstet-

183   Goodarzi (2018, 2020, 2022).
184   van der Waal et al. (2021).
185   van Hassel et al. (2023).

186   van der Waal et al. (forthcoming b); van Hassel et al. (2023). 

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3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

ric care circumscribes and confines them and punishes them for being difficult. 
People’s  bodies  are  ‘appropriated’  and  ‘handled’  through  being  put  on 
display without consent or being forced to comply, in a way that holds their 
bodies and birth captive.187 

The cross-cultural study on obstetric violence in students’ training lays bare the 
Dutch history of colonialism as a root cause of structural obstetric rac-
ism. It shows how obstetrics should be understood as a global modern institution 
through the linkage of two colonially related geopolitical places, namely South 
Africa  and  the  Netherlands.  In  both  places,  the  obstetric  professional  can  only 
constitute itself through engulfing the maternal body as its other, thereby repro-
ducing her racialisation and suppression. All remain, in different ways, excluded 
from the position of power and subjectivity within the obstetric institution, as all 
are appropriated into the obstetric subject that constitutes itself through othering 
the mother. The effect of colonialism is still visible in current day expressions of 
obstetric racism. 188 

3.5 

Consequences of obstetric violence 

In  the  #breakthesilence  stories,  short-  and  long-term  consequences  fol-
lowing  a  negative  experience  of  care  were  often  mentioned,  for  example: 
emotional trauma, difficulty in sleeping and being (too) scared to give birth again 
(tocophobia). The results of the quantitative study showed that 9 % of the wom-
en  who  give  birth  in  the  Netherlands  have  a  very  negative  or  traumatic  birth 
experience. 189This percentage is similar to 10 years ago: Stramrood et al. (2011) 
found that 9.1 % reported their labour and birth as traumatic. The quantitative 
study also showed that with every additional experienced category of upsetting 
disrespect and abuse, the number of (very) positive labour and birth experiences 
decreases  and  the  number  of  very  negative  ones  increases.  Stramrood  et  al. 
(2011) also looked into PTSD following labour and birth, which was found in 1.2 
% of the respondents. Although there is some evidence linking obstetric violence 
to the occurrence of PTSD following labour and birth,190 Dutch studies are lacking. 
Martinez-Vazquez et al. (2022) also found a link between obstetric violence and 
the occurrence of post-partum depression. We want to point out, however, that 
there can be negative consequences, such as a lack of trust, not being able to 
have a good birth experience, being betrayed and many other valid experiences 
that  are  not  captured  within  the  above  numbers  because  they  did  not  lead  to 
trauma.  The  2022  quantitative  study  found  that  36  %  of  people  giving  birth 
found something about the way they were treated during childbirth ‘upsetting’, 
hence important enough – keeping in mind the enormous amount of normalised 
obstetric violence – to upset them.191 

Having a negative experience with care can lead to a different organisation 
of care for the next pregnancy. A study on women’s motivations for choosing 
a high-risk birth setting against medical advice in the Netherlands was mostly 
due to previous or current negative experiences with care or conflicts in the birth 
plan. 192 This shows the resilience and creativity of pregnant people and midwives 

187   van der Waal forthcoming b).
188   van der Waal et al. 2021).

189   van der Pijl et al. (2022).
190   Martinez-Vazquez et al. (2021).
191   van der Pijl et al. (2022).

192   Hollander et al. (2017).

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3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

to organise emotionally safe care on the periphery of obstetric institutions. What 
is seen as ‘safe’ and ‘high risk’ differs from person to person and this differs es-
pecially between victims of obstetric violence and the obstetric institution. In the 
2020–2021 qualitative study, most mothers who were interviewed successfully 
organised  their  care  both  emotionally  and  physically  safe  outside  the  regular 
logistics and protocols of the obstetric system.193

We know that obstetric violence influences healthcare providers in the form of 
secondary trauma or secondary tocophobia. We need more research to know how 
widespread this is in the Netherlands. 

3.6 

Obstetric violence and Covid-19 

There is no direct evidence on obstetric violence and Covid-19 in the Neth-
erlands. However, there are some studies that looked into location of birth and 
women’s  birth  experiences  with  regard  to  the  Covid-19  pandemic  period.  One 
study  examined  women’s  birth  experiences  in  the  Netherlands  and  the  United 
Kingdom,  before  and  during  the  Covid-19  pandemic.  The  results  showed  that 
women  who  gave  birth  during  the  pandemic  reported  a  positive  birth 
experience  more  often  compared  to  women  giving  birth  pre-pandemic, 
despite the fact they reported less support and choice during labour and birth 
during  the  pandemic.  This  difference  in  experience  is  explained  by  the  lower 
expectations  of  women  during  the  Covid-19  pandemic.194  Another  study 
aimed to examine if the course of pregnancy and birth among low-risk pregnant 
women  in  the  Netherlands  changed  during  the  Covid-19  pandemic  compared 
to pre-pandemic. The results showed that during the Covid-19 pandemic, more 
women desired and had a home birth.195 Finally, there are indications that obstet-
ric racism increased during Covid-19. Midwife Pia Qreb reported remarks like ‘if 
our own people cannot have an extra person present during labour, others most 
certainly cannot’.196 

3.7 

Achievements and challenges

Since  2020,  much  progress  has  been  made  on  data  collection  on  ob-
stetric violence. Due to the two PhD-studies dedicated to the topic, extensive 
data  was  collected.  It  is  important  that  both  quantitative  and  qualitative  data 
are collected. When only quantitative data is available, then it remains difficult 
to understand the exact workings, experiences and system logics that make up 
obstetric violence. When only qualitative data is collected, though, we have no 
idea of the scope of the problem. With both types of data collected, we have now 
made a start in the Netherlands. It is only a start though – the perspective of 
many involved groups is still lacking, for instance. 

We  do  not  have  enough  research  on  the  intersection  of  obstetric  vio-
lence and obstetric racism. And marginalised groups, both in terms of groups 
with migration backgrounds, as well as groups with a diverse gender identity, are 
under-represented in both the quantitative and qualitative studies done so far. 
Currently, there is limited data on the experience of care providers with 
obstetric violence. The 2020–2021 study does take into account the perspec-

193   van der Waal (forthcoming b).

194   Van den Berg (2022).
195   Verhoeven et al. (2022).
196   https://www.thebestsocial.media/nl/kraamzorg-racisme-twitter/ 

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tives of midwives and doulas. 197However, there are no studies yet on midwives, 
doctors  and  nurses  working  in  obstetric-led  care.  It  is  essential  to  obtain  their 
perspectives in order to effectively understand care providers’ perspectives and 
improve obstetric-led maternity care. Another important under-researched per-
spective  is  that  of  birth  companions:  persons  supporting  pregnant  people  in 
labour. Most often this is the partner, but this could also be a family member or a 
friend. Currently, their perspectives in terms of negative experiences with 
care and trauma is under-researched. Birth companions have an essential 
role during labour and birth and their perspectives can provide valuable insight 
into how the birth environment is organised and what ways it can be improved. 
The  only  study  that  takes  doulas  into  account  is  the  2020–2021  qualitative 
study.198 

The quantitative results presented in this case study are not based on direct 
observations  of  obstetric  violence,  but  are  all  from  women’s  perspectives.  We 
have to acknowledge that objective measurement of the issue is difficult. 
Both  the  normalisation  of  obstetric  violence  and  subjective  interpretation  can 
lead  to  under-representation  and  overrepresentation  of  the  problem.  Also,  we 
have to acknowledge that in surveys, some women might be more prone to 
participate compared to others. To overcome this challenge, the recruitment 
was specifically aimed on various birth experiences, without emphasis on neg-
ative experiences or obstetric violence. Still, when measuring obstetric violence, 
the characteristics of the study population must be taken into account.199 

One of the most significant recurring challenges is the need to recognise re-
search outcomes in clinical practice and how to translate them to active 
changes in the medical setting. We already know enough to be able to say 
that obstetric care is not physically, emotionally and psychologically safe enough 
for people giving birth. In a rich country like the Netherlands, the quality of care 
should be higher. There is also enough knowledge to know how we must change 
the system: the focus should be on small-scale relational continuity of care. It is 
one thing to collect data and draw consequences and another thing to authenti-
cally change a system of care. 

197   van der Waal et al. (2022).

198   van der Waal et al. (forthcoming b).

199   van der Pijl et al. (2022).

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3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

3.8 

Relevant initiatives and their impact 

3.8.1 

Initiatives leading to political action

Relevance of the topic in political and institutional debate 

There  is  political  recognition  of  obstetric  violence.  After  the  first  Dutch 
#breakthesilence campaign in 2016, the Birth Movement created a report in-
cluding all the stories that were shared and asking for more attention to the bodily 
integrity of pregnant women and their right to informed consent. They submitted 
the report to the Ministry of Health, Welfare and Sport in February 2017, who 
responded by letter in April 2017, acknowledging the experiences and stating that 
the patient should be central to and involved in decision-making. However, it was 
also mentioned that while the advisory professionals acknowledge the problems, 
they do not believe this is a large-scale problem. Moreover, they argued by law 
protects all patients, the organisation of maternity care is changing and different 
parties are working on this. Therefore, the ministry believes that there are enough 
efforts to improve the position of pregnant people.200 

To our knowledge, there is no  institutional  recognition  of  the  problem  of 
obstetric violence in the Netherlands. It is not mentioned in any guidelines, 
policy documents or vision or mission statements of institutions or or-
ganisations  of  doctors  or  midwives.  There  is  a  guideline  on  maternity 
care outside the system,201 which provides guidance when pregnant women 
reject  recommended  care.  The  guideline  states  that  in  these  situations,  atten-
tion and respect for the wishes of the patient is important, without judgement. 
This is  challenging and requires advanced communicative skills. The goal is to 
inform the pregnant women as much as possible and make sure they understood 
the information and the available alternatives. The final decision belongs to the 
pregnant woman. Research shows that the decision to reject recommended care 
is  often  due  to  a  negative  experience  with  care  during  the  current  or  previous 
pregnancy.202  Since  the  Dutch  Society  for  Obstetrics  and  Gynaecology  (NVOG) 
and  the  Royal  Dutch  Organisation  of  Midwives  (KNOV)  created  this  guideline 
on how to care for people who wish to go outside of the regular protocol, it has 
become an important tool to resist obstetric violence, as it became eas-
ier for pregnant people to arrange care outside of clinical guidelines.203 
It has become more normalised that people have different wishes. Proof of this 
improvement is that a requisite for job applications for new midwives in one of 
the biggest hospitals in Amsterdam is that they ‘must like to care for people who 
wish to go outside of guidelines’. This was unimaginable a few years ago.204

200   https://zoek.officielebekendmakingen.nl/kst-31476-20.html.

201   https://www.nvog.nl/wp-content/uploads/2018/02/Leidraad-Verloskundige-zorg-buiten-richtlij-

nen-1.0-30-11-2015.pdf.

202   Hollander et al. (2017).

203   https://www.knov.nl/zoeken/document?documentRegistrationId=11862017.

204   https://www.werkenbijolvg.nl/vacatures/physician-assistant-klinisch-verloskundige-60801.html.

43

3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

Degree of recognition of the topic by healthcare providers

To our knowledge, except for some trainings and masterclasses (see below), 
there are, no official or institutional measures implemented to facilitate 
health personnel to understand the relevance of the topic and to under-
stand roots and manifestations and to prevent obstetric violence.

Degree of recognition of the topic by the general public and women 

In general, public awareness of the topic is low. Pregnant people are more 
and more aware of the need for respectful care and the risk of overmedical-
isation,  but  not  specifically  of  obstetric  violence.  The  awareness  that  is  there 
has not been raised by any institution. It has been raised by scholars, activists, 
mothers, midwives and doulas, and most effectively by the Birth Movement (Ge-
boortebeweging). The #breakthesilence (#GenoegGezwegen) campaign continues 
and receives much media attention. For a few years now, this has been coupled 
with the action #TakeResponsibility (#HandInEigenBoezem), wherein healthcare 
workers confess the obstetric violence they are responsible for or complicit in. 

After the first #breakthesilence campaign in 2016, the Birth Movement repeated 
the same campaign four years later, in 2020. In 2021, they did a variant of this 
action. This time, the Birth Movement asked women to send a message about 
their negative experiences to their care provider who was involved at the time. 
There were two types of cards: the first one was anonymous; women could share 
their story by writing it on a card and sending it to the care provider. The second 
card said, ‘Let’s Talk’, inviting the care provider to talk about the experience with 
the sender of the card and/or with other care providers. Several media channels 
reported  about  the  campaign.205,  206  The  campaign  was  met  with  much  resist-
ance from healthcare workers including those who are generally sympathetic to 
#breakthesilence as it was perceived as an individual attack on (often overbur-
dened) healthcare workers, rather than fighting obstetric violence as a systemic 
problem. The Dutch Society for Obstetrics and Gynaecology (NVOG) reacted 
with an official response, stating that they acknowledge women’s experience, 
but doubted that sending an anonymous card is a constructive solution to 
the problem. The Royal Dutch Organisation of Midwives (KNOV) support-
ed  the  campaign  and  motivated  their  members  to  participate.  In  their 
response, they mentioned obstetric violence as a worldwide phenomenon.207 In 
2022,  another  action  of  the  Birth  Movement  was  to  analyse  paternalistic,  au-
thoritative and incorrect statements on the websites of hospitals and midwifery 
practices. This action was effective in that most organisations who were publicly 
critiqued for their use of language agreed to rewrite their content. 

During Covid-19, the midwife Margot van Dijk did a similar action together with 
the Birth Movement to protest the refusal of a third person, mostly the doula, 
during labour: #StandUpforWomen (#Staopvoorvrouwen). The action was effec-
tive in that it reached a lot of media and some hospitals and midwifery practices 
loosened their policies afterwards. There have been other small initiatives to 
raise  awareness  and  there  are  more  and  more  stakeholders  who  are 

205   https://www.nu.nl/kind-gezin/6170027/geboortebeweging-roept-op-stuur-de-zorgverlen-

er-een-kaart-na-bevaltrauma.html.

206   https://www.rtlnieuws.nl/nieuws/nederland/artikel/5271337/geboortebeweging-bevalling-trauma-ervar-

ing-ziekenhuis.

207  https://www.knov.nl/actueel/nieuws/nieuwsbericht?newsitemid=45154304.

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3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

addressing  pregnant  people’s  rights  in  childbirth  and  thereby  resisting  the 
epistemic injustice in the medical system. 

3.8.2 

Initiatives to combat obstetric violence

Relevant initiatives to address the topic

Apart from the usual ways institutions facilitate formal complaints, there are no 
specific ways to file a complaint about obstetric violence. The Netherlands 
does not have an Observatory or similar body. However, the topic has been 
addressed in various ways, including by the Birth Movement as described previ-
ously. This has proven effective in the sense that they reach thousands of people 
with their Facebook page and are considered a steady source of resistance (and 
often regarded as a threat) by the medical establishment. Most people working in 
obstetrics know what the Birth Movement is and what they stand for. 

Relevant initiatives to involve and train health professionals 

There  are  several  trainings  and  school  programmes  organised  by  mid-
wives that use the term. The training centre, the Northern light (Noorderzicht), 
of Rebekka Visser has a day-long training called ‘obstetric violence’.208 The mas-
terclass programme, Ask the Midwife (Vraag de vroedvrouw), of Margot van Dijk 
has one masterclass devoted to obstetric violence.209 The training programme, 
Radical  Birthwork  (Radicaal  geboortewerk),  by  Madyasa  Vijber,  has  one  out  of 
six days devoted to obstetric violence and another day on obstetric racism. The 
2022 Humanising Birth Summer School, organised by the University for Human-
istic Studies, included many lectures on obstetric violence.210 Radical Birthwork, 
Ask the Midwife and the Humanising Childbirth Summer School have full days 
or masterclasses dedicated to the subject of obstetric racism, along with their 
attention to obstetric violence. 

There are also workshops and trainings that are not specifically about ob-
stetric violence, but that will make healthcare professionals more sensi-
tive to boundaries and respect, such as the Trauma-Informed Care workshop 
for healthcare professionals by Joyce Hoek Paula from the Bia Doula training, and 
Give Birth Better (Beval Beter) from gynaecologist Claire Stramrood.211
In terms of education for maternity care providers working in both mid-
wife-led care and obstetrician-led care, it is unknown to what extent ob-
stetric violence is embedded in the curriculum, though it is likely to be very 
little. The Birth Movement provides lessons on respectful care and care outside the 
guidelines one to two times a year in Amsterdam and Groningen. In Rotterdam, 
there was one class taught about obstetric violence this year by the first author of 
this case study to students who had never heard of the term within their studies. 
Due to the increasing attention to the subject, it is likely the topic will receive an in-
creasing amount of attention in the future. It is important that each different edu-
cation system focus on this topic, as every care provider that is linked to maternity 
care should acknowledge the problems that could arise from obstetric violence.

208   http://noorderzicht.com.

209   https://vraagdevroedvrouw.nl/masterclass-geboortezorg/.

210   https://rodantevanderwaal.com/summer-school-2022/.

211   https://bevalbeter.nl/zorgverleners/ 

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3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

Relevant initiatives to support women 

The Birth  Movement  has  a  24/7  phone  service  that  will  help  labouring 
people in need. They have a network of midwives throughout the country who 
can support pregnant people or take over their care. Both the Birth Movement and 
the Clara Wichmann Foundation support and help victims who want to make legal 
complaints or go to court. 

Foundation Birth Trauma (Stichting Bevallingstrauma) supports people 
who have had a traumatic birth experience. They have a network of spe-
cialised psychologists and psychotherapists. In recent years, there are also many 
independent midwives who have specialised in traumatic birth experiences. We 
are not aware of any other formal support systems.

There are many informal ways to get help and who will offer help though 
and  the  Birth  Movement  as  well  as  the  network  of  Collaborative  Mid-
wives (Samenwerkende vroedvrouwen) are the places to enter these networks. 
If someone posts a message on the Birth Movement Facebook page or calls and 
asks for help, they will be supported. There is a vast not very visible network of 
doulas,  mothers  and  midwives  in  the  Netherlands  who  are  committed  to  help 
pregnant and labouring people get the care they need either during pregnancy, 
after a traumatic experience, or before getting pregnant again. 212

Relevant initiatives to deconstruct general assumptions on childbirth

In addition to the initiatives described above, Concerning Maternity, an academic 
research network organised by the Care Ethics department of the Uni-
versity  for  Humanistic  Studies,  is  dedicated  to  deconstructing  the  un-
derlying structural causes of obstetric violence and dominant ideologies 
of  motherhood. The Wise Voice (Het Vroede geluid) is a political platform on 
midwifery  with  podcasts,  interviews  and  articles  critical  of  obstetric  care  as  it 
relates to gender, trans masculinity, capitalism, obstetric violence, exclusion and 
discrimination, inclusivity and diversity. Ask the Midwife (Vraag de vroedvrouw) 
also has articles and masterclasses aiming to deconstruct general assumptions 
about  childbirth,  both  with  regards  to  childbirth  physiology  and  pathology,  as 
well as with regards to the culture. Regarding obstetric racism, there is a working 
group on the subject at the midwifery academy Amsterdam, led by Bahareh Goo-
darzi. Goodarzi also created a working group on the subject of Diversity, Inclusion 
& Anti-Discrimination at the Royal Organisation for Midwives (KNOV). 

212   van der Waal 2022 (forthcoming b).

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3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

3.9 

Conclusions and recommendations

Make decentralised, autonomous midwifery care possible to give pregnant people 
control over their care

One of the most important lessons from the Netherlands is with regards to mid-
wifery. While midwifery-led care is not always free of obstetric violence, 
its most important contribution to the resistance against obstetric vi-
olence  is  that  it  provides  pregnant  people  with  a  whole,  autonomous  and  di-
verse  care  system  outside  of  the  institution  of  obstetrics.  Pregnant  people  in 
the Netherlands can hence (if they have the knowledge and capacity) relatively 
easily design and be in charge of the care they want. There are many autono-
mous independent caseload midwives for instance, that can provide the physi-
cally and emotionally safe and accessible, relational continuity of care needed 
for the humanisation of birth. The existence of autonomous midwifery care 
and homebirth gives pregnant people many options for how they want 
to give birth and gives them almost full control over with whom they want 
to give birth. As such, it gives them the possibility to practise resistance against 
obstetric violence themselves, rather leave them dependent on the level of re-
spectful maternity care the institution is able to facilitate. It gives them, in other 
words, a safe way out. 

Our  recommendation  would  be  to  invest  in  autonomous  midwifery.  Mid-
wifery that has enough time to give relational continuity of care does not have 
the  problem  of  obstetric  violence  in  the  way  that  obstetric  institutions  do.  By 
investing in autonomous midwifery, we lessen the power of the obstetric in-
stitution and our dependency on it. Also, it is an existing solution to the problem 
that  keeps  on  being  overlooked.  In  most  European  countries,  autonomous 
independent midwifery care still exists, even when they are not supported 
by  the  state  or  the  obstetric  system.  These  midwives  already  provide  the 
respectful care that we are fighting for when struggling against obstetric vio-
lence outside of the normal logistics and guidelines. The European Commission 
could, in setting up guidelines to prevent and decrease obstetric violence, strongly 
support and invest in the existence and proliferation of independent community 
midwifery-led care. Its focus must be on supporting and investing in existing care 
by autonomous midwives and make sure that they can practise safely and that 
their field can expand. 

However, to date almost all European countries have moved in the oppo-
site direction and true midwifery care, i.e. midwifery that has the freedom to 
work according to the midwifery philosophy of humane, individualised, relational 
continuity of care, has become more and more rare. Even in the Netherlands, the 
last country in Europe with a strong independent midwifery system, the govern-
ment is moving towards the centralisation and dismantlement of the independ-
ence of midwives, rather than investing in small-scale community care. Our most 
important recommendation would hence be to advance the decentralisation of 
obstetric care into community midwifery-led maternity care that is supported and 
not dominated by obstetrics as much as possible.

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3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

Create awareness on multiple levels

However,  not  all  pregnant  people  are  under  midwife-led  care.  The  ma-
jority of people gives birth in obstetrician-led care (especially primipara). 
Therefore, it is important that efforts to prevent obstetric violence are initiated 
throughout maternity care systems, as well as to create awareness among all 
types  of  maternity  care  providers  on  the  perspectives  of  pregnant  people  and 
their bodily autonomy and rights when receiving care in pregnancy and during 
childbirth. Furthermore, we must facilitate midwifery values, such as continuity 
of  care  and  relationality,  within  obstetric  settings.  Within  the  hospital,  au-
thoritative structures should be opposed and a safe and equal atmos-
phere between pregnant people, nurses, midwives and doctors must be 
facilitated. There must be attention to the workload and mental health 
of  professionals  working  within  the  hospital.  Teams  should  be  as  small-
scale, equal and respectful as possible. If we humanise working conditions, we 
humanise birth. Furthermore, the antenatal period must be used better to build 
relations of trust and in order to provide pregnant people with more information 
and exchange information on personal values and preferences. 

Informed consent is an essential way of creating awareness about the 
problem of obstetric violence because it is inextricably related, thus pro-
voking discussions and critical reflection. In medical settings, informed con-
sent requires urgent attention, as negative experiences with care often includes 
situations in which acts are performed without informing pregnant people, or acts 
are performed even they have been refused. 

