Despite experiencing a difficult first birth and pre-emptively lodging an ‘Informed Decisions-Birth Plan’, Grace* says her second birth experience resulted in post-traumatic stress disorder due to a lack of consent and agency.

"My husband and I were well aware that births don't have a 'plan' as my first labour started and ended quickly with a very poorly baby, requiring immediate c-section.

"We were thankful for the highly skilled interventions offered and were well informed every step of the way."

It was a very different and traumatic experience the second time around.

"There was so much panic from the medical staff who entered our room that we were confused and feared that our baby was in significant distress.

"My husband was trying to pump the breaks, knowing an instrumental delivery was only to be performed if there was no other option.

"I was crying. I felt powerless. I was on my back, and no one was talking to me or my husband.

"I knew what was happening. I knew I had lost all agency over my body. My eyes were tight shut. I wanted to forget all of this.

"I was sobbing. I hadn't asked if it could be done without the episiotomy as I'd planned.

"Too late, I had been cut. At this point, I thought… there's something wrong. They don't even have time to ask me for consent.

"I went inwards and told myself to do whatever they say. Get the baby out. This is bad.

"He was a healthy 9 APGAR baby, and there were no concerns for him at all. I was sobbing. I felt so confused and violated."

Grace says the hospital validated her concerns and hopes other women know their rights and make a complaint when a breach occurs.

"Thankfully, the hospital took our complaint very seriously and consulted with the midwife….and junior doctor who performed countless interventions without consent or with coerced consent.

"I can't undo what happened. It's irreversible. We know it happens all the time. We hope women are informed that they can complain and that these complaints are taken seriously."

Obstetric violence refers to any acts of violence, aggression, or abuse that women face during pregnancy, childbirth, and postpartum periods, according to Professor Alex Polyakov, Associate Professor and Obstetrician at the University of Melbourne.

"It encompasses a range of physical, psychological, and emotional abuses, as well as denial of informed consent and violation of women's rights during the birthing process," says Professor Polyakov.

One in 10 women experience obstetric violence

A lack of consent is one example of obstetric violence during childbirth; surprisingly, it's not uncommon.

A pioneering study by Western Sydney University, The Birth Experience Study, revealed more than one in 10 Australian women believe they have experienced some form of obstetric violence, leaving them feeling dehumanised, violated and powerless.

Research lead Dr Hazel Keedle said despite growing international recognition, obstetric violence is largely unrecognised in Australia.

"Our study offers much-needed insight into women's experiences of obstetric violence, which is widely defined as dehumanised treatment or abuse by health professionals towards the body or reproductive process of women. This is not about obstetricians but can be perpetrated by any health provider involved in the care of women," said Dr Keedle.

Study co-author Professor Hannah Dahlen AM, said the issue of obstetric violence needs urgent attention in Australia.

"A multi-level approach is needed involving consumer organisations, health care professional organisations and individuals, academics and health authorities in order for obstetric violence to be recognised, reported, reduced and legislated against in Australia.

"Experiences of obstetric violence are impacted by systemic issues such as health care professional education, staffing ratios and lack of access to continuity of care.

"Furthermore, it is recommended that health care professionals receive training to provide trauma-informed care to support women with a history of obstetric violence, previous trauma and/or a previous traumatic birth," said Professor Dahlen.

Modifiable causes of obstetric violence

Professor Polyakov says modifiable causes of obstetric violence include power imbalances, lack of education, systemic and cultural attitudes, and inadequate policies, laws and staffing.

"The causes of obstetric violence are complex and multifaceted, with a combination of structural, systemic, cultural, and individual factors contributing to its occurrence."

Power imbalances between healthcare providers and women

When healthcare providers hold a position of power and authority over women, it can lead to violations of women's rights and denial of informed consent.

Lack of education and training for healthcare providers

Healthcare providers not trained in informed consent, human rights, and respectful care are more likely to engage in abusive or violent behaviour.

Systemic and cultural attitudes towards women and childbirth

Obstetric violence can be perpetuated by cultural and societal attitudes that view women as passive or inferior, and childbirth as a medicalised procedure rather than a natural process.

Inadequate policies and laws to protect women's rights

A lack of clear policies and laws to protect women's rights during pregnancy, childbirth, and postpartum can contribute to obstetric violence.

Inadequate staffing and resource allocation

Overcrowding, understaffing, and limited resources in healthcare facilities can increase the risk of obstetric violence, as healthcare providers may feel overworked, stressed, and frustrated.

In addressing these modifiable causes, it may be possible to reduce the occurrence of obstetric violence and improve the quality of care for women during pregnancy, childbirth, and postpartum periods, explains Professor Polyakov.

"This may involve providing education and training for healthcare providers, advocating for implementing laws and policies that protect women's rights, and promoting cultural and societal attitudes that respect and empower women during the birthing process."

Solutions are multifaceted

Liz Wilkes, midwife and Managing Director of My Midwives, agrees, saying the solutions to preventing obstetric violence are multifaceted, and must involve a woman-centred approach in line with the government's maternity strategy.

Midwifery continuity of care is vital, but often it's fragmented, with women seeing many health care providers for different parts of their care - including a GP, midwife, junior doctor or a private obstetrician, explains Ms Wilkes.

"It makes care feel disjointed and does not allow trust to develop [so] women feel more frightened and can lead to difficult issues in communication which can then lead to difficult situations, obstetric violence or trauma.

"Seeing the same person or a very small group of people for all care tends to have better outcomes [for] a reduction in physical trauma, and therefore, the potential for risk of obstetric violence, and satisfaction and wellbeing for the woman." 

Protecting women from obstetric violence

The United Nations report on the mistreatment and violence against women in reproductive health services highlights a human-rights-based approach towards preventing obstetric violence.

There are many recommendations in the report, which states: "States have an obligation to respect, protect, and fulfil women's human rights, including the right to highest standard attainable of physical and mental health during reproductive services and childbirth, free from mistreatment and gender-based violence, and to adopt appropriate laws and policies to combat and prevent such violence, to prosecute perpetrators and to provide reparations and compensation to victims."

In Australia, education, training, funding and staffing are all crucial to preventing obstetric violence, explains Ms Wilkes.

"There is a strong need for education around informed choice and right of refusal. 

"Women often reflect that they felt coerced into decision making, and it is incumbent on the health professional providing education and seeking consent to provide all options." 

Doing nothing during the birthing experience must also be a choice. Otherwise, it isn't a choice, says Ms Wilkes.

"Health practitioners sometimes find this frustrating. Just to give an example, say continuous monitoring is recommended, and a woman refuses to have it, and the answer is, 'you have to have it here,' then that is not a choice.  Lack of choice factors strongly as a precursor to obstetric violence." 

"Health professionals need education to offer all options and to present evidence with sufficient time to allow for decision making.

"[They must] understand what they can and cannot do as a health professional.  Particularly in vaginal examinations and similar procedures, if a woman says 'stop,' the health professional must stop."

Resourcing is also potentially problematic, leading to issues around obstetric violence, explains Ms Wilkes.

"The speed at which health professionals must work and what they are required to do daily is problematic. 

"It does not excuse obstetric violence, but it is possible to see how things escalate.  There is a combination of a lack of resources from funding and staffing perspectives. 

"The quicker you try to do things, the more pressured the conversation and consent process … may become. 

"Providing all the information and waiting for the woman to decide takes significant time.

"So, anything that pressures and makes it possible for poor communication may lead to misunderstandings and potential trauma situations."

Professional development in respectful maternity care

The Maternity Consumer Network offers consent and respectful maternity care training covering obstetric violence.



*Name omitted to protect privacy