Obstetric Violence: Hidden in Silence

“When I was 24 years old, I was a victim of obstetric violence,” says Arpi Khalatyan. “It is not acceptable to discuss this type of violence, or even name and perceive it as such.”
Khalatyan was one of the first women in Armenia to share her experience of obstetric violence. 

Khalatyan says that women are vulnerable during childbirth, and it’s easy to convince them that the violence they are being subjected to is in the best interest of their child and themselves. “It’s enough to tell her that she is hurting her child, for example. Say ‘It’s necessary to…’ and that’s it,” she explains.

According to the World Health Organization (WHO), “Every woman has the right to the highest attainable standard of health care, which includes the right to dignified, respectful health care throughout pregnancy and childbirth, as well as the right to be free from violence and discrimination.”

Nevertheless, many women are subjected to obstetric violence, which not only violates their right to receive dignified and respectful health care but can also seriously threaten their life and health.

What Is Obstetric Violence?

According to the WHO, obstetric violence (or aggression) is characterized by acts such as “outright physical abuse, profound humiliation and verbal abuse, coercive or unconsented medical procedures (including sterilization), lack of confidentiality, failure to get fully informed consent, refusal to give pain medication, gross violations of privacy, refusal of admission to health facilities and providing medical care due to an inability to pay.”

The UN General Assembly’s report on violence against women in reproductive health services states that there are many manifestations of obstetric violence; however, they are mainly divided into three groups: physical, psychological and financial.

Forms of physical violence include unnecessary medical intervention and prescription of medicine, not upholding the normal course of childbirth, denying a woman her preferred birthing position, etc. The WHO has several recommendations for avoiding obstetric violence. These include refusing interventions such as episiotomy, Kristeller maneuver (the application of manual fundal pressure to facilitate childbirth), amniotomy, limiting the use of oxytocin, limiting the number of cesarean sections to 10-15% of general births, etc. 

Psychological forms of obstetric violence describe when a woman is subjected to degrading, disrespectful and/or discriminatory treatment. For example, when sexist and offensive remarks are made to a woman during medical care.

Financial obstetric violence describes when medical personnel refuse medical care to a woman due to an inability to pay. For example, according to Datalex, an online judicial database, a verdict was passed against OBGYN Nshan Gevorgyan in 2015. He was sentenced to 1.5 years in prison because he demanded money from the mother-in-law of a pregnant woman to carry out a cesarean section. When the family refused to pay, he denied medical assistance to the pregnant woman.

According to the Investigative Committee of Armenia, 16 cases have been investigated since 2017 concerning damage to the health of a woman or newborn child due to a medical service provider not carrying out their duties completely or correctly. Two of these cases resulted in an indictment and were sent to court, 11 of them were dismissed (ten due to lack of evidence, one due to exceeding the statute of limitations), three of them were suspended because the person who committed the crime could not be identified.

During the same period, 73 criminal cases were investigated for negligent death of a woman or her newborn child due to non-fulfillment or improper performance of professional duties by a service provider, two of which resulted in indictments. The proceedings of 29 cases were terminated (20 cases due to the absence of elements of a crime, five cases due to the absence of an incident of a crime, two cases exceeding the statute of limitations, one case due to the death of the perpetrator, one case due to the adoption of an amnesty law), the proceedings in 36 cases were suspended on the grounds that the perpetrator was unknown, the preliminary investigation of six criminal cases continues.

Convenient for the Doctor

“Obstetric violence is an actual problem,” says Dr. Norayr Ghukasyan, Deputy Director of the Maternity Hospital at Erebuni Medical Center. “In medical practice, unnecessary amniotomy [artificial rupture of membranes, i.e. breaking the waters], inducing labor, stimulations are being carried out, when a doctor decides that a patient has to give birth that day because it is convenient for them.”

According to Dr. Ghukasyan, if a doctor intervenes during childbirth, then they have to complete the process to the end. “In obstetric violence, there is the concept of ‘Crocodile Syndrome’. The crocodile is the only four-legged animal that can’t walk backwards. If a doctor decides to intervene in a 38-week pregnancy and administer any drugs, etc., then the patient can’t be checked out from the hospital and sent home to wait a while longer. This means that, even if they started the process incorrectly, they must see it through to the end. And because almost all of them are professional doctors, cases usually have a positive outcome. That is, the mother and child stay alive.”

Dr. Ghukasyan says that, even if a mother and newborn are alive, interventions that were administered during childbirth can result in health issues.