Make sure a guideline on care outside of the normal guidelines is developed to 
ensure people’s freedom to design their own care plan

One of the most successful initiatives to help victims of obstetric vio-
lence has been the guideline for working outside of care protocols. This 
has given people who have experienced obstetric violence the possibility to re-
ceive the care they need more easily. This can play an important role in tackling 
obstetric violence indirectly. We have seen that the existence of a guideline on 
care outside of guidelines has a positive effect on multiple levels. It gives pro-
fessionals reassurance that it is in fact possible to go outside of guidelines and 
gives  them  clear  steps  on  how  to  do  it.  This  lessens  their  fear  of  malpractice 
related to their fear of punishment and disciplinary actions.213 The guideline also 
validates pregnant people’s request for such care and hence gives them back the 
autonomy to design their own care and get back some control, which is of the 
highest importance for victims of obstetric violence. Finally, an official guideline 
on this matter provokes discussions about obstetric violence, informed 
consent and the value of guidelines in general. As such, it is a good way 
to discuss these topics within the maternity care system more broadly. 

213   van der Waal et al. (forthcoming b).

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3 THE NETHERLANDS by Rodante van der Waal and Marit van der Pijl

Address and tackle the problems of obstetric violence and obstetric racism at the 
same time 

Another lesson from the Netherlands is that the problems  of  obstetric  vio-
lence and obstetric racism have recently been addressed as equally se-
rious, connected problems in various trainings and working groups. In addition 
to obstetric violence, the Global North knows that another detrimental problem 
in obstetric care is obstetric racism. The issue of obstetric violence must be dealt 
with intersectionally, namely as always refracted through the problem of obstet-
ric racism. Maternal and neonatal mortality and  morbidity of people of 
colour and refugees is significantly higher than that of white people in 
Europe in all countries with data. If we focus merely on solving the issue 
of obstetric violence, we risk implementing reforms that will only be beneficial 
for people who are already receiving the best forms of care that we have to offer. 
Only when we deeply understand that violent structures such as classism, racism, 
misogyny and Islamophobia are intertwined within the obstetric institution, and 
all contribute to obstetric violence, we will be able to truly tackle the problem, 
rather than cover it up. 

Teach  all  birth  professionals  extensively  about  obstetric  violence  and  obstetric 
racism

Make sure that the topics of both obstetric violence and obstetric rac-
ism  are  an  essential  part  of  any  professional  training  to  work  in  the 
obstetric  system.  This  is  crucial  for  raising  a  new  generation  of  more 
critical and self-reflective professionals, but also for the professionals who 
themselves struggle over the presence and their forced complicity with obstetric 
violence  in  their  trainings.  As  long  as  we  are  sending  students  into  a  training 
field that we know is violent, we have an ethical obligation to teach them about 
obstetric violence and prepare them. Students furthermore need a structure 
of  confidential  support  to  speak  about,  and  professionally  deal  with, 
obstetric violence they have encountered or were pressured to participate in 
during their internships. 

49

4 SLOVAKIA by Barbora Holubová

4  SLOVAKIA  

by Barbora Holubová

4.1 

Executive summary

Obstetric  violence  is  a  specific  form  of  violence  against  women.  Conducted  by 
obstetric care providers on the body and reproductive processes of the woman, 
it is characterised by dehumanised assistance, abuse of interventionist actions, 
medicalisation and reversion of the process from natural to pathological.214 The 
recognition of women’s suffering related to childbirth and reproductive 
and sexual health is, however, not straightforward and requires targeted ini-
tiatives exposing this kind of violence. In Slovakia, the topic of obstetric violence 
has appeared in two parallel streams. One presents the forced sterilisation 
of Roma women and their long-term fight for justice from 2003 until now. The 
second stream relates to violent practices during giving birth and the con-
tinual recognition of obstetric violence as a systemic failure in the last decade.

The aim of the case study is to present relevant manifestations, roots, 
prevalence and groups of women most affected by obstetric violence in 
Slovakia based on available data. An additional aim is to describe the level of po-
litical and social recognition and effective measures that have been implemented 
in the country and which have raised awareness among the general public, the 
health sector and politicians. The report also presents measures with the poten-
tial to reduce the prevalence of obstetric violence.

Despite  the  lack  of  an  overall  legal  framework  for  obstetric  violence  in 
Slovakia, non-governmental organisations (NGOs) have used a human rights 
framework to address obstetric violence. Slovakia is also a good example 
of the tremendous importance of human rights organisations in countries 
where  the  control  and  enforcement  authorities  are  not  sufficient  and 
have a lack of capacity to address obstetric violence. The role of visual arts, 
for example, documentaries exposing obstetric violence, are a good practice to 
promote discussion and open ways for improvement. 

The forced sterilisation of Roma women and their long-term struggle for 
justice point to the relevance of having a dedicated advocacy organisa-
tion who have knowledge of international legal mechanisms to appeal to where 
the national legal system fails.

Slovakia is also a good example of how to raise awareness of obstetric 
violence through the implementation of independent monitoring based on 
women’s experiences with obstetric violence and by creating an independent net-
work of obstetric violence experts. Gradual and continuous pressure from NGOs 
has resulted in the engagement of state human rights monitoring institutions on 
the topic. Pointing out the systematic violation of women’s human rights during 

214   Molla (2022).

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4 SLOVAKIA by Barbora Holubová

childbirth has led to the first measures to prevent obstetric violence in Slovakia.

The main findings of this case study are as follows:

•  Visual artists and independent female filmmakers have contributed 
to  increase  public  awareness  and  bottom-up  women’s  engagement  in 
obstetric violence.

•  While a comprehensive definition of and legislation on obstetric vio-
lence are missing in Slovakia, some forms and aspects of obstetric violence 
are protected or sanctioned within selected acts.

•  Slovakia lacks valid population-based prevalence data on obstetric vio-
lence. Quantitative data on the prevalence of obstetric violence is available 
in a non-systemic way and based on non-randomised samples.

•  Numerous testimonies of affected women have revealed the multiple 
manifestations of obstetric violence, either in prenatal or postnatal care or 
during giving birth.

•  Several studies have revealed the level of discrimination in obstetric 
care  services,  the  forced  and  violent  sterilisation  of  Roma  women, 
and physical and verbal attacks and racial discrimination in the provision of 
healthcare.  Roma  women  receive  insults  from  doctors  and  nurses  and  are 
beaten, attacked, humiliated and neglected.

•  Forced  surgical  sterilisation  and  forced  castration  are  related  to 
people undergoing gender transition. Transgender people are a hard-hit 
group due to violations of their sexual rights, including forced surgical sterili-
sation due to Christian ideology and gendered stereotypes. 

•  Slovakia  is  among  the  European  countries  with  the  highest  number  of 
caesarean sections and episiotomy is a routine procedure often without 
medical indication.

•  The  root  causes  of  obstetric  violence  are  structural  gender-based 
discrimination,  sexism  and  power  imbalance.  The  objectification  of 
women and patients in the health system results in inhuman care provision. 

•  Racism against the Roma population translates to a discriminatory 

approach to Roma women in obstetrics. 

•  The setting of obstetrics health systems is based on the patriarchal 

and hierarchal relations between obstetricians and midwives.

•  The  Covid-19  pandemic  has  had  a  significant  impact  on  childbirth 
since 2020. It has shown that even slow progress can be stopped or reversed.

•  The long history of forced sterilisation illustrates the slow and gradual 

recognition of obstetric violence in Slovakia.

•  The  Ministry  of  Health  of  the  Slovak  Republic  is  implementing  two 
standard procedures to unify and improve the provision of health-
care during pregnancy and childbirth, which could prevent obstetric 
violence in the future. 

51

4 SLOVAKIA by Barbora Holubová

4.2 

Introduction

The  topic  of  obstetric  violence  appeared  in  Slovakia  in  two  parallel 
streams. The first stream presented cases of forced sterilisation of Roma wom-
en during communism before the political change in 1989, which led to a change 
in legislation, a judgment of the EU Court of Human Rights and an official apology 
from the Slovak Republic. The second stream renders the disproportionate and 
violent practices during the births, exposed by female filmmakers and women’s 
NGOs since 2016. The activities led to partial improvements; however, they are 
in the shadow of harmful or disrespectful obstetric practices. Both streams con-
verge and frame obstetric violence as a violation of women’s human rights, dis-
crimination and a violation of the right to adequate healthcare. 

An  important  characteristic  of  the  development  of  the  topic  in  Slovakia  is  the 
gradual  expansion  of  actors  and  stakeholders  involved  in  monitoring 
and advocacy for the elimination of obstetric violence. Although at the begin-
ning of the development of the topic, NGOs were exclusively involved, gradually 
the topic was adopted by public institutes for the protection of human rights. Lat-
er, international organisations also expressed support and demanded corrections.

Another inherent feature of the Slovak case is the role of visual art in initi-
ating  the  public  discussion on obstetric violence. Documentaries created by 
independent female filmmakers and seen by thousands in Slovakia pictured how 
babies were born in maternity hospitals, how doctors dealt uncooperative moth-
ers with a slap, how the medical staff treated women without respect, dignity and 
privacy and how the women left the maternity wards with trauma. The documen-
taries  contributed  significantly  to  the  state  of  obstetrics  in  Slovakia  beginning 
to be discussed throughout society. It was no longer just a topic of women on 
internet  forums  or  women’s  rights  activists  but  a  problem  concerning  children 
themselves, families and health professionals.

The forced sterilisation of Roma women and their long-term struggle for justice 
point to the relevance of having a dedicated advocacy organisation who 
have knowledge of international legal mechanisms to appeal to where the 
national legal system fails.

Slovakia is also a good example of the process of how to raise awareness of 
obstetric violence using the following strategies:

• 

• 

• 

• 

• 

Implementation of independent monitoring of women’s experiences with ob-
stetric violence

Creation of a network of obstetric violence experts

Engaging state human rights monitoring institutions

Pointing out the systematic violation of women’s human rights during child-
birth

Creating consistent and gradual pressure on the responsible state institutions 
for correction.

52

4 SLOVAKIA by Barbora Holubová

4.3 

Definitions and references

While a comprehensive definition of and legislation on obstetric violence are miss-
ing in Slovakia, some forms and aspects of obstetric violence are protected 
or sanctioned within selected acts. Particular crimes of obstetric violence and 
obligations to follow specific principles in order to prevent obstetric violence are 
encompassed in the Criminal Code and Healthcare Act by the following articles:

• 

Criminal Code Act. No. 300/2005 Coll.215

 »

 »

 »

 »

§159 (1) Whoever unlawfully removes an organ, tissue or cell from a 
living person, or who unlawfully procures such an organ, tissue or cell 
for  himself  or  another,  shall  be  punished  by  imprisonment  for  two  to 
eight years.
§159 (2) As in paragraph 1, whoever sterilises a natural person without 
authorisation shall be punished.
§158 Whoever negligently injures the health of another by violating an 
important  duty  resulting  from  his  employment,  profession,  position  or 
function or imposed on him/her by law.
§157 Anyone who negligently injures the health of another by violating 
an important duty resulting from his employment, profession, position or 
function or imposed on him by law shall be punished by imprisonment 
for up to one year.

•  Act  No.  576/2004  Coll.  on  healthcare,  services  related  to  the  provision  of 
healthcare  and  on  amendments  to  certain  laws  as  amended  by  Act  no. 
41/2013. 

 »

§40 (2) Sterilisation can only be performed based on a written request 
and  written  informed  consent  after  prior  instruction  of  a  person  fully 
capable of legal acts or the legal representative of a person incapable 
of giving informed consent or based on a court decision based on the 
request of a legal representative.216

•  Act  No.  576/2004  Coll.  on  healthcare,  services  related  to  the  provision  of 
healthcare  and  on  amendments  to  certain  laws  as  amended  by  Act  no. 
41/2013. 

 »

§11 (9) Rights and obligations of persons in the provision of healthcare; 
When providing healthcare, everyone has the right under the conditions 
established by this law to:
a)  Protection of dignity, respect for one’s physical integrity and psycho-

b) 
c) 

logical integrity,
Information regarding his state of health,
Information about the purpose, nature, consequences and risks of 
the provision of healthcare, about the options for choosing the pro-
posed procedures and the risks of refusing the provision of health-
care (§ 6 paragraph 1),

d)  Refusal to provide healthcare, except for cases in which, according 
to this law, healthcare can be provided without informed consent (§ 
6, paragraph 9),

e)  Decision on their participation in teaching or biomedical research,

215   https://www.zakonypreludi.sk/zz/2005-300.

216   https://www.zakonypreludi.sk/zz/2004-576#p40.

53

4 SLOVAKIA by Barbora Holubová

f)  Maintaining the confidentiality of all data related to his health condi-
tion, facts related to his health condition, if in the cases established 
by a special regulation) the healthcare worker is not exempted from 
this confidentiality,
g)  Alleviation of suffering,
h)  Humane, ethical and dignified approach of healthcare workers.217

Additionally, the international human rights framework is applicable, in par-
ticular: 

• 

• 

• 

• 

• 

• 

The right to human dignity

The right to the protection of health and the right to healthcare

The right to information and informed consent

The right to the protection of private and family life

The right to equality and non-discrimination

The right not to be subject to violence, torture and other cruel, inhuman and 
degrading treatment.

The following international conventions can be applied to obstetric vio-

lence: 

• 

• 

• 

• 

• 

• 

• 

Convention on the Elimination of All Forms of Discrimination against Women

International Covenant on Economic, Social and Cultural Rights

International Covenant on Civil and Political Rights,

Convention  against  Torture  and  Other  Cruel,  Inhuman  or  Degrading  Treat-
ment or Punishment 

Convention on the Rights of Persons with Disabilities

Convention on the Elimination of All Forms of Racial Discrimination 

Convention on the Rights of the Child. 

Relevant conventions adopted by the Council of Europe are the Convention for 
the Protection of Human Rights and Fundamental Freedoms, the Convention on 
Human Rights and Biomedicine, and the European Social Charter (revised).

217   https://www.zakonypreludi.sk/zz/2004-576#p9.

54

4 SLOVAKIA by Barbora Holubová

4.4 

Data collection and evidence on obstetric violence in Slovakia

4.4.1  Empirical evidence (quantitative and qualitative) 

In 2003, based on 230 interviews conducted with Roma women from marginal-
ised communities throughout Eastern Slovakia, a study found that most of the 
women  appeared  to  have  been  sterilised  without  prior  and  informed  consent. 
The study revealed testimonials of numerous cases of forced and violent 
sterilisation  of  Roma  women,  physical  and  verbal  attacks,  racial  dis-
crimination in the provision of healthcare, misinformation of these women 
on health issues and denial of access to health documentation.218

Another study was based on interviews with more than 140 Roma women who 
were  forced  or  forcibly  sterilised  or  had  reasonable  suspicion  that  they  were 
forcibly sterilised. Approximately 110 of these interviews were conducted with 
women who were sterilised or strongly suspected of having been sterilised after 
the fall of Communism. About 30 interviews remaining in this category were with 
women who were sterilised during the Communist regime as part of the practice 
of providing financial motivation for undergoing sterilisation.219 

Forced  sterilisation  and  forced  castration  relate  to  people  undergoing 
gender transition. To date, Slovakia was one of the last European countries that 
required transgender people to undergo mandatory castration (removal of repro-
ductive organs) when legally changing their gender (and therefore changing their 
name and birth number). At the same time, there is no legal regulation of the 
gender transition process. Slovak transgender people and LGBTI+ organisations 
have been trying to change this situation for over a decade.

Population-based quantitative data on the prevalence of obstetric vio-
lence is available in a non-systemic way and based on non-randomised 
samples. One such survey from 2021 refers to an online inquiry conducted by the 
NGO Citizen, Democracy and Accountability. Women disclosed various manifes-
tations of obstetric violence, such as the refusal of the presence of an accompa-
nying person during birth (61 out of 87 women), lack of consent to medical inter-
ventions (15 out of 59) and the course of the labour delivery entirely determined 
by the hospital staff (48 out of 86 women). A relatively high number of women 
experienced other painful procedures during their labour or delivery. For example, 
56 women (out of 94) experienced labour induction, 35 (out of 95) experienced 
episiotomy and 31 women (out of 95) underwent the Kristeller manoeuvre, which 
is not recommended by WHO and is prohibited in Slovak hospitals.220

A 2020 online survey found in the sample of 3 164 women who gave birth that 
48 % experienced episiotomy (28 % were not informed and did not consent to the 
intervention). In the survey, 23.92 % of respondents said that stitching maternity 
injuries  was  an  excruciating  procedure.  In  14.53  %  of  cases,  the  reason  for  it 
being painful was they did not receive anaesthesia.221

The prevalence of some forms of obstetric violence might be indicated by the 
administrative health data on incidents of medical procedures which are either 
prohibited or not recommended by WHO. In 2020, complications during and after 
childbirth concerned 16 795 women giving birth (29.9 % of the total number of 

218   Center for Reproductive Rights and Center for Civil and Human Rights (2003).
219   Center for Reproductive Rights and Center for Civil and Human Rights (2003).
220   Debrecéniová (2021).

221   Thominet (2021).

55

4 SLOVAKIA by Barbora Holubová

women  giving  birth).  The  most  common  cases  were  incisions  of  the  perineum 
(episiotomy) (9 864 women in labour) and tearing (rupture) of the perineum (6 
261 women in labour).222
Episiotomy is the most prevalent complication that women in childbirth experi-
ence, presenting from 13 % to 17 % of all complications. The number of episiot-
omies provided increased from 2018 to 2020, each year, even though the women 
reported the harm, pain and trauma that resulted from the procedure (see table 
below).223 Independent experts also pointed to the often unnecessary episiotomy 
provided without local anaesthesia.
The  second  most  prevalent  harmful  medical  procedure  connected  to  obstetric 
violence is tearing (rupture) of the perineum, from 7 % to 11 % of all complica-
tions. The number of these procedures also increased in the last three years (see 
Table below).224 

Table 2: Women giving birth with complications during childbirth

Complication during or after childbirth

Number of women giving birth

Number of women giving birth with complications 

Uterine rupture

Hysterectomy < 48 hours

Placental retention

Eclampsia ≤ 14 days

Blood loss > 1 500 ml

Shoulder dystocia

Sepsis

Episiotomy

Embolism

Tearing (rupture) of the perineum

Other

per 100 women giving birth

Total

2020

56 238

16 795

48

52

379

17

74

213

11

 2019

56 596

15 938

2018 

57 059

12 131

67

53

414

10

113

225

18

67

52

381

16

89

234

19

9 864

9 472

7 313

31

6 261

1 648

24

5 676

1 670

21

4 054

1 250

 % of women giving birth with complications

29.9

28.2

21.3

Uterine rupture

Hysterectomy < 48 hours

Placental retention

Eclampsia ≤ 14 days

Blood loss > 1.500 ml

Shoulder dystocia

Sepsis

Episiotomy

Embolism

Tearing (rupture) of the perineum

Other

0.1

0.1

0.7

0.0

0.1

0.4

0.0

17.5

0.1

11.1

2.9

0.1

0.1

0.7

0

0.2

0.4

0

0.1

0.1

0.7

0.0

0.2

0.4

0.0

16.7

12.8

0

10

3

0.0

7.1

2.2

Source: NCZI-National Centre of Health Information, 2022.

222   NCZI (2020).
223   NCZI (2018–2020).

224   NCZI (2018–2020).

56

4 SLOVAKIA by Barbora Holubová

Another  indication  of  inadequate  health  services  provision  is  indicated  by  the 
number of surgical births. Slovakia is among the European countries with 
the highest number of caesarean sections. The number of caesarean sec-
tions nearly doubled from 2004–2020 and are some 30 % of all births. Of the 16 
658 caesarean deliveries in 2020, 57.1 % (9 517) of interventions were indicated 
before delivery, 22.3 % (3 711) resulted from an acute situation during delivery, 
and 20.6 % (3 430) from an acute situation before delivery (see table below).225
In  2020,  of  the  total  number  of  56  238  births,  67.6  %  (38  043  births)  were 
spontaneous and the remaining 32.4 % (18 195) were surgical births. 
Due to operative delivery, the most frequently chosen procedure was caesarean 
section (91.6 %; 16 658 births). According to the National Centre of Health Infor-
mation, in other cases, it was necessary to finish the birth process with the help 
of a bell (vacuum extractor) (7.1 %; 1 288 births); rarely was the surgical method 
chosen during birth forceps (1.3 %; 233 births) or extraction (0.1 %; 16 births). 
The  statistics  show  that  the  older  the  mother  is,  the  higher  the  probability  of 
giving birth by surgical method (see table below).226

Table 3: Development of the number of births by the method of birth 
(2004–2020)

Method of 
birth

2004

2006

2008

2010

2012

2014

2016

2017

2018

2019

2020

Year

Total

51 968 51 094 53 457 55 012 54 975 54 584 57 027 57 452 57 059 56 596 56 238

Spontaneous 40 638 38 511 38 715 37 699 36 593 36 104 38 150 38 283 38 692 38 405 38 043

Surgical

10 765 12 222 14 376 16 874 17 982 18 054 18 432 18 681 18 367 18 191 18 195

Within which:

Caesarean 
section

Forceps

Vacuum 
extractor

Extraction

Pelvic end 

Expression

Other

Unknown/
unspecified

9 896 11 267 13 349 15 765 16 863 16 912 17 122 17 215 16 882 16 741 16 658

284

585

.

148

–

381

36

365

590

.

282

79

–

–

384

643

.

297

68

–

1

337

772

.

265

174

–

–

338

781

.

224

176

–

–

328

814

.

227

199

–

–

311

334

308

224

233

999

1 132

1 122

1 214

1 288

.

249

196

–

–

.

241

247

–

–

55

12

16

.

.

–

–

.

.

–

–

.

.

–

–

Total

100

Spontaneous

78.2

100

75.4

100

72.4

100

68.5

100

66.6

100

66.1

100

66.9

100

66.6

100

67.8

100

67.9

100

67.6

Percentage

Caesarean 
section

Forceps

Vacuum 
extractor

Extraction

Pelvic end 

Expression

Other

Unknown/
unspecified

19.0

22.1

25.0

28.7

30.7

31.0

30.0

30.0

29.6

29.6

29.6

0.5

1.1

.

0.3

–

0.7

0.1

0.7

1.2

.

0.6

0.2

–

–

0.7

1.2

.

0.6

0.1

–

0.0

0.6

1.4

.

0.5

0.3

–

–

0.6

1.4

.

0.4

0.3

–

–

0.6

1.5

.

0.4

0.4

–

–

0.5

1.8

.

0.4

0.3

–

–

0.6

2.0

.

0.4

0.4

–

–

0.5

2.0

0.1

.

.

–

–

0.4

2.1

0.0

.

.

–

–

0.4

2.3

0.0

.

.

–

–

Source: NCZI-National Centre of Health Information, 2022.

225   NCZI (2020).
226   NCZI (2020).

57

4 SLOVAKIA by Barbora Holubová

Administrative  data  on  the  crimes  of  illegal  sterilisation  is  collected  if  the 
offence is registered and investigated by the police. Since 2017, no such 
crime has been reported.

In-depth  interviews  with  38  Roma  women  living  in  eastern  Slovakia  explored 
their  experiences  in  reproductive  and  maternal  healthcare  settings.  Almost  all 
the women interviewed said they had been subjected to disrespectful treatment 
and  abuse  by  medical  personnel  in  gynaecology  offices  or  hospital  maternity 
departments. Their accounts described various forms of conduct that they found 
disrespectful, ranging from raised voices and shouting to degrading and offen-
sive forms of address and conduct to vulgar verbal abuse, including racial slurs 
and physical abuse. Some of the women also described feeling neglected during 
labour and childbirth and that they were treated only after non-Roma patients. 
They  also  said  that  they  were  not  fully  and  adequately  informed  about  their 
medical treatment. Some women also gave accounts of physical abuse by med-
ical professionals. Most of the women interviewed explained that they felt upset 
and humiliated at being placed in separate ‘Roma only rooms’ on top of other 
segregation.227

4.4.2  Relevant manifestations 

A broad monitoring of the current state of affairs in Slovak birthing facilities 
was conducted in 2015 and revealed several forms of obstetric violence.228 One 
of the forms of violent and rough treatment was not allowing women to free-
ly choose the position (during the first and second stages of labour) that would 
suit them and which would bring them relief from their pain. Women were thus 
forced during the first and second stages to stay in an uncomfortable, unpleasant 
and painful lying position the research interviews also recorded the tying of the 
legs in stirrups during the second stage).

