In her latest report to the United Nations General Assembly, the UN Special Rapporteur on violence against women, its causes and consequences outlined a human rights-based approach to the violence and mistreatment that many women suffer in reproductive health services, focusing specifically on childbirth and obstetric care. See 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, UN Doc. A/74/137, 11 July 2019. Noting a “lack of respect for women’s equal status and human rights,” the report highlights a number of human rights violations that women experience during childbirth and outlines the root causes of mistreatment during childbirth and obstetric violence. See id. It further calls on States to: collect reproductive health-related data, apply human rights and World Health Organization standards to maternity care, and to establish complaint and accountability mechanisms, among other recommendations. See id. at paras. 8-11, 81. While the report does not assert new or expanded interpretations of the relevant rights or obligations, it does synthesize many of the issues and adds to the growing body of international human rights guidance on ensuring informed consent in all reproductive health services. See id. at para. 14.
Childbirth & Obstetric Violence Overview
The report first defines obstetric violence as “violence experienced by women during facility-based childbirth.” See id. at para. 12. It then identifies examples from around the world. See id. at paras. 15-31. Informed by submissions from civil society organizations, the report notes that the following practices can constitute mistreatment, gender-based violence, or obstetric violence: neglect and unsafe conditions during labor; lack of out-of-hospital birth options; the use of the symphysiotomy procedure, which consists of surgically separating and widening a woman’s pelvis during childbirth, and which could amount to torture; the use of physical restraints, in some instances with shackles, or the use of mouth gags on detained or incarcerated women who are in labor or during their post-delivery recovery; the detention of women and their newborns in healthcare facilities as a result of their inability to pay hospital fees; the use of inexperienced medical personnel to conduct gynecological examinations; the use of the Kristeller maneuver, which consists on using pressure to facilitate vaginal births by “provok[ing] expulsion of the baby,” and is not medically recommended; and, the sharing of confidential information and performance of vaginal examinations in front of third parties without respect for patients’ privacy. See id. at paras. 18 -28.
Identified Causes of Mistreatment & Gender-Based Violence
The Special Rapporteur identifies some of the main causes of the practices listed above, including limitations within health care systems that impact the quality of care provided and result in poor working and unsafe conditions. See id. at paras. 39-40. At times, these limitations are driven by budgetary constraints and are affected by the overrepresentation of male medical providers in the gynecology and obstetrics fields. See id. The power imbalance between the patient and the medical provider, in which women depend on the provider’s “social privilege of medical authority,” may also result in providers abusing “the doctrine of medical necessity in order to justify mistreatment and abuse during childbirth.” See id. at para. 49.
Additionally, the report notes that discriminatory laws and practices, as well as gender stereotypes can result in violence and mistreatment against women. See id. at paras. 42-48. For example, laws that require spousal or third-party consent for medical treatments limit women’s decision-making authority, and stereotypes about “women’s natural role in society and motherhood limit women’s autonomy and agency.” See id. at paras. 42-46. Further, the Special Rapporteur emphasizes that many women experience intersectional discrimination in reproductive health services. See id. For example, Indigenous women, women from minority ethnic groups, and women with disabilities may be more likely to receive different or abusive treatment. See id. at para. 44. The report states that women with disabilities are often forced to end their pregnancies due to “negative stereotypes about their parenting skills and eugenics-based concerns,” and rural women or women from disadvantaged socio-economic backgrounds who experience abuse at the hand of physicians and are more at risk of maternal mortality. See id. at paras. 43-45.
In some instances, doctors perform procedures without the woman’s free and informed consent, constituting gender-based violence. See id. at paras. 21-25. The report explains that forced sterilizations and abortions, caesarean sections, episiotomies, and other invasive treatments are among the procedures sometimes performed without informed consent. See id. The report finds that women often receive information about procedures like caesarean sections during “labour, sometimes even during contractions, which makes it difficult for [them] to comprehend the information written on the [consent] form or to ask relevant questions.” See id. at para. 32.
Informed consent requires providing women with “full information about recommended treatments so that they can make informed and well considered decisions.” See id. The report emphasizes that “[i]nformed consent is a process of ongoing communication and interaction between patient and provider, and a signature alone is not an indication of informed consent.” See id. at para. 38. In particular, the report notes that the manner in which informed consent is established should consider the needs of the individual making the decision, and requires that disabilities, age, education level, and language abilities, for example, are taken into account when obtaining consent. See id.
Human Rights, Childbirth & Obstetric Violence
International human rights law requires that women’s right to the “highest standard attainable of physical and mental health,” including the right to “sexual and reproductive health, free of coercion, discrimination and violence,” is respected. See id. at para. 53-54. States have an obligation to protect women from violations committed by private parties, if their acts or omissions are attributable to the State. See id. at paras. 10, 51. When protecting women’s rights during childbirth, human rights treaty and regional bodies have also found that States have an obligation to respect, inter alia, the rights to life, privacy, non-discrimination, an effective remedy, and freedom from inhuman and degrading treatment. See id. at para. 55. For example, restrictions on the exercise of reproductive choice that result in women being forced to carry most pregnancies to term, even when they are the result of rape, incest, or will result in fatal fetal abnormalities, constitute a form of violence against women that may amount to inhuman and degrading treatment. See id. at para. 58. Similarly, the prosecution of medical professionals who perform home births, which effectively denies the service to women, may constitute a violation of women’s right to private life. See id. at para. 64. The forced or involuntary sterilization of women may also result in violations of the rights to private life, personal integrity and freedom, and freedom from cruel, inhuman and degrading treatment. See id. at para. 66-67.
Recommendations for States
While the Special Rapporteur praises some advances to address obstetric violence, violence against women, and mistreatment—for example, laws that require training for medical professionals and that focus on “pregnant and childbearing women”—the report includes a range of recommendations for States to ensure that they meet their obligations to prevent mistreatment and gender-based violence, and protect and respect women’s rights. See id. at paras. 69-75. Specifically, the Special Rapporteur calls on States to allocate sufficient resources to guarantee quality reproductive and maternal healthcare; conduct independent investigations when women report violence or mistreatment, which would require evaluating structural causes and gender stereotypes; cooperate with health institutions and civil society organizations that work in the areas of reproductive health and obstetric care; and address structural conditions in the health care system that contribute to discriminatory practices, and the lack of proper education and training for medical professionals on women’s rights. See id. at paras. 76-80. States must also adopt “laws and policies” that require informed consent and that respect women’s decision-making capacity about their reproductive health. See id. at 81.
With respect to discriminatory laws and gender stereotypes, the report calls on States to abolish spouse and third-party authorization for reproductive health services, repeal laws that criminalize abortion and allow criminal charges against women who seek emergency obstetric care, prohibit the forced sterilization of minority and Indigenous women, and provide compensation for victims. See id.
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