He also states that, at their clinic, measures are in place to prevent obstetric violence, and adds that their percentage of obstetric violence cases are low.

A study was conducted in 2016-2018 in Ghana, Guinea, Myanmar and Nigeria, financed by the WHO, UNICEF and other organizations. It found that 35.4% of respondents were subjected to physical and verbal abuse, stigma and discrimination.

Cesarean Sections Becoming More Common

“I believe that I could have avoided having a cesarean section,” says a 32-year-old woman who wished to remain anonymous. Her water broke at 38 weeks, and she went to the hospital. “The doctor said that I wasn’t dilated,” she says. “I was categorically against having a c-section. I was constantly in touch with a reliable American doctor abroad. She told me that we could wait a long time. On the other hand, my doctor who was convinced that I still wasn’t dilated told me confidently that ‘this is a cesarean.’ Nearly eight hours later, she clearly stated that I should get ready for a c-section. I insisted again that I didn’t want to. That’s when they told me I had to sign a document stating that I refused a cesarean section so the doctor would not be liable. In the end, I gave in because I got scared when they mentioned the waiver.”

As was already mentioned, the WHO recommends that the number of cesarean sections should not exceed 10-15% of overall births. In Armenia, however, the procedure is much more common and growing annually. According to Armenia’s National Institute of Health, the share of cesarean sections was 0.94% in 1980, 3.35% in 1990, 7.24% in 2000, 18.86% in 2010, 32.5% in 2018, 34.4% in 2019 and 35.9% in 2020. In Yerevan, the share of cesarean sections in 2020 was 42.5%.

Dr. Norayr Ghukasyan states that the decision to have a cesarean section is not solely up to the OBGYN. “For example, there are cases when an ophthalmologist makes the wrong decision and forces the doctor to do a c-section,” he explains. “Or, when a woman insists on having a c-section, because she is well informed that she may encounter problems with her vaginal anatomy.”

According to Dr. Ghukasyan, another issue is that pregnant women face many health issues. “There are illnesses that just don’t allow natural birth,” he says. “For example, acute spinal kyphosis, scoliosis, etc. They indirectly increase the number of cesareans. A century ago, women with these kinds of problems typically wouldn’t have had children.”

Dr. Ghukasyan lists several ways to reduce the number of cesarean sections: “Currently, I’m doing retrospective research for doctoral work. We’ve taken a look at the medical history of 30,000 patients and saw that the number of cesareans that did take place could have been reduced by 10-15%.”

According to Dr. Ghukasyan, there is now a new tool developed by the WHO to reduce the number of cesareans, called the Robson Classification. “To our delight, we’ve received a letter from the Ministry of Health stating that they want to implement this practice in Armenia,” he says.

Lack of Data

“Minutes before my baby was born, the doctor said I wasn’t dilated enough and it would be better if they did an episiotomy, which would not bother me later,” recalls a 36-year-old woman. “And I remember that she said I wouldn’t feel any pain, but I did. She just said that it was necessary and did it. They never had my approval or permission. I got to the hospital when my pains had just started, at 3:30 p.m. My baby was born at 7 p.m. At the time, I trusted my doctor. Only afterwards did I start thinking that maybe she did an episiotomy to quicken the process, because the birth was generally very short taking into consideration that it was my first one. On that day, it was my doctor’s son’s birthday. Maybe she wanted to finish quickly.”

In contrast to cesarean births, there’s no data on other types of interventions, such as episiotomy or the Kristeller maneuver, which are not recommended by the WHO. The Ministry of Health’s clinical guide for the prevention and management of postpartum bleeding also states that episiotomies should be avoided.

In response to EVN Report’s inquiry, the Ministry of Health stated: “Information on certain interventions during childbirth (forceps delivery, vacuum extraction, abortion) can be found in the National Institute of Health’s Statistical Yearbook. Data on other medical interventions during childbirth is not collected by the Ministry of Health, since these are reflected in patients’ medical histories.”

Article 25 of the UN General Assembly report on “A human rights-based approach to mistreatment and violence against women in reproductive health services with a focus on childbirth and obstetric violence” states that episiotomies are also widespread in countries such as Italy (50% of births) and Spain (89%). Moreover, it was reported that 61% of women in Italy who were subjected to an episiotomy were not given appropriate information and that their informed consent was not sought.

Article 27 of the same report also mentions the Kristeller maneuver, stating that this is also a widespread practice across the world, one which entails physical pressure on a woman, sometimes with the elbow, forearm or with the whole body, to facilitate childbirth. The highest rate of this practice is in Honduras, where it is used in 50-70% of vaginal births.