Another form of violation of the right to provide maternity care without violence 
was the implementation of the so-called Kristeller expression, i.e. pressure on the 
fundus.  This  practice  was  extremely  painful  for  women,  according  to  women’s 
descriptions,  performed  routinely  and  without  prior  communication  and  often 
without  their  consent.  It  can  be  considered  a  form  of  violence  and  cruel  and 
inhumane  treatment.229  In  some  cases,  the  episiotomy  was  performed  without 
consent or consciousness of the woman giving birth and a painful stitching of 
birth injuries, which is also a violation of the right to birth care without violence, 
torture and cruel, inhuman and degrading treatment.230 

A subsequent monitoring of the state of obstetrics in 2016 revealed fur-
ther serious violations of the human rights of women in connection with the 
provision of obstetric care in Slovakia, violations which seemed to be systemic.231 
The  violations  involved  all  human  rights  affected  during  births  and  were 
inflicted by individual healthcare professionals, healthcare facilities and 
the State:

• 

Interventions  and  practices  applied  were  often  in  conflict  with  interna-
tionally recognised medical guidelines. 

227   Centre for Reproductive Rights & Centre for Civil and Human Rights (2017).

228   Babiaková et al. (2015).

229   Babiaková et al. (2015).

230   Babiaková et al. (2015).
231   Debrecéniová (2016).

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4 SLOVAKIA by Barbora Holubová

•  The treatment of women giving birth often included elements of physi-

cal or psychological violence.

•  The right to information was violated throughout the entire birthing pro-

cess.

•  There  were  considerable  differences  between  medical  guidelines  gen-
erally accepted at the international level and the common practices 
applied by many Slovak healthcare facilities.232

Additional manifestations of obstetrics violence observed in Slovakia were:

•  Women did not have enough intimacy and privacy during childbirth; 
they  lay  in  overcrowded  rooms,  gave  birth  in  birthing  boxes  that  were  in-
sufficiently separated from each other or had chairs turned inappropriately 
towards the door during childbirth.233

•  Episiotomy is performed on almost every one out of two women giving 
birth, while in many cases it is done routinely and without a medical reason. 
These women cannot find effective help and a satisfactory solution to their 
problems (Women’s Circles).

•  There is no network of health services in Slovakia for women who have 
problems  with  wound  healing  after  childbirth,  experience  difficulties 
with breastfeeding or need mental healthcare. Such help is unavailable 
for a large group of women.

•  Awareness is insufficient about the possibilities of prevention and sup-

port in the area of mental health of women giving birth.234 

The discrimination faced by Roma women in obstetric care services and 
care in maternity hospitals and in gynaecological departments of many hospitals 
in Eastern Slovakia deserves particular mention, revealing elements of systemat-
ic and blatant racial discrimination, including segregation. Roma women are sep-
arated from white women and are placed in different rooms than white women. 
Roma women are often prevented from using the same bathrooms, toilets and 
eating facilities as white women. Their requests to be transferred to integrated 
rooms are ignored.235

Roma  women  encounter  insults  from  doctors  and  nurses.  Roma  women 
also receive lower-quality treatment or are refused treatment altogether. Some 
doctors have limited hours for Roma women or Roma women are forced to wait 
for  emergency  treatment  until  they  investigate  the  white  women  first.  Ambu-
lances  from  certain  hospitals  in  Eastern  Slovakia  either  refuse  or  hesitate  to 
provide services to pregnant women in Roma settlements, even when the woman 
is  already  giving  birth.  Corruption  among  medical  staff  is  endemic:  all  women 
are required to pay for services that are covered by health insurance, or they are 
provided with low-quality treatment if the health professionals feel that the bribe 
is  not  sufficient.  However,  Roma  women,  who  are  often  discriminated  against 
because of racial intolerance and who, perhaps because of their lower economic 
status cannot afford to pay bribes, feel this corruption even more acutely.236

232   Debrecéniová (2016).

233   Thominet (2021).

234   Žureková (2022).

235   Center for Reproductive Rights and Center for Civil and Human Rights (2003).

236   Centre for Reproductive Rights 2023).

59

4 SLOVAKIA by Barbora Holubová

Interviews with Roma women who use maternity health services in hospitals in 
Eastern  Slovakia  revealed  devastating  clashes  with  doctors  and  nurses.  Roma 
female patients are beaten, attacked, humiliated and neglected. Hospital 
directors,  doctors  and  nurses  openly  express  racist  views  about  female  Roma 
patients, whom they consider morally questionable, unable to provide for their 
children and who do not deserve healthcare. Many healthcare workers complain 
about the high number of Roma children and consider their high birth rate as a 
direct threat to Slovakia. These biased attitudes influence the behaviour of med-
ical personnel towards Roma patients who suffer from the consequences of poor 
reproductive healthcare and are otherwise marginalised, resulting in a negative 
impact on the overall health status of Roma women.237

Roma women interviewed in 2017 reported experiencing ongoing segregation in 
maternity care departments, racial harassment and humiliation, neglect, physical 
restraint and abuse during childbirth and failures related to informed consent and 
decision-making concerning medical treatment. All of these issues point to vio-
lations of Slovakia’s human rights obligations under international and domestic 
law and reveal an urgent need for the state to adopt effective and comprehensive 
measures to guarantee Roma women’s human rights and improve the quality of 
reproductive and maternal healthcare in Slovakia.238

4.5 

Root causes of obstetric violence 

Obstetric care in Slovakia is monopolised and institutionalised, concentrated al-
most exclusively in healthcare facilities. This, combined with women being par-
ticularly vulnerable during pregnancy and birth, makes obstetric care a specific 
phenomenon demonstrating a power imbalance.239 One of the root causes 
of  obstetric  violence  is  the  objectification  of  women  and  patients  in  the 
health system. Women are often not approached as persons but as objects of 
medical intervention. Objectification can be ‘we know what is best for you and you 
do not need to know it’. Women are often not granted subjectivity in childbirth. 
Women’s specific ideas of how they would like to give birth are perceived as in-
terfering with the competence of obstetricians and threatening their professional 
honour. The overall racism against the Roma population translates into dis-
crimination against Roma women from segregated communities in gynaecology 
and obstetrics. 

Condescending  behaviour  and  a  gendered  power  dynamic  contribute  to 
strongly disrespectful behaviour from healthcare providers to women, the denial 
of women’s autonomy, and pushing women into the role of passive receivers of 
ideas, requirements and procedures by medical personnel. The hierarchy of the 
medical  system  with  women  patients  and  clients  and  individual  persons  at  a 
lower rank than medical personnel puts symbolic and real power into the hands 
of medical personnel in situations where women are extremely vulnerable and 
depend on them.240 

The overall setting of the obstetrics health system is based on patriarchal and 
hierarchal relations between obstetricians and midwives. Several studies 
show that if low-risk mothers are cared for by midwives, they have a lower risk of 

237   Center for Reproductive Rights and Center for Civil and Human Rights (2003).

238   Centre for Reproductive Rights & Centre for Civil and Human Rights (2017).
239   Babiaková et al. (2015).
240   Babiaková et al. (2015).

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4 SLOVAKIA by Barbora Holubová

complications, interventions in childbirth or even caesarean sections.241 In some 
maternity hospitals, midwives are accepted and can fulfil their competencies in 
practice – caring for low-risk women giving birth and assistance during the birth. 
However, the situation is at a standstill in most maternity hospitals and the tradi-
tional concept of medically led birth persists. In this respect, improvement in the 
position of midwives in the care system for women in giving birth is minimal.242 
Since  the  number  of  gynaecological-obstetric  medical  personnel  is  decreasing 
yearly, it is likely that the role of midwives will become increasingly necessary for 
low-risk mothers. But there are currently only around 1 600 midwives in Slovakia 
and ideally, there should be one for every woman giving birth.243 

The  abuse  of  the  doctrine  of  medical  necessity  and  the  risk  approach 
contributes to the limited number of home births and the stigmatisation of giving 
birth in other than a medical institution. In Slovakia, it is not legally forbidden for 
a woman to give birth at home. It is not even legally established that a woman 
should give birth only in a medical institution of institutional healthcare. How-
ever, from the provisions of § 4 par. 3 of the Decree of the Ministry of Health 
of  the  Slovak  Republic  no.  364/2005,  it  follows  that  the  midwife  is  entitled  to 
perform defined actions (including physiological childbirth) independently, but in 
a  healthcare  facility.  Thus,  the  law  does  not  explicitly  prohibit  home  birth  but 
does not provide for it either: the midwife would act contrary to lege artis, the 
approved way of practising, and putting herself at risk of disciplinary or criminal 
prosecution.244

4.6 

Consequences of obstetric violence 

Maternal mortality results from severe obstetric complications and conditions 
which mostly do not lead to death. Maternal morbidity is not adequately meas-
ured,  however,  because  there  is  no  international  agreement  about  the  defini-
tion of the conditions and also because the recording of these conditions is not 
standardised in routine hospital discharge databases, the primary source of this 
data.245 Maternal death is defined as the death of a woman while pregnant or 
within 42 days of the termination of pregnancy, regardless of the duration and 
site of the pregnancy, for any cause related to or aggravated by the pregnancy 
or its management, but not from accidental or incidental causes. The maternal 
mortality rate is thus the number of all maternal deaths from direct and indirect 
obstetric causes per 100 000 live births. Because the number of deaths yearly 
is  so  low  in  most  countries,  data  is  used  covering  five  years  (2011  to  2015). 
Slovakia  reports  a  rate  below  5  per  100  000  births  in  2011–2015;  however, 
the number might be underestimated.246 The total death rate (mortality) of 
newborns between 2017 and 2020 rose slightly from 4.43 per thousand to 5.5 
per thousand.247 

241   Souter et al. (2019).
242   Žureková (2022).
243   Žureková (2022).

244   Grejtáková (2016).
245   European Perinatal Health Report (2015).
246   European Perinatal Health Report (2015).

247   Žureková (2022).

61

4 SLOVAKIA by Barbora Holubová

4.7  Obstetric violence and Covid-19 

The Covid-19 pandemic has had a major impact on childbirth since 2020. 
It has shown that even progress that is slow can be stopped or reversed. In prac-
tice, care for women has deteriorated significantly in many ways. For example, 
premature babies were separated from their parents, who did not see 
them  for  weeks.  Similar  cases  also  occurred  with  healthy  children  and  their 
mothers infected with the coronavirus.248

At  the  time,  the  recommendations  of  international  obstetric  organisations,  in-
cluding  the  Slovak  guidelines  issued  by  the  chief  expert  for  gynaecology  and 
obstetrics, were based on the fact that if a woman is capable of caring for a child, 
it is inappropriate to separate them and thus prevent breastfeeding. Despite that, 
NGOs and doulas observed an increase during the pandemic of violations 
of women’s rights. For example: 

•  Women were not provided with adequate post-partum care. They were often 
either sent home prematurely or were hospitalised in Covid wards without 
adequate post-partum care.

• 

Some hospitals impose a ban or set impossible conditions for the presence 
of a partner during childbirth, such being present in the delivery room only 
for 15 minutes.

•  At the beginning of the pandemic, the vast majority of maternity hospitals 

interfered with women’s rights in a significant way.249

A long-term doula, who accompanies women during childbirth and has experi-
ence in many maternity hospitals, described a harmful situation at that time:

‘I dealt with one woman who, when she wanted to leave the maternity ward 
on the second day after giving birth, the staff locked the door of the delivery 
ward so that she could not leave. It was solved only by the arrival of the 
police, who were called by the woman’s husband – a lawyer. After a conver-
sation between the police and the staff, the woman was released home.’250

The  NGO  Citizen,  Democracy  and  Accountability  monitored  complaints 
about the violation of healthcare provision and human rights related to prenatal, 
obstetric and postnatal care. The reference period of the monitoring was during 
the Covid-19 pandemic from March 2020 to March 2021. The findings indicate 
that  most  of  the  complaints  were  assessed  as  irrelevant  and  justifiable 
by  the  control  bodies.  Only  a  few  complaints  were  investigated  by  the  su-
pervisory  agencies,  mostly  labelled  as  ‘improper  provision  of  healthcare’ 
or ‘deficient medical records’. The remedy was based on ‘instruction of the 
responsible worker’ or a fine of EUR 400. In general, the monitoring found that 
an effective mechanism of control and remedies is missing in Slovakia and that 
the control bodies cover up violations of women’s rights in prenatal, obstetric and 
postnatal care.251

248   Žureková (2022).

249   Žureková (2022).

250   Žureková (2022).

251   Debrecéniová (2021a).

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4.8 

Achievements and challenges in collecting and monitoring data 

Systemic  monitoring  or  data  collection  of  obstetric  violence  is  not  established 
in Slovakia. Nor has an official observatory covering obstetric violence been es-
tablished in Slovakia. However, several NGOs have been mapping obstetric 
violence using a human rights approach for several years within specific 
projects, usually funded by an independent foundation, such as the Open Society 
Foundations. A survey on obstetric violence commissioned by the Office of the 
Public Defender of Rights was released in 2021. However, this was a one-
time, non-recurring activity. Moreover, the Public Rights Defender newly elected 
in November 2022 will probably have other priorities as he was assigned by the 
prevalently conservative national council.

4.9 

Relevant initiatives and their impact 

4.9.1 

Initiatives leading to political action

Relevance of the topic in political and institutional debate 

The debate and case of forced sterilisation of Roma women resonated with 
the public, due to the long-term campaign of and pressure from the NGO Centre 
for Reproductive Rights and the Centre for Civil and Human Rights. However, the 
long history of this issue illustrates the slow and gradual recognition of 
obstetric violence in Slovakia. 

In 2003, a study made up of 230 interviews conducted with Roma women from 
marginalised communities throughout Eastern Slovakia found that most of the 
women appeared to have been sterilised without prior and informed consent.252 
The case sparked discussion in Slovakia on the importance of ensuring patients’ 
informed consent before sterilisation or other medical procedures are performed. 

As a result, in 2004 new legislation was adopted introducing informed consent 
procedures, including a specific provision on informed consent before sterilisation 
and expanded protections for patients seeking access to their medical records. 
Despite these legal reforms, Slovak authorities have failed to take meaningful 
steps to investigate past instances of forced and coercive sterilisation and ensure 
that survivors are provided with effective remedies and reparations. Although the 
allegations  of  unlawful  sterilisation  elicited  responses  from  both  the  Ministry 
of Health and law enforcement authorities and although criminal investigations 
were opened, these investigations had numerous flaws and were ineffective.253

Between 2011 and 2013, the European Court of Human Rights (ECHR) upheld 
women’s claims and found violations of the European Convention in three sepa-
rate cases brought by Roma women. It dismissed state assertions that the ster-
ilisations  were  necessary  for  ‘health  reasons,’  reasoning  instead  that  because 
sterilisation is not a life-saving medical intervention, informed consent is always 
needed before the operation is performed. According to the ECHR, the women in 
these cases were treated in a manner that was paternalistic and incompatible 
with the principles of respect for human freedom and dignity because they were 
deprived of the chance to freely decide whether or not to be sterilised. The Court, 
therefore, found violations of their rights to freedom from inhuman and degrad-

252   Center for Reproductive Rights and Center for Civil and Human Rights (2003).

253   Centre for Reproductive Rights & Centre for Civil and Human Rights (2017).

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4 SLOVAKIA by Barbora Holubová

ing treatment and respect for their private lives and granted each applicant finan-
cial compensation between EUR 25 000 and EUR 31 000.254

In 2016, after a lengthy proceeding of 11 years, a Slovak court awarded a Roma 
woman  who  had  been  sterilised  in  1999  without  her  informed  consent  com-
pensation for the total amount requested (EUR 16 597). The hospital was also 
ordered to apologise to her formally. Following the reasoning and approach of 
the ECHR, the court ultimately found that the woman’s right to personal integrity 
had been violated.255

In November 2021, the Government of the Slovak Republic adopted the ‘Apology 
for sterilisations in violation of the law’, the purpose of which was primarily to 
express regret in cases that have a solid human rights dimension and to apolo-
gise for sterilisations in violation of the law, which were implemented in Slovakia 
in the years 1966–1989 and 1990–2004.

Degree  of  recognition  of  the  topic  by  healthcare  providers;  effective  measures 
implemented 

In 2021, the Ministry of Health of the Slovak Republic implemented two stand-
ards  and  procedures  to  unify  and  improve  the  provision  of  healthcare 
during  pregnancy  and  childbirth.  The  Ministry  of  Health  expects  the  intro-
duction  of  the  mentioned  standard  procedures  to  increase  the  acceptance  of 
the latest scientific knowledge in everyday obstetric practice with full respect for 
women’s rights in the provision of health services.256 However, the NGOs working 
in this area point to insufficient and ambiguously formulated measures for pre-
venting obstetric violence against women in the standards.257

The goal of the first standard procedure, called ‘Prenatal care for low-risk preg-
nancy’,  is  a  uniform  procedure  in  pregnancy  monitoring,  prevention  and  early 
detection  of  deviations  indicating  the  possible  emergence  of  maternal  compli-
cations.  The  intention  of  the  standard  is  also  early  detection  of  deviations  in 
the  prenatal  development  of  the  foetus  and  proper  preparation  for  childbirth. 
The goal of the second standard procedure, entitled ‘Care of a low-risk mother 
during childbirth’ is a uniform procedure during monitoring and assistance during 
childbirth for low-risk mothers.258 

Some of the measures in the standards procedures also relate to pre-
venting  obstetric  violence,  for  example,  rules  regarding  the  accompanying 
person,  informed  consent,  the  right  to  privacy  and  performing  an  episiotomy, 
i.e.  cutting  the  perineum.  According  to  the  new  standards,  routine  episiotomy 
is not recommended for spontaneous vaginal birth. Each workplace should now 
regularly audit episiotomies and other injuries to the perineum during childbirth. 
The  standards  also  point  out  that  all  operations,  including  episiotomy,  require 
the  informed  consent  of  the  mother.  The  previous  monitoring  found  that  the 
medical staff often equated informed consent only ‘with the mother’s automatic 
signature.’ However, the new standards introduce the requirement that all actions 
performed on the mother require her informed consent, which can be either ver-
bal or declarative, for example, the mother nods or makes a move to enable the 

254   Centre for Reproductive Rights & Centre for Civil and Human Rights (2017).
255   Centre for Reproductive Rights & Centre for Civil and Human Rights (2017).

256   Ministry of Health (2021, 2021a).
257   Žureková (2022).
258   Ministry of Health (2021, 2021a).

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4 SLOVAKIA by Barbora Holubová

action. Furthermore, the standards state that other medical procedures require 
oral informed consent.259 Finally, the standards give the mother the right to the 
presence of an accompanying person or persons during the entire birth process. 
However, their number is limited by the possibilities of the workplace. 

Degree of recognition of the topic by the general public and women 

Visual  artists  and  independent  female  filmmakers  contributed  to  raise  public 
awareness and bottom-up women’s engagement on obstetric violence.

The topic of harassment and trauma from childbirth has been discussed in online 
space and various social media platforms by women sharing their hospital expe-
riences since 2010. However, it was a documentary film that significantly raised 
the topic of obstetric violence. The documentary, ‘Medzi nami’ (Before I met 
you,260 directed by Zuzana Limová chronicles women’s efforts to maintain 
their dignity through childbirth and offers their testimonies. After the Slovak 
premiere of the film, a passionate societal discussion about obstetrics broke out. 
Women’s experiences suddenly made it into the evening news and the headlines 
of important newspapers. The documentary chronicles women’s efforts to main-
tain their dignity through childbirth and offers the testimonies of those who found 
the courage to speak out. The testimonies are supplemented by images captured 
during  weekdays  in  the  state  maternity  hospital  and  interviews  with  the  staff. 
It  was  filmed  on  the  premises  of  the  University  Hospital  in  Bratislava  with  an 
international team, but threats from the hospital blocked it for several months. 
The documentary intensified the topic of human rights by childbirth and is used 
to date as training material in public discussions for various types of audiences.

The  second  relevant  initiative  which  contributed  to  further  awareness-raising 
about  obstetric  violence  was  the  documentary,  ‘Neviditeľná’  [Unseen],  by 
director  Maia  Martiniak  in  2020.261  The  documentary  sparked  discussion 
and  intensive  media  coverage.  The  documentary  captures  women’s  sto-
ries, which open up the controversial and socially rejected topic of birth trauma. 
Complemented  by  real  births,  the  theme  of  trauma  is  investigated,  showing  a 
hidden  reality  in  society  and  making  visible  women  who  until  now  have  been 
silenced by the pressure of the environment or medical staff. The documentary in 
a sensitive way opens up the need for change not only in Slovakia but also in the 
world. After the documentary showed that women leave the maternity hospital 
traumatised, the recognition of the need to humanise Slovak obstetrics deepened 
even  more.  Civil  associations,  the  public  defender  of  rights  and  the  midwives 
themselves began to point out the shortcomings of the system more often.

The visual arts also contributed to recognising  the  structural  racism  in  ob-
stetrics  that  Roma  women  face  in  Slovakia.  The  Centre  of  Civil  and  Human 
Rights in cooperation with Roma male and female activists prepared a series of 
videos in 2021. The campaign, ‘Challenging barriers in access to justice through 
sharing stories of Roma women’, stressed why it is importance to stand up for 
human rights and highlighted the services of the Centre. Roma women shared 
their messages in the videos. The joint effort was to inspire other people to ac-

259   Ministry of Health (2021, 2021a).

260   Trailer: https://www.youtube.com/watch?v=iiEfB2sghVY.

261   Trailer: https://www.youtube.com/watch?v=Du3z-THFNh4; Media coverage: https://unseen.

film/press-festivals/; Discussion on the film at the Festival ‘One World’ https://www.facebook.com/

watch/?v=2083846875072520.

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4 SLOVAKIA by Barbora Holubová

tively defend their rights. One of the videos features the story of Mrs Jana – one 
of the Romani women who was forcibly sterilised by doctors in the past.262

4.9.2 

Initiatives to combat obstetric violence 

Relevant initiatives to address the topic

On 1 January 2019, the Ministry of Health approved the so-called standard 
procedures for prevention of obstetric violence titled, Mother and newborn 
care according to the principles of the Baby-friendly Hospital Initiative (BFHI).263 It 
defines the principles of care for the mother and child in the period before, 
during and after birth in medical facilities with the aim to support bonding and 
breastfeeding  as  much  as  possible.  According  to  the  Ministry,  the  tool,  which 
they created according to WHO recommendations, was created in response 
to information about the disrespectful treatment of women in connection 
with childbirth, which was brought to the attention of the third sector and the 
public  defender  of  rights.  Using  the  procedures,  more  than  200  gynaecolo-
gists-obstetricians, paediatricians, neonatologists, midwives and nurses 
from  all  hospitals  in  Slovakia  were  educated  about  the  positive  approach  to 
women and newborns. In Eastern Slovakia, education was also focused on the 
specific and cultural needs of the Roma population. 

The  Ministry  of  Health  has  also  created  tools  for  systematically  checking 
compliance with these procedures, i.e. a clinical audit that evaluates the ap-
plication of standards in practice. They were mainly implemented before the 
pandemic’s start, but they have stopped since 2020. The reason is the lack 
of funds and professional staff to carry out the audits. Following the start of 
the pandemic, compliance is monitored through internal assessments. Currently, 
however, there is not a single hospital in Slovakia that has a BFHI certificate.264 

Relevant initiatives to involve and train health professionals in recognising, under-
standing and preventing obstetric violence 

The initiatives involving the training of health professionals targeting the 
mistreatment of women giving birth and some aspects of obstetric vio-
lence have been organised more often by NGOs than state institutions. Nev-
ertheless, some of the courses at the medical universities indicate that the issues 
of obstetric violence might be perceived prevalently as communication or 
ethical issues and not as a violation of human rights or respective regulations, 
or even as a crime. 

Let’s talk about women’s human rights by childbirth265 is a series of work-
shops provided by the NGOs Citizen, Democracy and Accountability and 
Women’s  Circles  in  2018.  The  courses  targeted  professional  midwives  from 
hospitals  and  community  midwives  and  lactation  consultants.  The  aim  was  to 
promote discussion and provide education in the field of women’s rights in child-
birth, thereby promoting equal, respectful and effective cooperation of all those 
involved in childbirth. Education and increasing understanding of human rights 
– e.g. the right to privacy, information, dignity and respectful treatment – are nec-

262   https://poradna-prava.sk/en/videos/.

263   Ministry of Health (2020).

264   Žureková (2022).

265   http://odz.sk/vydarene-podujatie-workshop/.

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essary to eliminate violations of women’s rights during childbirth. The workshop 
strengthened all the actors present and created space for cooperation and their 
long-term involvement in the human rights activities of the NGOs. 

Strengthening  communication  skills  of  midwives  266  was  a  training  or-
ganised  by  the  NGO  Women’s  Circles  in  cooperation  with  the  Slovak 
Chamber  for  Nurses  and  Midwives  in  2019.  Midwives  were  trained  in  ef-
fective communication with women, emphasising emotional support of women 
in labour, active listening and an empathetic approach to their needs. The work-
shop’s goal was, through discussion and other interactive activities, to contribute 
to the professional discourse and raise the awareness of participating midwives 
about women’s rights, gender equality and unbalanced access to power, as well 
as about good practice in the field of maternity care that is evidence-based.

Human rights public discussions267 were organised by the Citizen, Democ-
racy and Accountability and Women’s Circles in five towns in Slovakia in 
2019. Students of medical study programmes (nurses and midwives) were the 
target group. The public discussions were about the conditions in which women 
give birth in healthcare facilities in Slovakia and the (dis)respect of their human 
rights in connection with childbirth. The society-wide discussion gained momen-
tum after the release of director Zuzana Límová’s documentary film ‘Medzi nami 
(Before  I  Met  You)’  in  Slovak  cinemas.  The  public  discussions  used  the  film  to 
boost the discussion with future healthcare professionals. 

Relevant initiatives to support women in the exercise of their reproductive rights.

The government agreed to the parliamentary proposal that a woman has 
the right to the presence of an accompanying person during childbirth. 
If the medical facility conditions allow it, the woman should also be allowed the 
company of several people. The declared incentive for drafting the parliamentary 
proposal is the lack of legislation to ensure the right of mothers to have persons 
of their choice present during childbirth. The public defender of rights point-
ed out the absence of legislation and recommended legislation in this 
area. The proposal also allows the possibility of limiting the presence of persons, 
namely  the  attending  physician,  to  the  necessary  extent  and  for  the  required 
time, taking into account the nature of the medical procedure. The amendment 
to the law is proposed to take effect from 1 June 2024.

Relevant initiatives to deconstruct general assumptions on childbirth

Transgender people are a hard-hit group due to violations of their sexual 
rights,  including  forced  surgical  sterilisation  due  to  Christian  ideology 
and  gendered  stereotypes.  Despite  a  long-term  fight  for  improvement  and 
partial success, their situation continues to be intolerable and the outlook tends 
to be negative.

Until  now,  Slovakia  is  one  of  the  last  European  countries  that  required 
transgender people to undergo surgical castration (removal of reproduc-
tive  organs)  when  legally  changing  their  gender  (and  therefore  changing  their 
name and birth number). At the same time, there was no legal regulation of this 
process. Slovak transgender people and LGBTI+ organisations have been trying to 

266   http://odz.sk/nasa-spolupraca/.

267   http://odz.sk/ludskopravne-diskusie/.

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4 SLOVAKIA by Barbora Holubová

change this situation for more than a decade.268

In 2019, a group of experts from various medical fields finalised a document 
entitled  ‘Professional  guidance  of  the  Ministry  of  Health  of  the  Slovak 
Republic on the unification of medical procedures when issuing a medical 
opinion in case of gender reassignment’. The document subsequently received 
the  support  of  the  Committee  of  the  Slovak  Psychiatric  Society,  which  brings 
together experts in the field of psychiatry in Slovakia. Despite this, the Ministry 
did not accept this document during the tenure of three different ministers.269

Finally, after the professional societies called on the Ministry again to adopt the 
guideline because the current situation threatened the provision of healthcare to 
transgender people and after several modifications, the guideline was finally 
approved by the Minister on March 2022 and is published in the Journal of 
the Ministry of Health of the Slovak Republic.270

The  guideline  regulates  the  gender  transition  process  and  strengthens 
legal certainty and transparency. It would enable the training of new spe-
cialists, thereby increasing the availability of healthcare for transgender people. 
The  most  relevant  success  of  the  guideline  is  that  it  abolishes  the  practice  of 
forced surgical sterilisation. According to the new rules, transgender people 
can choose between surgical procedures and hormonal treatment com-
bined with a test of living in their preferred gender for at least one year.271

Despite  that  Slovakia’s  first  comprehensive  gender  reassignment  protocol  and 
the establishing guidelines for gender recognition was signed and published and 
received a broad welcome from health professionals and the transgender com-
munity, the move has attracted numerous transphobic comments, with pres-
sure led by some conservatives. The Health Ministry suspended the document’s 
validity in May 2022.272

Moreover, in November 2022, some fundamentalist Christian NGOs submit-
ted a petition to the Slovak Government requiring them to withdraw the 
guideline forever and make it impossible to carry out any gender transitions and 
rewrite gender in Slovak territory. They want conversion therapies to be carried 
out in Slovakia. This happened less than a month after a terrorist attack in which 
two queer people were slaughtered in Bratislava.273

268   Iniciatíva Inakosť (2022).
269   Iniciatíva Inakosť (2022).

270   Iniciatíva Inakosť (2022).
271   Iniciatíva Inakosť (2022).
272   Iniciatíva Inakosť (2022).

273   Slovak Spectator (2022).

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4 SLOVAKIA by Barbora Holubová

4.9.3  Other relevant initiatives 

In July 2019, the UN Special Rapporteur against violence against women, 
Dubravka Šimonović, presented her report to  the UN General  Assembly on 
the human rights approach to mistreatment and violence against women in 
reproductive healthcare, with a focus on childbirth and obstetric violence.274 

The report, naming Slovakia and referring to monitoring studies prepared by Slovak 
NGOs, describes the current pattern of violence and other mistreatment of 
women in the delivery of maternity care in health facilities worldwide. The 
report also specifically deals with obstetric violence concerning women who 
belong to various minorities or face various disadvantages, including Roma 
women,  women  with  disabilities  and  women  with  a  lower  socioeconomic 
status.  Many  problems  or  shortcomings  have  been  present  for  a  long  time  in 
Slovakia as well.275 The report was promoted and used by several NGOs for their 
advocacy for improving the conditions of giving birth in Slovak hospitals. 

4.10  Conclusions and recommendations

Slovakia lacks proper and complex legislation and regulations and regu-
lar independent control mechanisms to prevent and eliminate obstetric 
violence and the violation of human rights related to childbirth. Aware-
ness of human rights in connection with the provision of antenatal, delivery and 
postnatal care on the part of responsible institutions and bodies is relatively low 
and the topic of obstetric violence has started to be recognised by the state 
authorities  only  slowly  and  recently.  The  topic,  however,  resonates  among 
women, who use the only-women spaces in social media and platforms created 
by dedicated women’s rights organisations to discuss it. 

Slovakia is failing in systematic data collection on human rights violations 
in the provision of prenatal, birth and post-partum care and is lacking initiatives, 
proactive actions and systemic approaches from state institutions and responsi-
ble control bodies.276 Further development of the issue can build on the previous 
initiatives of dedicated NGOs, documentaries and media coverage, which contrib-
uted considerably to increasing awareness of the violation of human rights dur-
ing childbirth. The public and some of the professional bodies (mainly midwives) 
are sensitised to change and improvements.

There have been improvements in some areas, for example, in relation to the per-
ception of the behaviour of medical staff towards women in labour, it has been 
noted that respect for women was missing. Another positive development is the 
recently adopted law that regulates the right to the presence of an accompanying 
person during childbirth.277 

Based  on  the  previous  independent  initiatives  and  findings  of  several  surveys, 
the following recommendations are proposed to improve the situation in 
Slovakia on obstetric violence: 

•  Ensure  the  provision  of  healthcare  in  a  way  that  respects  the  human 
rights,  human  dignity,  mental  health  and  emotional  wellbeing  of 
women during childbirth. 

274   Šimonović (2019).
275  Šimonović (2019).

276   Debrecéniová (2021a).

277   Žureková (2022).

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4 SLOVAKIA by Barbora Holubová

•  Ensure  effective  implementation  and  control  of  legal  and  adminis-
trative procedures and practices related to informed consent in maternity 
care following recommendations of the UN Special Rapporteur on the right 
of every person to the highest attainable level of physical and mental health. 

•  Systematically  collect  data  on  maternity  care  and  regularly  publish 

data.

•  Adopt standards in the field of obstetrics that will take into account 
scientific  and  medical  development  while  fully  respecting  women’s 
rights.

•  Ensure adequate financial resources for healthcare facilities to en-
sure a dignified environment for women in labour and satisfactory working 
conditions for healthcare providers.

• 

• 

Implement training for healthcare workers to increase awareness of the 
issue of human rights and violence related to childbirth.

Introduce effective measures that ensure an effective investigation and 
monitoring  of  the  segregation  of  Roma  women  in  maternity  care, 
stopping the practice and punishing those responsible. 

•  Create  an  effective  system  of  control  for  mothers  and  general  pa-
tients, in the event of a violation of basic human rights, to guarantee 
independent review and the sanctioning of relevant institutions and which 
will ensure compensation and redress for affected persons.278 

278   Thominet (2021).

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5 SPAIN by Stella Villarmea and Adela Recio Alcaide

5  SPAIN  

by Stella Villarmea and 
Adela Recio Alcaide

5.1  Overview

The Spanish National Health System (NHS) is financed by general state budg-
ets. Spaniards and foreign citizens who have established their residence in the 
national territory are holders of the right to health protection and healthcare.279 
The  NHS  includes  in  its  portfolio  services  for  pregnancy,  childbirth  and 
post-partum  care.  The  responsibility  for  the  territorial  planning  and  the 
provision of health services corresponds to the 17 regional governments, 
the Autonomous Communities. Voluntary private insurance is independent of the 
public system and has a variable population coverage among the different Au-
tonomous  Communities.  In  the  last  two  decades,  a  very  stable  proportion 
of births – four out of five births – has been attended in the NHS, while 
one  in  five  births  has  been  attended  in  private  centres.280  Practically  all  births 
are attended in hospitals, except for two midwifery-led birth centres for low-risk 
births281 and a residual and stable 0.3 % of women who give birth at home.282 
The home birth option is not included in the portfolio of public services; still, some 
women choose this option and are attended mostly by private midwives.

Spanish  perinatal  indicators  are  in  general  very  close  to  the  average 
of European countries – with a stable caesarean section rate of around 
25  %  since  2007  and  a  perinatal  mortality  of  2.5  per  1  000  births  in 
2019. Spain is, however, one of the countries in the European context that 
practises some interventions the most – e.g. instrumental deliveries.283 Nev-
ertheless, despite women’s right to achieve the highest level of sexual and 
reproductive health, recognised in Article 95 of the Beijing Declaration,284 in 
Spain, as in most middle- and high-income countries, rates of non-medically 
justified obstetric interventions – e.g. caesarean sections, episiotomies 
or induction of labour – are high and have been exceeding for decades 
what is recommended by the World Health Organization.285

The  high  prevalence  of  unjustified  obstetric  interventions,  the  over-medi-
calisation  of  childbirth  in  general  and  poor  maternal  experiences,  highlighting 
practices of gender discrimination in childbirth care, led to the founding of 

279   Law 14/1986. Available at: https://www.boe.es/buscar/act.php?id=BOE-A-1986-10499 

280   Ministerio de Sanidad (2022).
281   FAME (2020).
282   INE (2022).

283   Euro-Peristat (2022).

284   UN (1995).

285   WHO (1985).

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5 SPAIN by Stella Villarmea and Adela Recio Alcaide

women’s  organisations  –  such  as  the  association  Vía  Láctea,  [Milky  Way]  in 
1987 or El Parto es Nuestro [Childbirth is Ours] in 2003. Civil mobilisation – 
with  considerable  media  and  public  policy  impact  –  on  obstetric  care 
started  to  take  place  in  Spain  in  the  2000s.286  The  public  debate  led  the 
Ministry of Health in 2006 to initiate the development  of  the  Strategy  for 
Normal Birth Care, from now on the Strategy, aimed at (public) hospitals 
of the NHS. All relevant stakeholders took part in the process, coordinat-
ed by the Women’s Health Observatory: social and women’s organisations, 
scientific  and  professional  societies,  Spanish  regions  and  experts.  As 
stated by the Ministry of Health, the Strategy was a response to a social, 
professional and health administration demand, manifested in the presence 
of  the  progressive  medicalisation  and  increase  of  unnecessary  and  unjustified 
interventions in a physiological process with repercussions on health.287 

With the general objective of improving the quality of care while main-
taining safety levels, the Strategy, approved in 2007, considered four strategic 
lines:  to  promote  clinical  practices  based  on  the  best  available  scien-
tific  evidence,  to  encourage  the  participation  of  female  users  in  deci-
sion-making, to promote the specialisation and continuous training of pro-
fessionals and, finally, to promote research, innovation and dissemination 
of good practices.288 Thereby, actions were implemented to train and sensitise 
health providers and different guidelines were prepared that promoted a model 
of attention to childbirth focused on the physiology of the process and the needs 
of women and their families. These actions helped to incorporate new beneficial 
practices and to progressively abandon some of those without evidence of the 
benefits they provide or that, applied routinely, are harmful, such as episiotomy. 
Although  the  Strategy  was  proven  to  be  effective  in  curbing  the  esca-
lation  of  caesarean  sections  while  preserving  perinatal  safety  in  NHS 
hospitals289 and some obstetric interventions – such as episiotomy – decreased 
drastically, the Strategy was not enough to adapt clinical practice to rec-
ommended standards. Thus, years after its approval, the rates of instrumen-
tal deliveries, inductions, episiotomies or Kristeller manoeuvres continued to be 
well above what was recommended290 and women’s experiences continued to be 
marked by a lack of autonomy, namely, the violation of their right to decide.291

At  present,  obstetric  interventions  rates  are  still  well  above  that  rec-
ommended by health institutions – such as WHO or the Spanish Ministry of 
Health.292 In addition, maternal experiences continue to show that there is a large 
number  of  uninformed,  coercive,  unconsented  or  even  judicially  forced 
medical  interventions  when  the  woman  has  explicitly  rejected  them.  These 
practices  constitute  a  violation  of  their  physical  and  moral  integrity  and 
evidence women’s lack of autonomy during childbirth.293

The strong awareness raised by Spanish women’s organisations regarding 
rights in childbirth – some of the most representative at the present time being 
Childbirth is Ours and the Observatory of Obstetric Violence – has allowed sev-

286  Villarmea et al. (2016).

287   Ministerio de Sanidad (2007).

288  Ministero de Sanidad (2007).
289   Recio Alcaide & Arranz (2022).
290   Ministerio de Sanidad (2012).
291   OVO (2016).
292   Ministerio de Sanidad (2021).
293   Mena-Tudela et al. (2020).

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5 SPAIN by Stella Villarmea and Adela Recio Alcaide

eral  Spanish  women  to  denounce  the  mistreatment  received  during  childbirth. 
Consequently, in the first two Resolutions adopted by the CEDAW Committee 
regarding victims of obstetric violence, the State party was Spain – the 
case  S.F.M.  v.  Spain  in  2020294  and  the  case  of  N.A.E.  v.  Spain  in  2022.295  In 
both  cases,  the  CEDAW  Committee  recalls  the  obligation  of  the  State  to  abol-
ish customs and practices that constitute discrimination against women and 
considers that stereotyping affects the right of women to be protected against 
obstetric violence.296 

In recent years, Spanish birth activism has placed the issue of obstetric 
violence on the feminist and equality policy agenda and there has been a 
heated debate regarding the inclusion of obstetric violence in national 
legislation297 or in regional legislation, such as of the Autonomous Commu-
nities of Valencia298 and La Rioja.299 The tension between the resistance and/
or denial of some health practitioners and professional bodies – main-
ly  the  Spanish  Society  of  Gynaecology  and  Obstetrics  (SEGO)  and  the  General 
Council of Official Colleges of Physicians (CGCOM) – of the need to implement 
legal and medical measures to eliminate obstetric violence,300 on the one hand, 
and  activists’  call  to  legislate  the  phenomenon,301  together  with  other 
professional bodies – such as the Federation of Associations of Midwives of 
Spain,302 the Catalan Society of Obstetrics and Gynaecology, the Council of Medi-
cal Associations of Catalonia,303 and other medical, nursing or psychology student 
associations,304 on the other hand, is manifest. 

In 2020, at the initiative of Childbirth is Ours and the Observatory of Obstetric 
Violence,305 a series of contacts between women’s associations and the Minis-
try  of  Equality  began,  with  the  aim  of  ensuring  that  Spain  complies  with  the 
recommendations  on  obstetric  violence  by  international  organisations,  such  as 
the UN and WHO.306 In  2021,  the  Ministry  of  Equality  announced  the in-
clusion, in the reform of the National Organic Law 2/2010 of Sexual and 
Reproductive Health and of the Voluntary Interruption of Pregnancy, of 
the term ‘obstetric violence’ to address the phenomenon.307 Nevertheless, the 
term ‘obstetric violence’ has been excluded from the final Reform, due 
to the refusal of the cited professional bodies and the Ministries of Health 
and Justice, which said they were not feeling comfortable with the term.308 In the 
final Reform, the Law considers a chapter on the ‘Protection and guarantee of 
sexual and  reproductive rights in the gynaecological and obstetric field’, which 

294   CEDAW (2020).

295   CEDAW (2022).

296   A third Resolution by the CEDAW Committee regarding victims of obstetric violence in Spain was pub-

lished in 2023 (CEDAW 2023). Its content has not been included in this country case as the Resolution was 

published after the report was delivered.
297   El Diario (2022c).
298   El Diario (2021b).
299   Nuevecuatrouno (2022).
300   El Salto (2021).
301  El parto es Nuestro (2022a).

302   FAME (2022).

303   SCOG and CCMC (2022).
304   AEEE, CEP-PIE, & CEEM (2021).
305   El Parto es Nuestro (2020a).
306   Europa Press (2021).
307   El Diario (2021a).
308   El Diario (2022c).

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5 SPAIN by Stella Villarmea and Adela Recio Alcaide

addresses some manifestations of obstetric violence, such as the lack of 
informed  consent  or  the  ‘inappropriate  or  unnecessary  gynaecological  and  ob-
stetric interventions’, but avoids the use of the term.309 The exclusion of the 
term “obstetric violence” from the final text of the Law has been made despite 
the  advice  of  the  Public  Prosecutor’s  Council,  which  recommended  that 
gynaecological  and  obstetric  violence  –  as  a  form  of  violence  against 
women in the reproductive sphere – be included in the reform of the Law;310 
and despite the 35 textual mentions to obstetric violence in the amend-
ments311  prepared  by  the  political  parties  to  the  earlier  Draft.  In  any  case, 
Spain  already  acknowledges  the  term  ‘obstetric  violence’  in  regional 
laws: since 2020, in the Law 17/2020 of the Right of Women to Eradicate Sexist 
Violence312 of the Autonomous Community of Catalonia; and since 2022, in the 
Law 1/2022 of Equality of Women and Men313 of the Autonomous Community of 
the Basque Country. 

Spain is an interesting case study of responding to obstetric violence in 
the European context because of its political and legislative achievements 
in the area, and the crucial contribution of civil society to raise social 
and professional awareness about the occurrence of obstetric violence 
in Spain (and beyond).

5.2 

Definitions and references in the country

The Law of the Autonomous Community of Catalonia defines obstetric vio-
lence as a form of gender-based violence that:

‘consists in preventing or hindering access to truthful information, neces-
sary for autonomous and informed decision-making. It can affect different 
areas of physical and mental health, including sexual and reproductive health and 
may prevent or make it difficult for women to take decisions about their sexual 
practices and preferences and about their reproduction and conditions in which 
it is carried out, in accordance with the assumptions included in the legislation. 
It includes forced sterilisation, forced pregnancy, prevention of abortion 
in the legally established assumptions and the difficulty in accessing the 
contraceptives  methods,  methods  of  preventing  sexually  transmitted 
infections and HIV and assisted reproductive methods, as well as gynae-
cological practices and obstetrics that do not respect the decisions, the 
body, the health and the emotional processes of the woman’.

The term ‘obstetric violence’ is also recognised in the Law of the Autono-
mous Community of the Basque Country, even though it only names obstet-
ric violence as one among other forms of violence against women. The 
law also considers the incorporation of measures to promote the autonomy 
of women in pregnancy, childbirth and breastfeeding.

Furthermore,  although  the  term  obstetric  violence  is  not  explicitly  men-
tioned in other institutional documents (official guidelines, studies or state-
ments), some of its manifestations are addressed in the Reform of the 

309   Gobierno de España (2022).
310   Consejo Fiscal (2022).
311   BOCG Num. 122-2. https://www.congreso.es/public_oficiales/L14/CONG/BOCG/A/BOCG-14-A-122-2.

PDF#page=1.

312   Law 17/2020. Available at: https://www.boe.es/diario_boe/txt.php?id=BOE-A-2021-464

313   Law 1/2022. Available at: https://www.boe.es/buscar/doc.php?lang=en&id=BOE-A-2022-4849

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5 SPAIN by Stella Villarmea and Adela Recio Alcaide

National  Organic  Law  2/2010.  The  protection  and  guarantee  of  sexual  and 
reproductive rights in the gynaecological and obstetric field is articulated in Title 
III,  Chapter  II,  where  Article  27  states  that  public  services  will  devote  special 
efforts to: (a) mandatorily require the free, previous and informed consent 
of the women in all invasive treatments during delivery care; (b) reduce inter-
ventionism,  avoiding  unnecessary  and  inappropriate  practices  that  are 
not supported by scientific evidence; (c) provide respectful treatment and 
clear and sufficient information; and (d) guarantee the non-separation of new-
borns from their mothers and other people with a direct link to them, 
when unnecessary. In Article 28, the Law states that the Health Administrations 
will promote the carrying out of studies on practices in the gynaecological 
and obstetric field that are contrary to the principles established in the 
previous article and in the national and international recommendations 
on respectful childbirth. Article 29 articulates training of personnel of gy-
naecology and obstetrics services to respect and guarantee women’s rights. 
Finally, Article 30 establishes that the Sexual and Reproductive Health Strat-
egy will include a section on prevention, detection and comprehensive 
intervention  to  guarantee  sexual  rights  in  the  gynaecological  and  ob-
stetric field and that a Common Protocol of Actions will be approved to this 
end, which will be taken as a framework by Autonomous Communities for the 
prevention of praxis contrary to what is established in Chapter II of the 
Law.

Also, the Strategic Plan for Effective Equality between Women and Men 2022–
2025314  of  the  Ministry  of  Equality  includes  the  action  to  ‘guarantee  prena-
tal,  birth  and  postnatal  care  that  respects  human  rights  and  the  will 
of women’, mainly by defining and responding to ‘violence in the sexual and 
reproductive sphere as well as inappropriate or unnecessary gynaeco-
logical  and  obstetric  interventions  within  the  framework  of  the  reform  of 
the Organic Law 2/2010 of Sexual and Reproductive Health and Interruption of 
Pregnancy’.