The Right to Informed Consent

Svetlana Avagyan is a yoga instructor and doula—a woman who assists another woman during childbirth. In the past several years, she has assisted 25 births, helping mothers as they go through the stages of childbirth. In her experience, several medical interventions take place in certain cases without a woman’s consent.

“For example, when doing an episiotomy, they have to explain that an incision will be made that will later be stitched. But instead of asking a woman if she consents or not, they just cut,” she explains. “There have been cases when they have done an episiotomy without informing the woman. Some women don’t even know that an incision has been made. But it seems this is considered normal in Armenia. If I speak about this, people are surprised that I’m surprised that doctors perform an episiotomy without consent.”

Violeta Zopunyan, Director of Center for Rights Development NGO, says: “As a rule, the reaction from patients is that they weren’t properly informed. For example, if a cesarean section should be done or not, or other interventions. In many cases, a doctor can, on their own initiative, carry out a given intervention without taking into account clinical characteristics, the general situation or the patient’s wishes.”

It’s important to note that even having a signature on paper does not mean that a woman gave consent to a given intervention by being properly informed.

“Even when they are given any medical document to sign, do you know what they say? ‘If you want, you can read it.’ This is not normal,” says Zopunyan. “They have to say, ‘Take this document and read it. If you have any questions, ask them and then at the end you should sign.’”

“Women have the right to receive all the information about recommended treatments so that they can make informed and well-considered decisions,” states Article 32 of the UN General Assembly report. “The International Federation of Gynecology and Obstetrics recognizes that the implementation of informed consent is an obligation, even though it can be challenging and time-consuming.”

The same report states that this is an issue almost all over the world and even in countries such as Germany, France, Sweden and the United States.

Do Not Leave a Woman Giving Birth Alone

“It’s important that a woman should not be left alone during the stages of childbirth,” says psychiatrist Arpi Khalatyan. “I was alone in the birthing room for three hours. There was only one nurse that would come and go near the door. This is somewhat understandable, since the medical staff is busy, but a woman can faint, fall, and there would be no one beside her.”

Several clinics allow someone to be with a woman when giving birth, for example, her husband. Some women also use doula services.

“I very much agree that someone should accompany a pregnant woman,” says Dr. Ghukasyan. “Let the pregnant woman decide if she would prefer to have a doula or her husband or sister with her. Their presence is considered normal during childbirth and is very important. And not because doctors ‘cut, tear and damage’ but because childbirth is a very serious process that a woman undergoes. A study was done in Israel which found that labor pains are equal to the pain of amputating a phalanx of the finger without pain medication. Can you imagine feeling that pain every three minutes?”

Be Patient to Avoid Complications

According to Dr. Ghukasyan, the key to avoiding complications in obstetrics is to be patient. “If I’m rushing and want to quicken the process so I can finish an hour early, then I can confidently say that I will end up spending that one hour stitching tears and wounds,” he explains. “Moreover, I will worry for 40 days if there will be complications. If you are not aggressive, then you won’t have complications.”

There’s an opinion that doctors often rush and carry out unnecessary interventions due to fatigue and being overworked.

“There are professionals that are very in demand and can conduct as many births as any other OBGYN would in a month,” says Zopunyan. “I understand that it’s the patient’s right to choose, but it should be stopped if the issue of quality arises.”

She also explains that doctors often work at several clinics and don’t get any rest. “For example, if they were on night duty and the next day they go to work at another clinic, naturally, this would lead to so much exhaustion that the doctor would be inclined to carry out unnecessary interventions.”

Dr. Ghukasyan does not rule out that these can become a reason for obstetric violence. “But I believe that many principled doctors, who are extremely busy, decline and allow other doctors to conduct a birth,” he says.

According to him, however, the root of obstetric violence is the unprotected OBGYN. “The unprotected OBGYN thinks it’s better to not take a risk and do a cesarean if, for example, the birthing process is slow or if it’s twins,” he explains. “The OBGYN working in the regions [outside Yerevan] is unprotected because they don’t even have a surgical nurse who, if let’s say the fetal heartbeat drops, can assist in managing to get the baby out alive. The state has to protect them and also force them to not carry out this type of violence.”

In this case, professionals find it important to implement legal tools, synchronize international standards with local regulations and oversee their application, which should be done at the state level.

Names of women who have been victims of obstetric violence and other identifiable data have not been published taking into account the sensitivity of the topic.

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