Even if the topic of obstetric violence is institutionally addressed, there is a dis-
tance between the current institutional approaches in Spain, both on the 
regional and national level, and the approach of birth rights activism and 
international  organisations,  such  as:  WHO  in  2014,  in  the  Prevention  and 
elimination of disrespect and abuse during facility-based childbirth statement;315 
the United Nations in 2019, in the Report of the Special Rapporteur on Violence 
against women, its causes and consequences on a human rights-based approach 
to mistreatment and violence against women in reproductive health services with 
a focus on childbirth and obstetric violence;316 the Council of Europe in 2019, in 
its Resolution 2306 of October 2019 on Obstetric and gynaecological violence;317 
the CEDAW Committee in its Views of 2020 and 2022;318 and the European 
Parliament  in  2021  in  its  View  of  21  January  2021,  on  the  EU  Strategy  for 
Gender Equality.319

The definitions of and references to, obstetric violence, as they are found in the 
aforementioned declarations of international organisations, all locate ‘obstet-

314   Ministerio de Igualdad (2022).
315   WHO (2014a).

316   UN (2019).

317   Parliamentary Assembly (2019).

318   CEDAW (2020; 2022).

319   European Parliament (2021).

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5 SPAIN by Stella Villarmea and Adela Recio Alcaide

ric violence’ at the axis of human rights violation, gender-based violence 
and clinical malpractice, considering elements of both respectful treatment 
and quality care. In all of them, the term ‘obstetric violence’ refers to disre-
spectful and abusive treatment, systematic deprivation of women’s right 
to autonomy and other elements of poor-quality care, such as failure to 
adhere to evidence-based best practices, that women may experience from 
healthcare providers during pregnancy, childbirth and the post-partum period. 

Despite the above declarations, this type of gender-based violence and their 
underlying gender stereotypes remain invisible to an important part of soci-
ety, which understands gender-based violence’s most severe manifestations as 
an exceptional confluence of concrete factors, instead of as a result of structur-
al inequalities derived from the core prevalent idea of women´s inferiority 
and subordination.320 The term ‘obstetric violence’ has the potential for 
addressing these structural and gender dimensions of the phenomenon 
and frames the discussion of abuse and disrespect within the broader field of 
structural  inequalities  and  violence  against  women.321  It also validates 
the  lived  experiences of those who were subjected to this form of violence, 
including professionals who witnessed it.322 

For these reasons, the ambiguity of the Spanish approach can be seen. In the 
national approach, it does not fully acknowledge the term and its references in the 
international framework and ignores its basis of gender discrimination and 
other  structural  causes,  therefore  disregarding  key  policy  recommendations 
made  to  the  States  to  address  its  driving  factors  and  leaving  the  legislative 
initiative without crucial tools to eradicate the phenomenon. In the region-
al approach, although the Catalan Law recognises and defines in detail obstetric 
violence as violence against women, it does not consider international recommen-
dations and does not formulate the needed specific guarantees to address 
its  structural  causes.  The  Basque  Law  also  falls  short  by  not  considering  the 
structural causes of obstetric violence and addressing the autonomy of women 
only as something to be promoted instead of to be guaranteed.

5.3 

Data collection and evidence on obstetric violence in the country

Bringing mistreatment and violence against women in reproductive health ser-
vices to  the  surface requires information that accurately depicts a  violence 
that is socially normalised. The occurrence of obstetric violence in Spain 
is evidenced mainly through the perinatal indicators of official statistics 
– which account for the prevalence of unnecessary and dangerous obstetric inter-
ventions. It is also present in academic research, media analysis and news 
and publications by birth rights associations. Such information challenges 
customs, practices and beliefs that, even if normalised, constitute violence and/
or discrimination.

5.3.1  Empirical evidence (quantitative and qualitative) 

Official  indicators  reveal  the  generalised  use  of  non-evidence-based  clinical 
practices in Spain (see table below). The evaluation, carried out years after the 
approval of the Strategy for Normal Birth Care, showed that none of the ob-
stetric interventions for which a measurement was made complied with 

320   Lorente Acosta (2020).

321   Sadler et al. (2016).

322   Verity and Pickles (2022).

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5 SPAIN by Stella Villarmea and Adela Recio Alcaide

the standards set by the Ministry of Health for the evaluation, except for the 
application of the epidural. Medical practices used to accelerate labour – such 
as  oxytocin  administration,  amniotomies,  Kristeller  manoeuvres,  epi-
siotomies  and  instrumental  births  –  are  used  much  more  frequently  than 
necessary, putting the mother’s and baby’s health in danger, as the Ministry of 
Health warned.323 Note that we refer to 2012, as this year is the only with an 
official  source  of  information  available  for  several  indicators  in  the  table.  For 
those indicators for which there are subsequent updates, such as the caesarean 
section or episiotomy rates, their evolution has been added in the 2018 column.

Table 4: Process and results indicators on obstetric interventions com-
parison to standard in NHS hospitals, 2012–2018

Result 
2012

Result 
2018

Ministry of Health 
Standard

Process and result indicator

 % of amniotomies performed

 % of spontaneous labours with oxytocin 
administration during labour

46.6 %

53.3 %

(*)

-

 % of induced labours

19.4 %

34,2 %

 % of births with a fully completed partogram 
sheet

 % of births with locoregional analgesia

 % of vaginal births with lithotomy position 
was maintained throughout expulsive

 % of vaginal births in which the Kristeller 
manoeuvre has been performed

 % of episiotomies in normal births

 % of protocols that include all the 
recommendations for care during normal birth

 % instrumental births

 % births with vacuum

 % of forceps births

 % births with spatulas

 % caesarean sections

 % vaginal births after caesarean section

 % of women surveyed who say they were not 
separated from their newborn

52.1 %

72.2 %

87.4 %

26.1 %

41.9 %

15.5 %

19.5 %

10.2 %

6.1 %

3.2 %

22 %

44.2 %

50.2 %

-

-

-

-

(**)

-

18.8 %

13.1 %

3.9 %

-

21.8 %

-

-

Do not perform 
routinely

5–10 %

< 10 %

100 %

30–80 %

< 30 %

0 %

< 15 %

100 %

< 15 %

< 7 %

< 5 %

< 5 %

< 15 %

60–80 %

≥ 80 %

Source: Author, based on the Report on Delivery and Birth Care in the National Health Sys-
tem 2012, Ministry of Health324 and the Report on Perinatal care in Spain, 2010-2018.325
(*)  %  of  amniotomies  performed  and  %  of  births  with  locoregional  analgesia  are  clearly 
under-registered in the 2018 source, as noted by the Ministry of Health.326 For this reason, 
and in order to avoid confusion, these data are not included in the table.

(**) This indicator is not available for 2018. If we consider the percentage of episiotomies over 
total vaginal deliveries instead of over total normal deliveries (which do not include instru-
mental deliveries) the 2012 indicator would be 40% and the 2018 indicator would be 27.5%.

323   Ministerio de Sanidad (2012).

324   Ministerio de Sanidad (2012).

325   Ministerio de Sanidad (2021).

326   Ministerio de Sanidad (2012).

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More recent indicators collected by the Ministry of Health show that, although the 
episiotomy rate in NHS has become closer to quality standards – the episiotomy 
rate decreased to 27.5 % in 2018 – other indicators such as induced births 
have increased from 9.5 % in 1997 to 34.2 % in 2018.327 Furthermore, cae-
sarean section rates remain stable and persist well above the reference 
standards (< 15 %): 22 % in NHS hospitals and 36.5 % in the private sector – 
and are alarmingly high in some hospitals, with rates over 50 %.328

Regarding the variability of obstetric interventions across regions, it is worth re-
calling that competences in health in Spain are transferred to the Autonomous 
Communities. Caesarean section rates are widely variable in Spain and con-
sistent across time. In 2020, the last year available, the Basque Country is the 
Autonomous Community with the fewest caesarean sections and one of the two, 
together with Navarra, that comes close to the reference rate, with 14.8 %; while 
Extremadura reaches the maximum, with 31.9 % of births being by caesarean 
sections.329 Although the average age of mothers is lower in Extremadura than 
in Basque Country, a woman has twice the chance of undergoing a caesarean 
section  if  she  gives  birth  in  Extremadura  than  in  Basque  Country.  In  addition, 
the variability in rates between Autonomous Communities can also be observed 
between public and private hospitals: systematically in each Autonomous Com-
munity, caesarean section rates are significantly higher in private than in 
public hospitals – a fact with no medical justification, since it is the public 
health system that attends most of the high-risk births that are more likely to 
end up  in  caesarean sections. In general, the  private  healthcare  system  is 
more likely to perform more instrumental births and more episiotomies 
than the public system.330 

Regarding obstetric violence prevalence, 38.3 % of women reported having 
suffered it while giving birth or in the post-partum period, according to recent 
survey in Spain.331 Of all the surveyed women (17 541), 45.9 % indicated that 
they were not informed about the procedures they had been subject to, 
nor were asked to provide express consent; 34.5 % stated that they were 
criticised for their behaviour with ironic or discrediting remarks; 31.4 % had 
been treated with nicknames or childish diminutives; 48 % indicated that 
they found it impossible to resolve their doubts, or to voice their fears or con-
cerns; 44.4 % perceived that they had undergone unnecessary and/or painful 
procedures and of these, 52.3 % were neither provided with reasons nor 
asked to give consent and 31.1 % were provided with reasons, but were not 
asked to give consent. Thus, a total of 83.4 % were not requested to provide 
informed consent. 

Of those women who suffered miscarriage or perinatal loss (n=1 108), 36.5 % 
perceived unnecessary or unjustified care and 70.8 % of the cases did not 
feel they had received physiological support during the process. Of all the 
participants, 35 % answered that they did not feel they received any support 
during the post-partum period in their questions about feeding and baby care. 
Of those who chose breastfeeding, 7.6 % did not feel they were supported 
or helped to resolve doubts or overcome difficulties. Regarding interventionism 
and  medicalisation  during  birth,  women  giving  birth  in  private  healthcare 

327   Ministerio de Sanidad (2021; 2012).
328   El Diario (2022a).

329   Ministerio de Sanidad (2022).

330   Recio Alcaide (2015).

331   Mena-Tudela et al. (2020).

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5 SPAIN by Stella Villarmea and Adela Recio Alcaide

had a higher interventionism rate, less satisfaction, felt more insecure 
and  vulnerable  and  perceived  more  obstetric  violence.332  Other  investi-
gations point out that women in Spain can be victims of obstetric violence 
regardless of their age, educational level and socioeconomic status, but 
women who have a high level of support from their partner are less likely 
to experience situations of verbal and psychological types of obstetric violence.333

5.3.2  Relevant manifestations 

Manifestations of obstetric violence in Spain can be grouped in three categories: 
deprivation  of  the  right  to  autonomy  during  the  stay  at  a  healthcare 
facility; non-evidence-based clinical practices; and other manifestations 
of  disrespect  towards  women  in  labour,  such  as  verbal  abuse  or  lack  of 
intimacy and contact between mother and child. They all have in common the 
subordination of women and the violation of their right to health and 
respect in their decisions.

Deprivation of the right to autonomy

The autonomy of women during childbirth is guaranteed in Spain by Law 41/2002 
of Patient Autonomy,334 which in Article 8 on Informed Consent establishes that 
‘[a]ny action in the health of a patient requires the free and volunteered con-
sent of the affected, once they, having received the information provided 
for in Article 4, have assessed the options of the case’. Further to this, Article 
9  b)  states  that,  in  life-threatening  situations  in  which  it  is  not  possible  to 
obtain the patient’s consent, doctors can act on their behalf without having 
to  consult  them,  although  they  must  consult  their  relatives  or  close  friends.  It 
is  worth  noting  that  this  does  not  mean  doctors  can  act  against  the  patient’s 
decisions  whenever  there  is  an  emergency  situation,  but  that  this  can  only  be 
done if, in addition to the vital emergency, the person is unable to express 
herself.

Informed  consent  for  medical  treatment  related  to  reproductive  and 
birth services is a fundamental human right.335 Women have the right to 
receive full information about recommended treatments so that they can make 
informed and well-considered decisions.336 Nonetheless, the lack of informed con-
sent or its misuse is often reported by Spanish women and takes many forms.337 
Irrespective of the law, a common belief of medical professionals in clinical 
settings is that parturients do not need to make informed decisions, and 
that instead they mostly have simple preferences which can be ‘grant-
ed or rejected by the practitioner’.338 Rather than using the literal legal 
notion of ‘free and informed decision-making’ contained in the current Law 
41/2002, some alternative expressions are used to reduce women’s de-
cision-making,  such  as  ‘participating  in  decision-making’,  ‘decisions  will  be 
adopted jointly between the doctor and the patient’ or ‘the patient will always 

332   Mena-Tudela et al. (2021).

333   Martínez-Galiano et al. (2021).
334   Law 41/2002 of Patient Autonomy: https://www.boe.es/buscar/act.php?lang=es&id=BOE-A-2002-
22188&tn=1&p.
335   UN (2019).
336   UN (2019).
337   Mena-Tudela et al. (2020).

338   Fernández Guillén (2018).

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be informed prior to the intervention’.339 In the paragraphs that follow, different 
forms of women’s right deprivation of autonomy in Spain will be dissected, from 
the less severe to the most blatant, i.e., explicitly forced obstetric interventions.

A first form of a lack of informed decisions consists of not informing women 
about obstetric intended interventions, different options, or consequenc-
es, as well as not requesting informed consent – acting therefore with-
out women’s consent. Research has shown that these ways of violating service 
user’s autonomy are not exceptional in Spain: according to the Spanish Obser-
vatory of Obstetric Violence,340 in more than half of the cases (50.7 %), women 
were  not  informed  of  the  obstetric  intervention (e.g., induction, Kristeller 
manoeuvre  or  episiotomy)  that  was  going  to  be  performed.  In  60.8  %  of  the 
cases, they were not told why a certain manoeuvre was recommended. 
In 76.6 % of the cases, they were not informed of the different options for 
action (including the expectant attitude). In general, the possible consequences 
(80.4 %) or the secondary effects of the intervention (84.6 % of the cases) were 
not  explained.  Finally,  in  half  of  the  cases  (50.1  %)  health  providers  acted 
without the subject’s consent.

Testimonies  help  bring  light  to  how  the  lack  of  request  for  informed  consent 
occurs. Testimony 1 in Annex 2 relates to a woman giving birth in 2015, whose 
informed consent was not requested for an amniotomy, who was also co-
erced  into  undergoing  a  Kristeller  manoeuvre341  three  times,  and  who  was 
insulted for rejecting it.342
A  similar  experience,  but  from  2013,  was  published  by  the  non-governmental 
organisation Childbirth is Ours. Testimony 2 in Annex 2 is from a woman whose 
informed consent was not requested for a Kristeller or an episiotomy or a vacu-
um, while she was accused of not pushing better.343
These testimonies are by no means exceptional. Many similar stories, re-
porting a lack of the right to make informed decisions, have been gathered, clas-
sified and published throughout the years by the association Childbirth is Ours 
and can be read online.344 Especially dramatic is Testimony 3 in Annex 2, where 
N.N.’s lawyer, reports that when she went to give birth to her first daughter in 
2011, several trainee doctors used forceps on her for the sole purpose of learning 
how to use them, causing very serious injuries to the baby’s head and health.345
The above testimonies show subordination, lack of decision-making and de-
fencelessness. They also show discomfort when being insulted and punished 
– ‘hysterical’ –, when challenged as incapable – ‘before you pushed better’ –, 

339   Fernández Guillén (2018).

340   OVO (2016).

341   The Kristeller manoeuvre (fundal pressure) continues to be a common practice in Spain, with a rate 

reaching up to 26 % in vaginal deliveries (Ministerio de Sanidad 2012) and is totally discouraged in the Clin-

ical Practice Guide for normal childbirth of the Spanish Ministry of Health (Ministerio de Sanidad 2010b) and 

by WHO, in recommendation 40 of the WHO recommendations on intrapartum care for a positive childbirth 

experience (WHO 2018a).

342   OVO (2016).

343   Testimony available at:

https://www.elpartoesnuestro.es/relatos/los-peligros-de-querer-decidir-por-una-misma?field_centro_value=&field_

story_tax_tid %5B %5D=4715&sort_by=field_count_value&sort_order=ASC.

344   Testimonies are available in the testimonies section at:

https://www.elpartoesnuestro.es/relatos?field_story_tax_tid %5B0 %5D=4715&field_centro_value=&sort_or-

der=ASC.

345   Fernández Guillén (2018).

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or when the professional shows a haughty attitude – ‘she stood with her arms 
crossed behind the midwife and ordered him to make me an episiotomy’. Above 
all, women describe a feeling of being powerless, a fear of real danger typical 
of those who are not empowered in a situation but are instead made passive – 
‘Not like that, you can “break her head’’.’
In these situations, information was not given to women and medical actions were 
taken directly without asking them, thus infringing the right to make informed 
decisions and reinforcing gender stereotypes about women’s subordina-
tion, as if they are passive or unable to decide about their own health and 
reproductive processes. But the most severe violations of the right to au-
tonomy and integrity in maternity care take place when women are forced to 
accept particular interventions despite explicitly refusing them. In certain cases, 
in Spain, women have been threatened by their health providers with the 
request of a court order to coerce them to undergo an induction or cae-
sarean section.346 As a consequence of these cases, a statement was signed by 
16 Spanish NGOs in February 2020,347 warning of the dangers of judicialization 
and criminalisation of childbirth in Spain.348

These threats have come true in situations in which women have been forced 
by  a  court  order  to  a  hospital  admission  for  immediate  induction  of 
childbirth or to undergo a forced caesarean section. In the so-called ‘Ovie-
do case’ in April 2019, the judge of the Court of Instruction No 1 of Oviedo, a 
city in Northern Spain, ordered the transfer to the Central University Hospital of 
Asturias  (HUCA)  of  a  woman  ‘who  had  exceeded  42  weeks  of  pregnancy’.  The 
woman had gone to the hospital to perform a foetal wellbeing check-up because 
she had passed 42 weeks of gestation. The Maternity Service proposed that she 
had an induction, as it was what is technically called a ‘chronologically prolonged 
gestation’. Instead, the pregnant woman returned home, where she had intended 
to give birth with her midwife and went into labour naturally. That same after-
noon, local police officers showed up at her home with a court order, issued at the 
request of the HUCA’s Sub-directorate of Critical Surgical Services. The reason for 
her forced admission was the need to perform an ‘immediate labour induction’. 
However, 36 hours passed before a caesarean section was finally performed.349 
The Constitutional Court of Spain endorsed in June 2022 the compulsory admis-
sion of the pregnant woman to give birth in HUCA,350 a sentence that was strongly 
criticised by feminist groups.351 This case is a good example of how women’s lack 
of rights to autonomy and physical integrity is active not only in clinical settings, 
but also in judicial settings – where gender stereotypes are reproduced – while 
Law 41/2002 states that citizens are holders of those rights even if there is a 
medical indication for an intervention. Another case of being forced by a court 
order to an immediate intervention happened in Elche, a city in Eastern Spain, 
in  September  2019,  when  a  court  order  forced  a  pregnant  woman  –  who  had 
refused the surgery – to undergo a caesarean section352 in disregard of the Law 
of Patient Autonomy. 

346   Brigidi & Busquets-Gallego (2019).
347   The statement addressed to leading Spanish institutions in the field of health and equality can be read 

here: https://www.elpartoesnuestro.es/sites/default/files/public/official_statement_epen.pdf.
348   El Parto es Nuestro (2020b).
349   El País (2019); La Voz de Asturias (2019).
350   Expansión (2022).
351   El Parto es Nuestro 2022b; OVO 2022).

352   El Español (2019).

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In addition, some forced caesarean sections occur without the mediation of the 
judicial power – they are simply performed against the explicit decision of 
the  woman,  by  ignoring  her  or  her  (desperate)  request.  This  is  the  case 
of  a  woman  who  gave  birth  at  the  beginning  of  the  Covid-19  pandemic.  Her 
harsh testimony353 (see Testimony 4 in Annex 2) allows us to understand what 
happened: she was about to give birth vaginally, but suddenly realised that the 
medical team was preparing to perform a caesarean section. She begged not to 
have it done and not to be ignored. But, without answering her, they performed 
it. As reported, the gynaecology department of the hospital had activated a pro-
tocol only two days earlier, according to which any birthing woman infected with 
coronavirus had to undergo a caesarean section. The reason for the protocol was 
assuming that a caesarean section is shorter in time than a vaginal delivery and 
hence the risk of contagion for the staff would be lower. And so, without any ex-
planation, they dragged her into the operating room and performed a caesarean 
section on her that she did not need.354

Non-evidence-based clinical practices 

Common  medical  practices  that  are  not  based  on  scientific  evidence,  whether 
used to accelerate childbirth – as time is a scarce resource in birth care355 
– or to improve the comfort of health providers, to the detriment of the 
good course of birth and the safety and wellbeing of the parturient (and 
baby) – such as the lithotomy position during the expulsive, the lack of intimacy 
or accompaniment, the use of haloperidol, the inclination to programme births 
– are:

Episiotomy:  An  episiotomy  is  a  deep  cut  in  a  woman’s  perineum  that 
reaches the pelvic floor muscle to surgically assist the parturient to have a vaginal 
delivery. Although this procedure can be beneficial for the baby and the mother if 
medically necessary, if not needed or done without the informed consent of the 
mother, it can have severe physical and psychological effects on the mother and 
constitute gender-based violence, an act of torture and inhuman and degrading 
treatment.356  Episiotomy  and  post-partum  suture,  when  performed  without  in-
formed consent and without anaesthesia, can have significant repercussions on 
the person’s sexual and reproductive life and mental health – the scars resulting 
from this practice can be present for the rest of her life.357 Among episiotomy 
potential  adverse  effects  are  anal  sphincter  dysfunction,  urinary  incontinence, 
dyspareunia  (pain  during  sexual  intercourse)  and  a  higher  frequency  of  third- 
and fourth- degree tears.358 Episiotomy rates in Spanish public  hospitals de-
creased from 77.7 % in 1997 to around 28 % in 2018,359 but the standard 
of the Ministry is under 15 %.360 In private healthcare, the rates are higher 
than in the NHS.

353   Podcast Parir en el Siglo XXI [Giving birth in 21st century], Chapter 5 (Part 1): ‘Name it’: https://www.rtve.
es/play/audios/parir-en-el-siglo-xxi-el-podcast/parir-siglo-21-capitulo-5-ponerle-nombre/6538419/.
354   Barret Cooperativa 2022).
355   Fernández Guillén (2020).
356   UN (2019).

357   UN 2019).

358   Ministerio de Sanidad (2012).
359   Ministerio de Sanidad (2021).
360   Ministerio de Sanidad (2012).

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The ‘husband’s stitch’: Some women have claimed to be victims of a su-
ture procedure after episiotomy (El País 2018). This procedure of unknown preva-
lence, which applies more stitches than necessary, is carried out, supposedly, 
for the sexual satisfaction of the husband. Overstitching the vaginal opening after 
birth, closing it with one or two extra stitches to narrow it to, supposedly, give 
the husband more pleasure is a strongly harmful patriarchal practice. It is not an 
express request of the woman or her partner, but an initiative of the practitioners 
themselves. It is usually made without knowledge of the woman.361

Caesarean  section  abuse:  When  medically  justified,  caesarean  sections 
are effective in preventing both maternal and perinatal morbidity and mortality. 
However,  like  any  other  major  surgical  operation,  it  is  associated  with  certain 
short- and long-term risks, such as a higher prevalence of maternal mortality and 
morbidity or an increased risk of uterine rupture, ectopic pregnancy, stillbirth and 
premature delivery in subsequent pregnancies. Short-term risks for newborns de-
livered by caesarean section include impaired immune development, an increased 
likelihood of allergy, atopy and asthma, as well as increased respiratory problems 
and obesity. WHO concluded in its 2018 Statement that, at the population level, 
caesarean section rates greater than 10 % are not associated with a reduction 
in  maternal  and  neonatal  mortality  rates  and  that,  ideally,  caesarean  sections 
should  be  performed  only  when  medically  necessary.362  However,  as  shown,  in 
Spain there are regions exceeding the 30 % rate. There are also hospitals 
where rates are 50 % or more. 

Unnecessary vaginal exams: Vaginal exams consist of inserting the finger(s) 
of one hand into the pregnant woman’s vagina to measure the parameters of the 
dilation phase. Vaginal exams are intrusive and painful for the woman and can 
carry germs from the outside environment into the cervix, where they can cause 
greater damage. The recommendations of the Ministry of Health are to limit the 
number of vaginal examinations to the essential minimum, advising not to per-
form more than one every three hours, unless necessary. Instead, there exists an 
abuse of vaginal examinations. Its prevalence is unknown, although evident 
through women testimonies. According to WHO, excessive vaginal examinations 
are a direct cause of possible infections363 that may affect the newborn ending 
up with an admission in a neonatal unit, as may have been the case of S.F.M. v. 
Spain, the first case of obstetric violence confirmed by the CEDAW Committee.364

Unnecessary use of instruments such as forceps or suction cups: For-
ceps are an obstetric instrument in the form of pliers, which, inserted into the 
woman’s  vagina,  normally  after  an  episiotomy,  serve  to  help  foetal  extraction 
from the outside. Its use increases the performance of episiotomies and the risk 
of perineal trauma with long-term sequelae and can therefore condition the de-
velopment of the sexual life of the women in whom it is practised. As shown in 
the previous table, in Spain, the percentage of instrumental deliveries over the 
total of vaginal births (around 19% in recent years) is above the recommended 
standard (<15% of total vaginal births) – in 2019, Spain was the country that 
performed the most instrumental deliveries in Europe.365

361   El País (2018).

362   WHO (2018b).

363   WHO (2014b).

364   CEDAW 2020).

365   Euro-Peristat (2018, 2022).

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Use of haloperidol during birth: The administration of haloperidol, a pow-
erful  antipsychotic  to  a  parturient  is  an  obsolete,  dangerous  practice,  with  no 
scientific  support.  Although  said  to  be  given  as  an  antiemetic,  in  Spain,  it  is 
actually  used  as  a  sedative  and  it  can  be  considered  a  form  of  chemical 
submission.366 Its prevalence is unknown but its use is evidenced through wom-
en’s testimonies.367 The Spanish organisation, Childbirth is Ours, has launched the 
campaign, Haloperidol in Childbirth Never Again to denounce and eradicate this 
practice.368 Recently, the High Court of Justice of the Valencian Community has 
affirmed in a judgment that women can be drugged with haloperidol in childbirth 
without their permission, in yet another example of how gender stereotypes in 
clinical settings are reproduced in the judicial sphere, in disregard of the Law of 
Patient Autonomy.

Kristeller manoeuvre: The Kristeller manoeuvre is pressure on the uterine 
fundus to increase abdominal pressure during delivery, either with one hand, two 
or the forearm, together with the contraction and towards the maternal pelvis, 
in order to shorten its duration and assist in the delivery of the baby. Although it 
is contraindicated due to its potential risks by WHO and the Spanish Ministry of 
Health, it persists in 26.1 % of vaginal deliveries in the Spanish NHS.369 The 
risks for newborns include, among others, increased likelihood of complications 
of  shoulder  dystocia:  clavicle  fracture,  head  trauma  and  sternocleidomastoid 
muscle tear; Erb’s palsy, which results from injury to the nerves in the brachial 
plexus that control movement of the shoulders, arms and hands; fractured hu-
merus or ribs; hypoxia; internal organ injuries; bruises and increased intracranial 
pressure;  cephalohematoma  and  intracranial  haemorrhages.  The  risks  for  the 
mother include bleeding and bruising, uterine rupture and uterine inversion, which 
can cause severe bleeding and, in extreme cases, lead to removal of the uterus, 
increased risk of third- or fourth-degree perineal tears, urogenital prolapse, pla-
cental abruption, rib fracture and contusions. Spanish activists have denounced 
this practice in the campaign, Stop Kristeller: A Matter of Gravity.370

Separation of mothers and their newborn: As the Strategy states, ‘during 
the first two hours after birth, the newborn child is in a state of tranquil alert. 
This enables early olfactory recognition of the mother, which is very important 
for establishing a bond and adapting to the post-partum environment. The sep-
aration of the mother and child alters this process and reduces the frequency of 
successful breastfeeding. The skin contact entails other benefits for the newborn 
–  a  quicker  recovery  from  stress,  the  child’s  glycaemia,  acid-base  equilibrium 
and temperature are regulated earlier – and for the mother – reduction of the 
uterus via secretion of oxytocin. The bond between mother and child increases 
the duration of maternal breastfeeding and prevents negative emotional reac-
tions’.371 In Spain, research has found that experiencing skin-to-skin contact pro-
tects mothers against post-traumatic stress disorder symptoms one to five years 

366   Olza-Fernández (2021).

367   Testimonies available at: https://www.elpartoesnuestro.es/sites/default/files/public/testimonios_madres.pdf

368   Campaign, Haloperidol in Childbirth Never Again:

https://www.elpartoesnuestro.es/informacion/campana-haloperidol-en-el-parto-nunca-mas?fbclid=IwAR3nGayGb-

yASB1ebpaL7Kg_e93cjzv1v_DK_IopWfLFeSGBy4xF4kbvaJJY.

369   Ministerio de Sanidad (2012).
370   El Parto es Nuestro. Campaign, Stop Kristeller: A Question of Gravity: https://www.elpartoesnuestro.es/
informacion/campanas/campana-stop-kristeller-cuestion-de-gravedad

371   Ministerio de Sanidad (2007).

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following birth.372 Nevertheless, mother-newborn separations are relatively 
frequent (50% prevalence in 2010) in Spain373 – where among the strong and 
unjustified barriers in the way of parents taking care of their newborns, they are 
probably the most emotionally painful intervention. Activists have strongly 
denounced mother-newborn separations, whether in the birth room – through 
the campaign of Childbirth is Ours, Never Separate374 – or in the neonatal unit 
– with another campaign from the same organisation, United at NICU: Do Not 
Separate Us, A Matter of Health.375

Cascade of interventions: In Spain, interventions during childbirth are not 
usually made alone – one intervention often leads to another and then another, 
giving rise to a ‘cascade of interventions’. For example, women often arrive at 
the  hospital  in  labour  and,  without  need,  synthetic  oxytocin  is  administered  to 
speed up labour. This gives rise to contractions that are worse than physiological 
ones, which usually requires pain relief, which is usually applied as epidural an-
aesthesia, which increases difficulty in pushing, which increases the chances of 
an instrumental delivery, Kristeller, caesarean section or episiotomy, which leads 
to further possible interventions. In fact, any obstetric intervention can directly 
or indirectly increase the chances of ending up cutting or damaging a woman’s 
genitalia, affecting her subsequent sexual and reproductive life.

Other interventions: Examples of medical practices that do not follow rec-
ommendations based on scientific evidence are the excessive use of oxytocin, the 
excessive use of amniotomy or rupture of the amniotic sac, forcing the woman to 
deliver in the lithotomy position, preventing her from moving freely during child-
birth, directing her pushes during delivery, forbidding her to drink water and eat, 
shaving her perineum, applying an enema, tying her arms during the caesarean 
section,  performing  the  Hamilton  manoeuvre376  without  her  informed  consent, 
disregarding her privacy, depriving her of the company of her choice, especially 
during caesarean sections or instrumental deliveries, and poor care in the case 
of perinatal death.

Other manifestations of obstetric violence

Other forms of obstetric violence in Spain are related to acts of verbal disre-
spect or mistreatment – i.e. expressions that aim to subjugate the birth-
ing woman; deprive her of her right to decide and autonomy; infantilise, 
discredit  and  ignore  her  requests  and  decisions;  and  undervalue  her  ability  to 
give birth. Derogatory and out-of-place language reflects the power imbalance 
between women and health workers and the gender stereotypes that presuppose 
that women should be obedient, passive, complacent and to not question medical 
decisions. These deeply embedded gender stereotypes allow that verbal 

372   Hernández-Martínez et al. (2020).
373   Ministerio de Sanidad (2012).
374   El Parto es Nuestro. Campaign, Never Separate:

https://www.elpartoesnuestro.es/informacion/campanas/campana-que-no-os-separen

375   El Parto es Nuestro. Campaign, United at NICU: Do Not Separate Us, A Matter of Health:

https://www.elpartoesnuestro.es/informacion/campanas/unidos-en-neonatos-no-nos-separes-es-una-cuestion-de-

salud

376   The Hamilton manoeuvre is a method of attempting to trigger labour by separating the membranes of 

the amniotic sac from the uterus through vaginal exploration.

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abuse  and  sexist  comments  to  women  in  labour  be  publicly  tolerated. 
Newspapers  speak  openly  about  ‘elderly primiparas’,  referring  pejoratively  to 
women who give birth for the first time and are older than a certain age. In an 
interview,  a  midwife  acknowledged  saying  to  a  woman  in  labour:  ‘if  you  don’t 
push,  I’ll  give  you  a  blow  that’ll  make  you  go  through  the  wall’  among  other 
threats to her.377

Research  has  compiled  some  of  the  expressions  used  in  Spanish  delivery 
rooms which undervalue or diminish the ability of women to give birth,378 
such as:

• 

• 

• 

‘To clean the guard’’, used to refer to forcing births with drugs, manoeuvres 
or surgery so that no woman gives birth at night and interrupts the rest of 
doctors and midwives on duty, or to leave the guard free for emergencies. 
This is of special relevance since research has shown that the distribution of 
unscheduled caesarean sections by time of birth is not uniform. The propor-
tion of women in Spain that deliver via an unplanned caesarean section is 
higher in the early hours of the night (from 10 pm to 3 am) and much lower 
during the remaining hours of the night and the rest of the day.379

‘To give birth to the woman’ or ‘to make the woman give birth’, as if the 
woman did not give birth by herself, but ‘birth/it’ is done to her. 

‘Teaching forceps’, used to refer to forceps that are performed not out a 
true indication but to teach its technique to students.

All these expressions account for the passive role and the lack of power expected 
from women during birth. But the expression ‘the husband’s stitch’ goes well 
beyond that, reproducing one of the most rancid sexual stereotypes: that of a 
sexual duty or service towards men, disregarding women’s sexual health. We are 
aware through testimonies that ‘the husband’s stitch’, or ‘the husband’s suture’, 
has happened in Spain, as it can be read in Testimony 5 in Annex 2, retrieved 
from El País (2018).

The 2020 CEDAW Committee’s decision on obstetric violence380 contains a clear 
allusion to out-of-place language as in the supposed annoyance of mothers 
who  want  to  breastfeed  their  newborns:  ‘the  baby  was  bottle-fed  without  the 
permission of the mother, who wanted to breastfeed her daughter but was not 
allowed  to  do  so  because  “mothers  ringing  the  bell  are  a  nuisance’’.’  Also,  the 
subsequent  2022  CEDAW  Committee’s  decision  on  obstetric  violence381  takes 
account of several expressions that were used to infantilise the claimant, when 
she was forced to undergo a caesarean section (see Testimony 6 in Annex 2), 
with  phrases  such  as:  ‘caesarean  yes  or  yes,  and  that’s  it’,  or  ‘calm  down,  kid, 
that’s it’.

These expressions and situations reflect an unbalanced power situation and 
disrespect for women’s rights to integrity, decision, autonomy and sexu-
al or reproductive health. 

377   La Voz de Galicia (2010).
378   Fernández Guillén (2015).

379   Costa-Ramón et al. (2018).

380   CEDAW 2020

381   CEDAW (2022).

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5.4 

Root causes 

Understanding how health systems constraints, gender stereotypes and 
power dynamics favour the violation of human rights during childbirth in 
the case of Spain is necessary to decide which recommendations and innova-
tive practices to promote. Regarding health systems conditions and constraints, 
a crucial issue is the paradigm of technological childbirth, that is, a series 
of beliefs, attitudes and practices in which professionals have been ed-
ucated – and are assumed by society – which maintains that by default 
intervention-assisted births are better. This paradigm makes health provid-
ers carry out unnecessary and harmful interventions, which alter the evolution 
of many births, creating a series of problems and complications that then must 
be resolved with more interventions, usually caesarean sections or instrumental 
births.382  Thus,  it  is  not  the  interventions  that  should  be  questioned,  but  their 
inadequate  use  or  abuse  and  how  scientific  evidence  is  integrated  in  medical 
decisions.

When analysing structural root causes in Spain, one should distinguish between 
public and private healthcare. Especially in the private sector, the advantage 
of  planning  daytime  births  v  unplanned  vaginal  deliveries  of  varying  dura-
tion  and  financial  incentives  for  doctors  and  hospitals383  influence  the  deci-
sion-making  process  of  health  providers.  Births  during  weekends  and  holidays 
are  becoming  less  and  less  frequent  in  Spain.384  Overmedicalisation  in  private 
healthcare is also well known.385 Nevertheless, the Strategy directly excluded 
private hospitals from its scope while, paradoxically, private hospitals are the 
ones that most need to adapt practices to scientific evidence. With regard to pub-
lic hospitals, the systematic and stable differences in childbirth care indicators 
between the 17 Autonomous Communities, who under the Spanish system are 
responsible for territorial planning and the provision of health services, show that 
different health policies and organisational forms drive different results 
(with caesarean rates ranging from 15% to 32% across regions). 

Another crucial issue is that the mechanism of coordination that should ensure 
that the recommendations of the Strategy are transmitted to the Autonomous 
Communities and from there to practice in the hospitals through updating 
protocols and staff training does not work correctly. Thus, five years after 
the approval of the Strategy, only 15.5 % of the NHS hospitals had incorporated 
all the main recommendations for birth into their protocols. This highlights the 
need to update care protocols according to Strategy recommendations, 
but also shows that positive changes depend basically on the interest of the 
professionals of the hospital and above all, of the people responsible for 
the service.386 The Ministry of Health explicitly considered the lack of knowl-
edge or updating of health providers about the evidence-based recommen-
dations of the Strategy among the causes of the low level of compliance with 
care indicators. 

A  very  important  fact  is  that  the  normalisation  of  obstetric  violence  in-
creases according to the student’s year of study, i.e. a lower perception of 
obstetric violence is found among more advanced students, thus being essential 

382   El Diario (2022a).

383   Visser et al. (2018).
384   Recio Alcaide & Müller (2016).
385   Recio Alcaide (2015).
386   Ministerio de Sanidad (2012).

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to change the training of health personnel and continue their solid founda-
tion in ethics, gender and human rights.387 The training of health personnel 
should take in account that there is a higher perception of obstetric violence 
among Spanish female health professionals388 and that, while the propor-
tion of women in obstetrics and gynaecology is higher than men, gynaecology 
and obstetrics services continue to be led mostly by men.389 

Other structural problems are the low ratio of midwives390 and their insuf-
ficient autonomy to attend births. Optimal staff conditions would ensure that 
lack  of  time,  staff,  funding,  infrastructure  or  resources,  shift  changes, 
night shifts, weekends and vacation days do not play a key role in the excess 
of  inductions  or  caesarean  sections.391  The  fact  that  in  Spain  there  are  hardly 
any alternatives to medicalised birth in a hospital, such as midwife-led 
birthing centres for low-risk births or home birth within the NHS, favours 
the model of birth with non-evidence-based interventions.

Gender stereotypes are active in Spain, as in the rest of EU countries, and 
reinforce the belief that women are inferior to men and their roles in so-
ciety are different. Even if most gynaecology and obstetrics professionals in 
hospitals in Spain are women (70%), 100% of parturient are women and gen-
der  stereotypes  of  submissiveness  are  projected  onto  them,  not  onto  medical 
services personnel, mostly led by men. Regarding pregnancy and birth, gender 
stereotypes  emerge  when  the  correct  behaviour  of  women  is  equated  to 
leaving everything to the doctor’s judgement or when women are judged or told 
off for making decisions, e.g. not getting an epidural.392 It is not well seen that 
a woman screams in labour instead of being calm, that she lets herself be 
carried away by her body, or that she decides or questions medical practices. 
Women  are  very  frequently  treated  as  inferior  in  health  settings  and  they 
are infantilised – being addressed with a familiarity that they have not 
requested is commonplace. 

In the case of S.F.M. v. Spain,393 the Committee observed that the administrative 
and judicial authorities of Spain employed stereotypical and thus discriminatory 
notions  by  assuming  that  it  is  for  the  doctor  to  decide  whether  or  not 
to perform an episiotomy, stating without explanation that it was ‘perfectly 
understandable’  that  the  father  was  not  allowed  to  be  present  during  the  in-
strumental delivery and taking the view that the psychological harm suffered by 
the complainant was a matter of ‘mere perception’ – but that they did show 
empathy towards the father when he stated that he had been deprived of 
sexual relations for two years. In the case of N.A.E. v. Spain,394 the Committee 
observed again that the administrative and judicial authorities of the State party 
applied stereotyped notions and, therefore, were discriminatory, assuming, for 
example, that it is the doctor who decides whether or not to perform the 
caesarean section without duly analysing the various evidence and reports pro-
vided by the complainant that precisely indicated that a caesarean section was 
not the only alternative, or by assuming that the psychological injuries suffered 

387   Mena-Tudela et al. (2020).
388   Mena-Tudela et al. (2020).
389   El Parto es Nuestro (2022c). 
390   Diario Médico (2022); El Diario (2022b); El Periódico de Aquí (2022).
391   Recio Alcaide & Müller (2016); Costa-Ramón et al. (2018).
392   UNED (2015).
393   CEDAW (2020).

394   CEDAW (2022).

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by the complainant were a matter of mere perception. 

In general, there is a lack of awareness that women’s decisions must be 
respected even if they go against medical criteria. Gender  stereotypes  im-
pede seeing that the Law 41/2002 of Patient Autonomy also applies to 
women in labour. Health professionals acknowledge patriarchal system as 
an  underlying  factor  of  obstetric  violence.395  The  sexism  of  the  Spanish 
Society of Obstetricians and Gynaecologists (SEGO) was denounced by activists 
when the cartoons of the SEGO electronic gazette offered a degrading image of 
Spanish women396 and the complaint had a huge impact in the media.397 

When  analysing  midwives’  experiences  regarding  obstetric  violence  in  Spain, 
most claimed to have witnessed obstetric violence and to have been trained 
to practise it. The experiences described by staff were clear examples of insti-
tutionalised violence against women giving birth and their babies. Among 
the sentences that midwives used to describe obstetric violence are398: ‘to pre-
pare a woman for c-section, without more indication that the interest is finishing 
before dinner time’; or ‘do not explain it to the women ... the less they know 
the better’; or ‘they teach us that we have to protect each other, if we wit-
ness any violence we always excuse ourselves by saying that what happened is 
right, we never say the truth to women or support them’; or ‘denying women 
water  or  being  able  to  stand  and  walk  during  labour’;  or  ‘doing  an  episiotomy 
without being indicated’; or ‘I saw a woman’s mouth being covered so that 
she could not scream’ ; or ‘accusing the woman of not wanting to give birth’.

The dynamics of power between health centres and patients are another cause of 
abuse and violence, aggravated by gender stereotypes about the role of women 
in  society.  As  the  UN  Rapporteur  highlights399:  ‘the  health  provider  has  the 
power  of  authoritative  medical  knowledge  and  the  social  privilege  of 
medical authority, while the woman is largely dependent on the provider for 
information and care. A woman during childbirth is also particularly vulner-
able. Although providers do not necessarily have the intention of treating their 
patients badly, ‘medical authority can thus foster a culture of impunity, when 
human rights violations do not only go unremedied, but unnoticed. This power 
imbalance is particularly apparent in instances in which providers abuse 
the doctrine of medical necessity in order to justify mistreatment and abuse 
during childbirth’. In Spain, these power dynamics are heavily established. None 
of the narratives and situations detailed here reflect a balanced power situation 
between patients and health staff. Unnecessary interventionism, to improve the 
comfort of health staff to the detriment of the good progress of delivery, does 
not reflect a balanced power situation either.

395   Mena-Tudela et al. (2022).
396   El Parto es Nuestro (2011°).

397   El Parto es Nuestro (2011b).

398  Olza-Fernández & Ruiz-Berdún (2014).

399   UN (2019).

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5.5 

Consequences 

The use and abuse of non-evidence-based clinical practices and the violation of 
the  right  to  integrity  and  autonomy  during  childbirth  have  long-lasting  conse-
quences on women’s sexual, reproductive and emotional/mental health, 
but also on the health of their newborns and on professionals. General 
adverse effects are a higher prevalence of maternal and newborn mortality 
and morbidity while effects have been described in detail for each concrete 
clinical practice in section 5.3.2. Childbirth can be a traumatic event for many 
women which can take years to recover from and different studies have found 
a high prevalence of trauma symptoms following childbirth.400

The health providers who work in pregnancy and birth care may also suffer 
this  violence,  feeling  like  accomplices  in  participating  in  it,  and  being 
traumatised after witnessing abusive and/or violent practices in a mo-
ment  of  maximum  vulnerability  for  the  parturient.  Naturally,  it  can  be 
difficult  for  professionals  to  accept  that  they  have  received  professional 
training and have been socialised in a paradigm based on the superiority of 
technological and intervened childbirth.401 Research has studied the conse-
quences of obstetric violence for healthcare professionals who have participated 
in birthing processes in Spain, in a survey on their opinion of obstetric violence.402 
To  the  question  of  giving  examples  of  obstetric  violence  that  they  had 
experienced, their literal answers were very diverse, e.g.: (1) ‘they taught me to 
pull the baby’s head, the systematic use of episiotomy, oxytocin, shaving of the 
pubis and enemas – against my better judgement and against the desires of the 
woman’; (2) ‘when a woman is sedated so that she remains quiet and compliant 
and  doesn’t  bother  to  healthcare  professionals’;  (3)  ‘when  a  student  performs 
an unnecessary instrumental vaginal delivery only to learn the technique’; or (4) 
‘when someone shouts that the woman isn’t doing it right and that she is going 
to kill her baby’. 

Obstetric violence also produces changes in some areas which affect the 
lives of healthcare staff. In some cases, they distrust other personnel when 
they diagnose and suggest treatment. Some of them abandon their jobs in 
hospitals to devote themselves to assist births at home. Others remain in their 
jobs, but suffer serious consequences, such as burnout or other psychological 
problems: ‘I fight for women’s rights, but nobody is fighting for me. My ethics, my 
principles don’t pay the bills. I give up’. The personal cost for sensitised staff is 
high. Many had to leave or change workplaces or even professions and suffered 
from secondary post-traumatic stress disorder.403 The cost of obstetric 
violence for themselves was described with sentences like: 

(1) ‘It forced me to leave the hospital. I changed hospitals several times’; (2) 
‘I had to leave and start attending home births’; (3) ‘I suffered burnout and 
mobbing. I stopped attending births’; (4) ‘I have had symptoms of depres-
sion and I’ve been crying remembering the delivery room, traumatised. A 
gynaecologist hit me once when I was gently and politely touching his arm 
to ask him to stop making a brutal Kristeller manoeuvre to a young woman 
in labour. The girl asked to stop and it continued and continued. It seemed 
like a rape. I still want to cry and have nightmares’; (5) ‘many times, I went 
home crying and had nightmares related to past births. And above all I have 

400   Olza-Fernández (2013).

401   Wagner (2001).

402   Ruiz-Berdún & Olza-Fernández (2016).

403   Olza-Fernández & Ruiz-Berdún (2014).

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felt deep guilt for having been accomplice to such violence’; or (6) ‘I have 
come to think that many of the complications that arise are our fault. And 
I know that I am right because the vast majority of births are complicated 
by the unnecessary work’. 

As these words show, health professionals can also suffer obstetric violence as 
well as its aftermath, e.g., long-lasting emotional distress or effects in their 
professional career and personal lives.

Other consequences of obstetric violence include a strengthening of gender 
stereotypes and inequality, on which discriminatory attitudes are based. When 
women’s  right  to  decide  is  stolen  and  their  right  to  autonomy  is  disrespected, 
sexist stereotypes about the passive and submissive role of women in 
society are reaffirmed. Each childbirth in which the woman’s right to autonomy 
is ignored feeds existing biases instead of confronting them, contributing 
to normalising the mistreatment and discrimination, not only in the field 
of  medicine.  This  is  manifested,  for  example,  in  the  inability  of  the  Spanish 
justice system to prevent and defend women from violence and discrimination 
against them. It is the case of S.F.M. v. Spain,404 where the CEDAW Committee 
considered that ‘stereotyping affects the right of women to be protected 
against  gender-based  violence,  in  this  case  obstetric  violence  and  that 
the authorities responsible for analysing responsibility for such acts should exer-
cise particular caution in order not to reproduce stereotypes. It is also the 
case of N.A.E. v. Spain,405 which had also to be taken to the CEDAW Committee, 
after appeals to the Constitutional Court in Spain and to the European Court of 
Human Rights were dismissed. As WHO also acknowledged in its Announcement 
on World Patient Safety Day 2021,406 ‘since maternity care is affected by issues 
of equality and gender violence, the experiences of women during childbirth 
can empower or inflict emotional harm and trauma’.

5.6  Obstetric violence and Covid-19 

The setback experienced in women’s rights during the Covid-19 pandem-
ic deserves a separate mention. On 13 March 2020, WHO published recommen-
dations on childbirth care, post-partum and lactation regarding the coronavirus 
disease407 that have not yet changed.408 In them, WHO indicated that all pregnant 
and  post-partum  women  and  their  newborns  –  including  those  with  confirmed 
or  suspected  Covid-19  infections  –  have  the  right  to  high-quality  care  before, 
during  and  after  childbirth,  including  mental  healthcare.  The  recommendations 
emphasise that a safe and positive childbirth experience includes: being treat-
ed with respect and dignity, having a companion of choice during delivery, 
developing clear communication with maternity staff, accessing appropriate 
pain relief strategies, engaging in mobility during labour where possible and 
adopting the birth position of choice. 

404   CEDAW (2020).
405   CEDAW (2022).
406   WHO (2021).
407   WHO (2020).

408   Coronavirus disease (COVID-19): Pregnancy, childbirth and the postnatal period: https://www.who.

int/news-room/questions-and-answers/item/coronavirus-disease-covid-19-pregnancy-and-childbirth#:~:-

text=What %20care %20should %20be %20available,childbirth %2C %20including %20mental %20health 

%20care.

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If Covid-19 is suspected or confirmed, health workers should take all appropriate 
precautions to reduce risks of infection to themselves and others, including hand 
hygiene and appropriate use of protective clothing like gloves, gown and medical 
mask.  When  asked  if  pregnant  women  with  suspected  or  confirmed  Covid-19 
need to give birth by caesarean section, WHO clarifies that WHO advice is that 
caesarean  sections  should  only  be  performed  when  medically  justified 
and that the mode of birth should be individualised and based on the woman’s 
preferences, alongside obstetric indications. When asked if a woman with sus-
pected or confirmed Covid-19 can touch and hold her newborn baby, WHO advice 
is affirmative: close contact as well as early and exclusive breastfeeding 
helps a baby to thrive. The mother should be supported to breastfeed safely, with 
good  respiratory  hygiene,  hold  her  newborn  skin-to-skin  and  share  a  room 
with her baby.

Nevertheless, Spanish activists have denounced that during the Covid-19 pan-
demic there has been an increased loss of control by women in their re-
productive processes and rights by violating the right to their autonomy, their 
integrity and their capacity to make informed decisions about their reproductive 
health.409 Indeed, Childbirth is Ours has denounced that, during many months of 
the  pandemic,  the  association  received  a  great  number  of  complaints  and 
concerns not only from women, but also from health staff, mostly mid-
wives, about the violation of the rights of women and newborn that occurred 
during childbirth as a result of the pandemic.410 The most frequent complaints 
had to do with: (a) The violation of the right of women to be accompanied 
during childbirth by a person of their choice, both in Covid-19 positive and PCR 
negative women, against WHO recommendations; (b) The violation of the right 
of women not to be separated from their newborn without a medical indica-
tion that supported it, alluding to logistical reasons. In many Spanish hospitals, a 
protocol for the separation of infants of asymptomatic mothers with positive PCR 
or  pending  confirmation  was  imposed,  against  WHO  recommendations;  (c)  The 
obligation to give birth with a mask; (d) Having been subject to induced 
labour protocols and even caesarean section, if suspected Covid-19, against 
the  WHO  recommendations;  and  e)  Having  been  subject  to  interventions 
aimed at accelerating and shortening the time delivery, such as the use of 
oxytocin or instrumentalisation of childbirth, against WHO recommendations. Re-
search has also described the impact of the pandemic on new and expectant par-
ents in Spain, showing that the main issues for them were the limited access of 
partners to antenatal care services and mother–newborn separation.411

409   El Parto es Nuestro (2021).
410   El Parto es Nuestro (2021).
411   Colaceci et al. (2022); Vila-Candel et al. (2022).

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5.7 

Achievements and challenges 

There is an evident lack of official information on obstetric violence. Although 
the CEDA Committee in 2020 specifically urged Spain to conduct research into 
obstetric violence,412 no official reports, studies, surveys or statistics have been 
launched so far. No official information exists on the violation of the right 
to  autonomy of  women  giving  birth  and, although aggregated information 
regarding perinatal indicators is available, information is scarce at the hos-
pital level, especially in the private sector. This prevents women from making 
informed decisions on where to give birth, based on objective information that 
is collected by official statistics and exists but is not made public. The su-
pervision of hospital centres and the annual compilation and publication of 
data by hospital, both for public and private hospitals, on the percentage 
of caesarean sections, inductions, episiotomies and other reproductive health in-
dicators, easily accessible to users, is a long-held request of Spanish activism, 
but has not yet been granted. It is also a widely indicated recommendation 
by national and international organisations, such as the UN,413 the Spanish 
Ministry of Health (Ministerio de Sanidad 2012), the Council of Europe in its the 
Resolution on Obstetric and gynaecological violence, the CEDAW Committee,414 
WHO415 and the general recommendation on the public availability at the hospital 
level  of  indicators  of  delivery  care,  made  in  the  WHO  Statement,  ‘Appropriate 
Technology for Birth’.416

5.8 

Relevant initiatives and their impact 

5.8.1 

Initiatives leading to political action

Relevance of the topic in political and institutional debate

Spanish  activists  have  been  denouncing  obstetric  violence  for  years.  However, 
politicians and institutions have only focused on childbirth care, which caused the 
approval of the Strategy in 2007 without a human rights violation approach. It 
has been in the last four years when, together with the fourth feminist wave 
and the recognition by international institutions of the phenomenon, obstetric 
violence  has  begun  to  gain  relevance  in  political  and  institutional  de-
bate. The first sentence of the CEDAW on obstetric violence – Spain being the 
state party – was known at the end of February 2020 and, also in 2020, the term 
‘obstetric violence’ was included in the Law 17/2020 of Catalonia and debated 
within the Ministry of Equality at the request of Childbirth is Ours. The debate at 
the  political  and  institutional  level  has  become  manifest  on  several  occasions. 
The pressure exerted by medical colleagues and colleges who reject the term has 
had an effect – with the final non-inclusion of the term obstetric violence in the 
Valencian Law, in the Law of La Rioja and in the Reform of the Sexual and Repro-
ductive Health Law of the national legislation. However, the term was included in 
March 2022 in the Basque Country legislation. 

412   CEDAW (2020).

413   UN (2019).
414   CEDAW (2020).
415   WHO (2014a).
416   WHO, (1985).

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In raising awareness, the birth rights movement has been pivotal in the 
2020s, when requesting the Ministry of Equality to include the term in national 
legislation both formally – through allegations – and informally – through cam-
paigns on social networks. Along with these actions, the complaints and tenac-
ity of the victims and their lawyers were decisive – after receiving refusals 
from the Spanish judicial system, they took their cases to the UN, working and 
waiting for years to obtain recognition of the violence to which they had been 
subjected. Recognition of the topic by some healthcare providers also played a 
major role.

Degree of recognition of the topic by healthcare providers

There exists a strong resistance and denial of some health practitioners 
and professional bodies. The General Council of Official Colleges of Physicians 
(CGCOM) and the Spanish Society of Gynaecology and Obstetrics (SEGO) reacted 
to the announcement of the inclusion of obstetric violence in national legislation 
asserting that the term is offensive, does not conform to reality and crim-
inalises professionals. In their statements, they emphasise that they adhere 
to the position issued by the scientific community’ and guarantee the absence 
of violent acts in patient care. They recall the commitment of the specialists in 
gynaecology and obstetrics to ensure the wellbeing of women. The use of the 
term ‘violence’, they argue, is offensive since obstetric procedures that may be 
considered excessive and inappropriate would, in any case, be actions based on 
the principle of beneficence, seeking the best for women. They further state 
that the medical profession asks for caution and not to create unnecessary social 
alarms  that  can  contribute  to  deteriorating  the  necessary  trust  between  the 
doctor and his patient; rigour to denominate professional practices and respect 
for specialists who work with dedication, service, humanity and ethics.417

Other professional bodies, such as the Federation of Associations of Midwives 
of Spain,418 argue that obstetric violence is exercised against the human rights 
of women because they are women (that is why it is gender violence) and goes 
against their dignity and integrity, with the aggravating factor of the special vul-
nerability  that  occurs  in  the  circumstances  surrounding  reproduction.  Obstetric 
violence not only harms women, it also degrades the professionals who carry it 
out and goes against their own ethics and dignity. They also said that nobody 
can say that they are not aware of the existence of obstetric violence in 
the public and private health systems in Spain. 

The Catalan Society of Obstetrics and Gynaecology and the Council of Medical 
Associations of Catalonia419 declared that the use of the term ‘obstetric violence’ 
generates rejection in most health professionals, to the extent that it suggests 
intentionality and willingness to exercise violence against women. Professionals 
perceive that their professionalism is questioned when the goal of every pro-
fessional is to ensure the health and wellbeing of the people it assists. Neverthe-
less, the SCOG also declared that, despite the discomfort that the term obstetric 
violence may generate, it has been internationally recognised and adopted by the 
United Nations and by the European Commission, among other organisations and 
institutions. The Generalitat of Catalonia itself has regulated it and defined its 
meaning in the Law 17/2020 of Women’s Right to Eradicate Sexist Violence. They 

417   CGCOM (2021); SEGO (2021).
418   FAME (2022).
419   SCOG (2022).

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concluded that it is appropriate, therefore, to overcome the rejection that 
the term initially provokes to grasp its real meaning and be able to enter 
into the debate of the substantive issues. 

Finally,  medical,  nursing  and  psychology  student  associations420  reacted 
with a position statement in which they request the updating of both teaching 
material and protocols, due compliance with international recommendations on 
the obstetric practices in all state hospitals, development of specific legislation 
that protect the people present in the obstetric circuit from this type of violence 
and greater visibility of this problem.

In  summary,  women’s  complaints  over  the  years  through  testimonies,  cam-
paigns  and  legal  proceedings,  together  with  the  recent  recognition  of  inter-
national organisations and the self-reflection of the health providers them-
selves, support increasing awareness of the problem of obstetric violence among 
practitioners and staff.

Degree  of  recognition  of  the  topic  by  the  general  public  and  women,  effective 
measures  implemented,  how  was  awareness  raised  and  resistance  overcome, 
role of local social movements and bottom-up approach

Improving childbirth care in Spain has been and is a collective effort. Among 
local  associations,  movements  and  networks  that  have  fought  for  birth  rights 
in  Spain  are,  for  example:  Dona  Llum  [Women  Birth],  El  Parto  es  Nuestro 
[Childbirth is Ours], Iniciativa para la Humanización de la Asistencia al Na-
cimiento y la Lactancia [Initiative for Humanisation of Birth and Breastfeeding 
Care], Naixença [Birth], Observatorio de Violencia Obstétrica [Observatory 
of Obstetric Violence], Parir en Libertad [Give Birth in Freedom], Plataforma 
Pro Derechos del Nacimiento [Pro Birth Rights Platform], Umamanita [Peri-
natal and Neonatal Death Support], and Vía Láctea [Milky Way], among others. 
Together  with  decision-making  professionals,  policymakers,  institutions  and 
health centres – teams and individuals belonging to different civil or civic 
spheres – they have all contributed to raise recognition of the topic of 
obstetric violence.

Detailing the contribution of so many participants is beyond the scope and length 
of this report. But Annex 1 offers a description of how one of those grass-
roots associations – El Parto es Nuestro [Childbirth is Ours] – contributed 
to the reform of the birth care system in Spain. Its bottom-up approach 
is paradigmatic on how women’s movements have raised awareness and 
overcome resistance in Spain.421

Contacts  between  associations  and  public  institutions  have  continued  through 
the  years,  regardless  of  the  type  of  national  or  regional  governments.  But  it 
has been during the current legislature (from 2019 up to now), thanks 
to all birth rights activism and increasing awareness of the Ministry of 
Equality, that obstetric violence was definitely positioned at the national 
political and institutional level, forcing all stakeholders to make their views 
known and giving obstetric violence unprecedented visibility in the media.

420   AEEE et al. (2021).

421   Villarmea et al. (2016).

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5.8.2 

Initiatives to combat obstetric violence

Relevant initiatives 

In addition to the initiatives put in place by birth activism described previ-
ously, obstetric violence – or some of its manifestations, especially overmedical-
isation – has been addressed in the Strategy for Normal Birth Care of the 
Ministry of Health, in the cited regional legislation of Catalonia and the 
Basque Country – which name obstetric violence as one more type of violence 
against  women  –  and  in  the  Reform  of  the  Law  2/2010,  which  –  without 
naming the term – deals with several of its manifestations and provides solutions 
to some problems encountered by the Strategy.

As revealed, the Strategy has only been effective to a certain extent. Among its 
barriers is the fact that it is voluntary and that its implementation remains 
subject to the will of health advisers, hospital managers and service heads. Pro-
viding a solution to this problem is the goal of the common protocol of actions 
reflected  in  the  Reform  of  Law  2/2010,  but  its  effectiveness  remains  to  be 
seen. Besides, the inclusion of the term in regional legislation, by itself, cannot 
correct the problem effectively. Recognition in the law must be accompanied 
by effective measures that address the structural causes of the phenomenon.

There  are  no  institutional  initiatives  or  support  to  denounce  obstetric 
violence except the legal and financial support – sometimes via crowdfund-
ing  –  offered  by  activism.  Denouncing  cases  of  obstetric  violence  is  a 
long and tortuous road for victims and their lawyers since, as the CEDAW 
Committee  states,  they  face  gender  stereotypes  in  the  very  judicial  processes 
that are supposed to protect their rights.422 It is also worth emphasising that the 
views  of  the  CEDAW  Committee  have  so  far  been  ignored  by  Spanish 
institutions and the victims have not yet been compensated.

Initiatives  to  involve  and  train  professionals  in  recognising,  understanding  and 
preventing obstetric violence 

One of the strategic lines of the Strategy is to promote the specialisation and 
continuous training of professionals. To this end, the Strategy recommen-
dations are: (a) To train in knowledge and skills of medical and nursing staff, 
both  during  early  education  and  development  of  a  professional  career;  (b)  To 
facilitate the training of trainers; (c) To train health personnel to improve com-
munication with women and share decisions and responsibilities; and (d) 
To include equity aspects in training activities, taking in account the gender 
perspective, with special emphasis on the empowerment of women, multicul-
turalism and diversity. At this point, a wide variability was observed between 
Autonomous Communities, both in the number of courses that have been 
organised  and  attendees.  Regarding  the  professional  profile  of  the  attend-
ees, midwives attend in greater numbers (40 %), followed by paediatricians 
(19 %), nurses (14 %), obstetricians (13 %), family doctors (8 %) and other 
professionals 6 % (physiotherapists, social workers and lactation monitors). The 
over-representation of midwifes shows the need to guarantee that continuing 
education reaches all personnel uniformly in a coordinated manner.

422   CEDAW (2020); CEDAW (2022); Fernández Guillén (2022).

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The CEDAW Committee has recommended that Spain provide obstetricians and 
other health workers with adequate professional training on women’s reproduc-
tive health rights and to provide training  to  judicial  and  law  enforcement 
personnel.423 In this sense, the Reform of the National Organic Law 2/2010 
of Sexual and Reproductive Health and of the Voluntary Interruption of 
Pregnancy considers in Article 29 the training of the personnel of the gynaecol-
ogy and obstetrics services for the respect and guarantee of women’s rights. It 
has recently been shown that educational interventions remain an effective way 
to change health sciences students’ perception of obstetric violence.424 
In the meantime, some training on obstetric violence for professionals and 
university students is in place.425

Initiatives to support women in the exercise of their reproductive rights, especially 
the right to enjoy a positive, respectful and free-of-harm birth experience and to 
support victims of obstetric violence

Initiatives to support women in the exercise of their reproductive rights are found 
in the Strategy, the Reform of the National Organic Law 2/2010 and birth rights 
activism.

The chapter on the ‘Protection and guarantee of sexual and reproductive 
rights  in  the  gynaecological  and  obstetric  field’  of  the  Reform  of  the 
National Organic Law 2/2010 is intended to guarantee women the exercise 
of  their  reproductive  rights,  especially  the  right  to  enjoy  a  positive,  respectful 
and harm-free childbirth experience, since it recognises in Article 27 the right to 
mandatorily require the free, prior and informed consent of women in all 
invasive  treatments  during  delivery  care;  to  reduce  interventionism,  avoid-
ing  unnecessary  and  inappropriate  practices  that  are  not  supported  by 
scientific evidence; to provide respectful treatment and clear and sufficient 
information; and to guarantee the non-separation of newborns from their 
mothers and other people with a direct link to them. 

Regarding  initiatives  to  support  victims,  it  is  the  very  health  institution, 
whether public or private, which paradoxically provides the applicable – and 
limited – health services to overcome the consequences of the institu-
tional violence of obstetric violence. In addition, the Preliminary Draft foresees 
advice  to  women  about  their  rights  and  the  provision  of  channels  for 
claims  that  may  be  made  by  those  who  have  been  affected  by conduct 
contrary to those established in the respective Chapter. This support can be not 
only psychological, but also legal. Currently, victims basically only receive the 
support of women’s associations committed to rights during childbirth.

423   CEDAW (2020).
424   Mena-Tudela et al. (2020).

425   El Parto es Nuestro & Lo Cascio (2021).

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Initiatives to deconstruct general assumptions on childbirth, (over)medicalisation 
of reproductive health, gender and other stereotypes, naturalised behaviours, be-
liefs, practices or power dynamics

Under the umbrella of the Strategy, a series of guidelines were published, with 
recommendations based on the available scientific evidence: Clinical Practice 
Guideline  on  Care  for  Normal  Childbirth,426  Clinical  Practice  Guideline  on 
Breastfeeding,427  Clinical  Practice  Guideline  on  Care  during  Pregnancy 
and Puerperium428 and Neonatal Care Guideline,429 as well as the National 
Strategy for Sexual and Reproductive Health.430 They all contributed to de-
constructing general assumptions on childbirth and reducing overmedicalisation.

The Reform of the National Organic Law 2/2010 foresees a Common Protocol of 
Actions to protect sexual and reproductive rights in the gynaecological and ob-
stetric field, which will include the necessary measures so that the health sector 
contributes  to  guaranteeing  sexual  and  reproductive  rights  in  this  area.  Above 
all, a huge effort has been made by CSOs to deconstruct general assumptions 
on  childbirth,  the  overmedicalisation  of  reproductive  health,  gender  and  other 
stereotypes, beliefs, practices and power dynamics. A good example can be found 
in the peer and support groups organised by Childbirth is Ours – online and in 
person – where women support each other and exchange information and 
in the numerous campaigns carried out by the organisation.

5.9 

Conclusions and recommendations

Clinical practice regarding birth care in Spain continues to be excessively inter-
ventionist. Despite recent health policy efforts, there is much room for clinical 
practices being aligned to standards and recommendations, thus being evidence- 
and values-based. Childbirth, a physiological process that should be treat-
ed as such, is frequently full of interventions with no medical justification 
from the moment the woman enters a hospital. Private healthcare especially 
stands  out  for  its  unwarranted  interventionism,  although  overmedicalisation  is 
widespread in the public system too. Women and newborns – but also health 
staff – suffer overmedicalisation directly on their bodies, minds and lives, with 
physical, mental and other consequences in the short and long run. More-
over,  many  of  the  excessive  or  routine  interventions  are  performed  without 
the woman’s informed consent or even with its explicit denial – this con-
stitutes  a  forced  intervention,  thus  violating  her  human  right  to  integrity 
and to decide on her body and reproductive processes. Ignoring autonomy 
and violating physical integrity constitute abuse and mistreatment, that is often 
accompanied by degrading and humiliating comments which further strip 
women of their decision-making power.

The ideal of technological childbirth, gender stereotypes, organisational 
factors, working conditions of health professionals and medical power over 
patients are structural causes behind mistreatment during childbirth care. The 
internationally  accepted  notion  of  describing  this  structural  ‘mistreatment’ 
during  childbirth,  pregnancy  and  post-partum  care  is  obstetric  violence.  De-
spite some recent efforts to legally recognise the existence of obstetric violence 

426   Ministerio de Sanidad (2010b).
427   Ministerio de Sanidad (2017).

428   Ministerio de Sanidad (2014).

429   Ministerio de Sanidad (2010°).

430   Ministerio de Sanidad (2011).

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in Spain, either regionally or nationally, medical colleges’ pressure on regional 
and national governments has had an effect, dissuading some of the initial 
intentions to legally recognise it and protect women from this type of 
violence.  However,  professional  awareness  on  the  issue  is  high.  Spanish 
civil society and women’s complaints have played a crucial role in raising 
awareness on the subject, with an impact on public health policies. But it 
has been in recent years, with the fourth feminist wave and the recognition 
by international institutions of the phenomenon – including two sentences of 
the CEDAW Committee on obstetric violence in which the State party is Spain – 
that obstetric violence has begun to gain relevance in political and institutional 
debates as a human rights issue.

There is a need to accompany the institutional recognition of obstetric violence 
with effective measures, sufficient guarantees and coordination to address 
its causes, to change the paradigm of medicalised birth with staff training 
and  updating  and  to  ensure  that  the  Law  41/2002  of  Patient  Autonomy 
applies  to  pregnant  women.  The  Reform  of  the  National  Organic  Law 
2/2010 of Sexual and Reproductive Health and of the Voluntary Inter-
ruption of Pregnancy was an opportunity not to be missed.

In the light of the above conclusions, the following concrete recommendations 
are made for Spain:

Institutional  recognition  of  the  occurrence  of  obstetric  violence.  Spain 
should legally recognise the occurrence of obstetric violence and its causes as a 
widespread and systematic phenomenon and as a form of violence against wom-
en.  Recognising  the  mistreatment  that  women  are  subjected  to  during 
childbirth and its structural causes helps to increase awareness and to 
address its driving factors. The adoption of legislative and policy measures to 
address violence against women during reproductive health services has already 
been addressed by the UN (2019). Admitting the existence of obstetric vio-
lence means recognising the gravity of the testimonies of women.

Allocation  of  sufficient  funds  for  staff,  equipment,  training,  birth  care 
and improvement. Women’s right to achieve the highest level of sexual and re-
productive health is recognised in Article 95 of the Beijing Declaration (UN 1995), 
of  which  Spain  is  a  signatory.  To  meet  this  obligation,  Spain  must  devote  the 
necessary available resources to sexual and reproductive health as well as adopt 
a  human  rights–based  approach  to  determining  needs  and  budget  allocations. 
Staff  conditions  should  be  optimal:  organisational  and  logistical  changes 
should  be  made  to  ensure  that  lack  of  time,  staff,  infrastructure  or  re-
sources, shift changes, night shifts, weekends and vacation days do not 
play a key role in excessive medical interventions. 

Guarantee  of  medical  practices  supported  by  scientific  evidence  and 
eradication of outdated practices or those based on beliefs and customs. 
Evaluation and monitoring of indicators on childbirth care in Spain reveal a lack 
of adaptation of clinical practice to the standards of and recommenda-
tions  by  national  and  international  health  institutions.  The  surplus  of  medical 
interventions  and  the  unjustified  variability  across  regions  and  hospitals  have 
been  highlighted  in  different  statements  and  studies.  The  crisis  caused  by  the 
Covid-19 pandemic has led to a setback of medical practices without the sup-
port of scientific evidence, despite the available specific recommendations from 
WHO  for  pregnancy  and  delivery  care  during  the  pandemic.  A  mechanism  of 
coordination and control should ensure sufficient guarantee that clinical 
practices are evidence- and values-based.

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5 SPAIN by Stella Villarmea and Adela Recio Alcaide

Inclusion of the recommendations of the Strategy for Normal Birth Care 
and associated guidelines in hospital protocols and regional health plans. 
The inclusion of the Strategy recommendations in hospital protocols offers a guar-
antee of a clinical practice that is more in line with these recommendations, as 
its evaluation concluded that the presence of a complete protocol is related 
to  better  compliance  with  the  Strategy  recommendations  (Ministerio de 
Sanidad 2012). However, five years after the approval of the document, only 15.5 
% of the NHS hospitals had incorporated all the main recommendations for birth 
into their protocols. The level of adherence to the Strategy needs to be raised; 
leaving it at the level of recommendations has not introduced the expected prac-
tical  implementation,  despite  the  strong  scientific  evidence  that  supports  each 
recommendation. Protocols and regional health plans should include rec-
ommendations listed in the Strategy and all its clinical practice guide-
lines  and  associated  documents.  Updates  should  include  recommendations 
for high-risk births. A mechanism should ensure its compulsory inclusion in 
hospital protocols and regional health plans. 

Extension of the scope of the Strategy to private healthcare. The Strategy 
has meant progress and has had a positive and significant effect on improving 
childbirth care. Hence, the implementation of its strategic lines and recommen-
dations  must  be  considered  a  public  health  issue  with  no  distinction  between 
public or private health. After all, it is in private centres where a greater number 
of  obstetric  and  medical  interventions  are  carried  out  without  the  support  of 
scientific evidence. The eradication of violence during childbirth requires 
a cross-cutting approach from which private healthcare cannot be ex-
cluded.

Guarantee  of  informed  consent  for  women  in  labour.  Spain  must,  in  ac-
cordance  with  United  Nations  and  human  rights  recommendations:  (1)  Guar-
antee the proper and effective application of the requirement to obtain 
informed consent in accordance with human rights standards; (2) Adopt 
laws and policies on health that are effective for the application of the re-
quirement of obtaining informed consent in all reproductive health services. 
Policies should be along the lines of guaranteeing rights that are already covered 
by the law, for example with adequate monitoring of practices around informed 
consent in hospitals and correction where necessary; and (3) Respect women´s 
rights to integrity and autonomy to make informed decisions about their 
reproductive health.

Transparency,  improvement  of  the  evaluation  of  birth  care,  and  publi-
cation  of  the  main  indicators  by  hospital.  There  is  a  lack  of  transparency 
regarding  birth  care  information  at  the  hospital  level,  especially  in  the  private 
sector, that prevents citizens from making informed decisions based on objective 
information that should be public. The supervision of hospital centres and the an-
nual compilation and publication of data by hospital, both for public and 
private hospitals, on the percentage of caesarean sections, vaginal deliveries, 
episiotomies and other reproductive health indicators is essential. Its results by 
hospital must be public and easily accessible to users of reproductive health 
services, as recommended widely by international institutions. Carrying out stud-
ies on obstetric violence that highlight the prevalence of the situation 
and orientate public policies to fight such violence is indispensable, as pointed 
out by the CEDAW Committee.431

431   CEDAW (2020, 2022).

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5 SPAIN by Stella Villarmea and Adela Recio Alcaide

Greater  recognition,  number  and  autonomy  of  midwives  in  hospitals,  as 
adequate professionals to attend normal births. One of the key recommenda-
tions in the Ministry of Health’s Clinical Practice Guideline on Care for Normal Child-
birth on the profile of professionals is that hospital teams promote low-risk birth 
care, preferably by midwives, as long as birth develops within normal limits. It 
also recommends that women in labour be attended individually by a midwife 
during the whole length of their stay.432 To that aim, the low ratio of midwives 
and their insufficient professional independence must urgently be addressed. 

Training of health professionals and continuous updating of their skills 
and knowledge in accordance with the available scientific evidence. Ed-
ucational  programmes  to  train  and  update  health  professionals  on  matters 
of  health,  law,  gender  and  relevant  disciplines  have  been  found  to  be 
critical. This type of education is included in one of the four strategic lines of the 
Strategy;433 the development and continuation of such programmes was recom-
mended by the Ministry of Health in the 2012 evaluation.434

Training on obstetric violence with a gender and human rights perspec-
tive  for  health  and  judicial  personnel.  Adopting  a  gender  and  human 
rights perspective to train health and judicial personnel on obstetric vio-
lence, and developing awareness-raising actions on its consequences for women, 
newborns and health providers, is of utmost importance to address human 
rights  violations  against  women,  as  indicated  in  the  recommendations  of 
international organisations – e.g., UN, Council of Europe and CEDAW Committee.

Adaptation  of  birth  care  spaces:  guarantee  of  joint  mother-newborn 
admissions and 24-hour access to neonatal units for mothers and com-
panions.  The  European  Charter  for  Hospitalised  Children,  approved  by  the  Eu-
ropean  Parliament  in  1986,  expressly  includes  ‘the  right  of  the  child  to  be 
accompanied by their parents or the person who replaces them, for as long as 
possible during their stay in the hospital, not as passive spectators, but as active 
elements of hospital life’. And yet, the Ministry of Health recognises that ‘there 
are still barriers to family access to neonatal units. The newborn has the 
right to receive maternal or paternal care and its development is linked in part 
to the quality of the future interaction with their family’.435 The hospitalisation 
of mothers and their children in individual rooms should be guaranteed and the 
neonatal intensive care units should have their doors open 24 hours a 
day  for  the  mother  and  her  companion,  with  care  focused  on  the  family  and 
wellbeing, as recommended by the Ministry of Health.436

Guarantee  options  other  than  hospitals,  such  as  birth  centres,  run  by 
midwives in the public health system. The fact that there are hardly any al-
ternatives to medicalised birth in a hospital, such as midwife-led birthing 
centres for low-risk births or home birth within the NHS, strengthens the 
model  of  highly  intervened  births.  Options  other  than  hospitals  should  be 
available that citizens can choose within the Spanish public health system, 
the place they prefer to give birth, be it a hospital, a birth centre or their 
own  home,  if  safety  conditions  are  met,  as  recommended  by  the  UN  (2019), 
professionals437 and experts.438

432   Ministerio de Sanidad (2010b).
433   Ministerio de Sanidad (2007).
434   Ministerio de Sanidad (2012).
435   Ministerio de Sanidad (2010a).
436   Ministerio de Sanidad (2010a).
437   FAME (2020).
438   Ruiz-Berdún et al. (2022).

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Annex 1

Annex 1 - Evolution of the 
obstetric violence debate 
in Spain: the case of 
Childbirth is Ours

The evolution of the debate on obstetric violence in Spain is the result of a col-
lective action (see above section 5.8.1). Describing the actions of so many partic-
ipants is beyond the scope and length of this report. But the report considers 
it important to offer a description of the actions undertaken by at least 
one of those grassroots associations. The authors have chosen El Parto 
es Nuestro [Childbirth is Ours] because its bottom-up approach is para-
digmatic of how women’s movements raise awareness, overcome resist-
ance and contribute to the reform of the birth care system in Spain.439

To  portray  the  evolution  of  the  debate  on  obstetric  violence  in  Spain, 
Annex 1 uses the philosophical Theory of Controversies440– which classi-
fies polemic exchanges or debates into three ideal and technical epistemic types: 
discussions, disputes and controversies – to illuminate how critical ration-
ality and civil action shaped the evolution of the debate on obstetric vi-
olence and played a key role in implementing effective measures against 
it in Spain.441

Phase 1 of the debate: ‘discussion’

According to the Theory of Controversies, a debate is in a phase of ‘discussion’ – 
in Dascalian terms – when disagreements are considered as experts-only issues. 
During this first phase of the debate on birth care then, birth care was meant 
to be discussed exclusively by professionals. As a consequence of this, already 
in 2002 Spanish obstetricians were being criticised for not allowing women to 
participate in decisions about their maternity care.442 To counterbalance the ap-
proach where only experts are allowed to be involved, in order to bring the dis-
cussion of birth rights to the table and birthing women’s voices to be heard, the 
association El Parto es Nuestro was founded on the basis of the previous 
group Apoyocesáreas [Caesarean Sections Peer Support] by 21 mothers and 1 
father in October 2003. A transcription of an oral statement of motivation 
by one of its founders on what led to set up the association can be read in 
Testimony 7 in Annex 2.

439   Villarmea et al. (2016).
440   Dascal (1998).
441   Villarmea et al. (2016).
442   Johanson et al. (2002).

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Annex 1

As described in its bylaws, the aims of the association are: (a) to provide psy-
chological  support  to  women  recovering  from  caesareans  and  traumatic 
births; (b) to improve maternal and infant care in Spain, promoting the respect 
for  the  WHO  recommendations  and  human  rights related to reproductive 
health  and  the  elimination  of  discrimination  against  women;  (c)  to  pro-
vide information on physiological, emotional and social aspects of reproductive 
and perinatal health and care; (d) to decrease the rate of unnecessary cae-
sareans and traumatic births; (e) to recover mothers’ and families’ role 
as  leading  actors  in  childbirth,  promoting  the  perception  of  childbirth  as 
a physiological process to banish fears and non-evidence-based inter-
ventions; (f) to offer legal support; (g) to promote independent midwifery 
studies; and (g) to support breastfeeding.

Since its creation, Childbirth is Ours has served to offer support to women who 
experience traumatic deliveries; to provide information to pregnant women and 
their  partners;  to  bring  the  topic  of  obstetric  violence  to  the  attention  of  the 
media; and (d) to reach out to institutions. The association’s intervention in the 
‘discussion’ helped move the polemic arena of the debate into the next phase, 
that of a ‘dispute’. 

Phase 2 of the debate: ‘dispute’

During  the  second  phase  of  ‘dispute’,  birth  rights  activism  becomes  an  active 
party in the debate. In this period, the association Childbirth is Ours plays a role in 
framing questions and answers as precisely as possible disputable issues. None-
theless, it was often the case that the organisation and its members were placed 
as ‘newcomers’ or outcasts in the exchange around birth matters; that is, birthing 
women were still be seen as tangential or lateral parties in obstetric debates.

Between 2004 and 2007, members of the association gave talks in civil and 
professional  forums,  such  as  obstetric  conferences,  midwifery  meetings  and 
breastfeeding  courses.  They  pointed  at  obstetric  violence  and  the  need 
to  hear  mother’s  voices.  They  contacted  the  media,  ombudsmen,  deci-
sion-makers  and  other  stakeholders,  and  also  wrote  letters  commenting 
news or reports on birth care.443 Since their primary goal was to ‘make the 
issue public’ – that is, to start a discussion in society and to offer proposals for 
improvement – some members of the association became very active in 
the media to highlight what was later to be labelled ‘obstetric violence’.

In 2004, the short film, Por tu propio bien [For your own good],444 fictional-
ly featured a man delivering a baby to draw attention on how mistreatment is 
more clearly seen if performed on a man than on a woman. The film ended with 
the line ‘Birth is Ours! Give it back to us!’’, a reference to the name of the birth 
rights  association.  Two  other  documentaries,  produced  by  Spanish  public 
television, explored the field: Los dolores del parto [Birth pains]445 analysed the 
rise in caesareans, and (2) De parto [On Labour]446 offered an in-depth analysis of 
obstetric care in Spain. Both documentaries interviewed several members 

443   Fernández del Castillo (2004).

444   Icíar Bollaín, Por tu Propio Bien, 2004, http://www.youtube.com/watch?v=rxpVqK8oNi0 [accessed 30 July 
2013].

445   Francesca Campoy, Los Dolores del Parto, http://www.youtube.com/watch?v=ddty4WuUaYU [accessed 30 

July 2013].

446   Mariona Ortiz and Anna Masllorens, De Parto, http://www.youtube.com/watch?v=ls8UT2WbGkg [accessed 

30 July 2013].

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Annex 1

of the association to build a general depiction of the problem. 

El País, the mostly read newspaper in Spain, also published two articles. A 
well-known journalist, Rosa Montero, wrote the piece ‘The disaster of giving 
birth’447 in a Sunday edition in 2006. The article provoked a flood of supportive 
letters by women who thanked the author for highlighting the problem. There 
were also letters from obstetricians who complained about how the approach of 
the piece and mentioned the risks of childbirth. Shortly after, a four-page spe-
cial main article about care during childbirth, entitled ‘Childbirth is mine’, 
was also published in this same newspaper448 and led to a cascade of conversa-
tions and declarations.

The  above  description  of  the  dispute  reflects  a  situation  in  which  there  is  no 
agreement on the general framework, goals or values in the debate save for 
the fact of the disagreement itself. Hence, the parties attempt to find and present 
claims and arguments that would fit conclusions known in advance, regardless of 
their reception by the other party. Nonetheless, disputes are informative: the cog-
nitive gain of disputes consists in better and clearer identification of distinctions 
between the parties.449

Phase 3 of the debate: ‘controversy’

During  a  phase  of  technical  ‘controversy’,  debates  that  arise  around  a  specific 
topic soon spread to other issues, thus reflecting a deep disagreement as to 
basic premises in factual, methodological or conceptual matters. But at the same 
time, this phase of the debate allows for mutual exchange of perspec-
tives as well as appropriation of the other parties’ views. The continuous 
dialogue  and  incorporation  of  alternative  perspectives  generate  profession-
al innovation and social change. For all those premises, the scientific/social 
debate  around  childbirth  in  Spain  from  2007  until  today  can  be  defined  as  a 
‘controversy’, in technical terms. 

Many  of  the  obstetric  controversies  relate  now  to  when  and  why  particular 
medical interventions are or not necessary – e.g. they debate on the stand-
ard caesarean rates, the use of analgesia or anaesthesia during childbirth, the 
episiotomies’  ratio,  or  the  convenience  of  vaginal  exams  after  37  weeks,  the 
handling of the amniotic sac and the prohibition of partners in surgical rooms. 
Research shows that linguistic or conceptual innovation helps to turn a ‘dis-
cussion’ or a ‘dispute’ into a ‘controversy’.450 Thus, for example, when childbirth 
activism  employs  new  terms  like  ‘unnecaesarean’,  ‘caesared  woman’,  ‘de-
humanised birth’, ‘gynaesaur’ or ‘obstetric violence’, it helps shift the field 
of debate to epistemological ‘controversy’. The use of new terms to convey new 
conceptualisations unveil the deep disagreements while also opening the door for 
accommodation and negotiation of standpoints. 

Childbirth  is  Ours’  actions  of  approaching  the  institutions  and 
raise-awareness  campaigns,  undertaken  from  2001  until  2007,  brought  a 
major result. In 2007, the Spanish Ministry of Health launched the Strategy 

447   Rosa Montero, ‘El Desastre de Parir’, El País, 13 August 2006, http://elpais.com/diario/2006/08/13/
eps/1155450419_850215.html.

448   Luz Sánchez-Mellado, ‘El Parto es Mío’, El País Semanal, 25 March 2007, http://elpais.com/dia-

rio/2007/03/25/eps/.

449   Dascal (2005).

450   Villarmea et al. (2016).

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Annex 1

for  Care  during  Normal  Childbirth  in  the  National  Health  System.  The 
Strategy incorporated many of the changes suggested by the Parto es Nuestro 
group.  Moreover,  it  explicitly  recognised  that  the  document  had  been  prepared 
in response  to  a  demand  from  women’s  groups, health professionals and 
regional health authorities, and was thus the result of the combined work of 
all of them.451

The Strategy addressed a widespread feeling that birth care could be im-
proved by promoting the participation and prominence of women during 
labour. It even described such participation and prominence as the fun-
damental objective of the document. The input of birth rights activism was 
also emphasised by clearly stating that women’s  groups  were  increasingly 
demanding  the  right  to  give  birth  with  total  respect  for  their  privacy, 
full participation in decision-making and improved conditions for them-
selves and their babies. The document referred to the increasing number of 
health professionals who see this movement as an opportunity for debate and 
agreement. It emphasised that women are demanding greater participation 
in the decisions surrounding birth care. For those reasons, professional bod-
ies had recently created protocols and guidelines which include revisions of some 
widely accepted practices.452 In sum, the whole Strategy was presented to ensure 
the improvement of quality care and recognition of the importance of birthing 
women’s role.453

The influence of the Strategy and social activism was shown in the subsequent 
publication  of  the  Recommendations  on  Care  during  Childbirth  in  2008  by  the 
Spanish  Society  of  Gynaecology  and  Obstetrics  (SEGO),  which  substituted  the 
Protocol  of  Care  during  Normal  Childbirth  published  in  2003.  The  introduction 
signalled that a conceptual shift had recently taken place in Spain as to 
obstetric  practice  and  birth  care.  The  essential  change  was  described 
as placing the mother at the centre of care.454 The Recommendations say 
that the SEGO is making the effort to humanise birth in response to social 
demand and to ensure maternal and foetal safety.455

Through the years, Childbirth is Ours offered information and raised awareness 
among users and health providers through a number of campaigns, par-
ticularly the campaigns: ‘Against Routine Episiotomy’ and ‘Transparency Regard-
ing Obstetric Data’ in 2007; ‘Never Separate’ in 2008; ‘Discovering Maternity’ and 
‘Together in Neonatal Intensive Care Units’ in 2012; ‘Stop Kristeller: A Question of 
Gravity’ in 2013; ‘Born During Working Hours’ in 2016; and ‘Don’t Go in Alone’ in 
2021. All these campaigns contribute to build the present polemic exchange as a 
field of inventive investigation, where innovations and discoveries lead so much 
to main cognitive products as to best medical practice.

451   Ministerio de Sanidad (2007).
452   Ministerio de Sanidad (2007).
453   Ministerio de Sanidad (2007).
454   SEGO (2008).
455   SEGO (2008).

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Annex 2

Annex 2 - Testimonies

Testimony 1

‘I am a worker at a regional hospital and, to my surprise, when I went to give birth 
at the hospital where I work and everyone knows me, I felt like an object. They 
broke my bag without informing me. They ‘half’ forced me to have an epidural, 
because of the risk to my daughter. They didn’t even let me turn around in 
bed  while  I  dilated.  The  gynaecologist  tried  to  do  the  Kristeller  manoeuvre,  or 
whatever its name is and when I refused it three times, she got angry (and 
then accused me of being hysterical in front of my professional colleagues). 
After  her  anger,  she  stood  with  her  arms  crossed  behind  the  midwife  and 
ordered him to do an episiotomy on me, although the midwife himself had told 
me, before the gynaecologist arrived, that it wouldn’t be necessary if we gave him 
time to get my baby down.’

Testimony 2

‘Things  got  serious  when  the  other  gynaecologist  showed  up.  She  directly 
climbed  on  top  of  my  belly  (‘Kristeller  manoeuvre’),  causing  me  unbearable 
damage  since  the  area  was  already  quite  sore  after  having  worn  the  monitor 
bands  for  more  than  five  hours.  The  other  gynaecologist  tells  me  off  because 
‘before you pushed better!’ while I am trying to say that they are doing to me 
a lot of damage and the gynaecologist is above me mercilessly crushing me and 
kneading my belly ... Horrible! But it didn’t end there ... The ‘respectful gynaecolo-
gist’ went to attend a caesarean section and the other one stayed with me. At that 
moment, they kicked my partner out of the delivery room. She stood between 
my legs, told me that they were going to remove my baby with a type of tiny 
suction cup (they call it a ‘kiwi’), did an episiotomy, put the suction cup on me 
and right away my daughter was out with a bump in her head.’

Testimony 3

‘Her defencelessness made her an ideal candidate for the ‘educational’ prac-
tice of forceps. Four students tried to extract the baby with the instrument while 
the tutor directed them: ‘Not like that, you can ‘break her head’ [verbatim 
quote from the testimony of the witness in the Preliminary Proceedings followed 
in  the  Court  of  Instruction  No  12  of  Barcelona].  And  they  broke  it.  Of  course, 
this young mother was not told about the indications, benefits, alternatives and 
potential risks of instrument use, nor was her consent sought. Her permission was 
not  asked  for  these  instruments  to  be  used  by  students  and  residents  without 
sufficient skill and training.’

Testimony 4

‘I was in full dilation and someone said: “well, the birth set is right here”. And then 
the gynaecologist said: “to the operating room, to the operating room”. And that’s 

106

Annex 2

when they told me: “what’s going on? Do you want to push?” And I said: “yes, yes, 
I’m popping her out! She’s coming!” And that’s when they laid me down, I see the 
blue sheet and I say: “no, no, no, don’t do a caesarean section, I don’t want a 
caesarean section”. As soon as I saw it … “but what are you doing? I’m telling you 
what I want. Well, listen to me at least. Tell me that it can’t be this or that… I don’t 
know. But tell me. I mean, tell me something, don’t ignore me!’’.’

Testimony 5

‘She narrates that she herself discovered after her first delivery, in 2002, that she 
had undergone the so-called “husband stitch”: at the time of stitching, the gynae-
cologist, with a wink, told me that she was going to leave me like a virgin. I 
did not discover until sometime later that this meant that she had narrowed my 
vaginal opening’.

Testimony 6

‘However, the doctors arrived with the decision made, stating “caesarean yes or 
yes, and that’s it”. When the author [of the communication, i.e. the claimant] 
requested information, the doctor did not provide it, but instead infantilised her 
by replying “don’t worry, I’ll take care of you” … The author requested that the 
child be given to her father, to which she was told “calm down, kid, that’s it”.’

Testimony 7

‘Most of us had come to motherhood in our thirties with a certain degree of 
professional and economic security and the feeling that the feminist goals 
(or at least the ‘true’ feminist goals like access to work and education, right to 
abortion and equality before the law) had been fought and won a long time 
ago.  We  thought  we  could  sit  back  and  enjoy  the  fruits  of  our  mothers’  and 
grandmothers’ struggle without any further effort or contribution to the feminist 
cause. We thought that sexist discrimination only affected women of the lower 
social classes. But that was until we gave birth to our own children. Then 
we were humiliated, infantilised, used and brutally divested by doctors, 
nurses, and even our own families, of our pride and fantasy that equality 
had already been achieved.’ 

107

European Commission
Case studies on obstetric violence: experience, analysis, and responses
Luxembourg: Publications Office of the European Union 2024
ISBN 978-92-68-09042-8
doi: 10.2838/712175

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