Background

India accounted for 17.0% of the global burden of maternal deaths in 2015 (WHO et al. 2015). In 2016, the maternal mortality ratio for the country was estimated at 130 per 100,000 live births (NITI Aayog, 2018) – close to twice the Sustainable Development Goal (SDG) (Goal 3.1) of 70 maternal deaths per 100,000 live births. Since the launch of the National Rural Health Mission (NRHM) in India in 2005, increasing institutional deliveries has been proposed as a solution to reducing maternal deaths (Ministry of Health and Family Welfare, 2005). This is aligned with the goal of improved maternal health and the wider discourse on safe motherhood through biomedical institutional forms of care (Storeng & Béhague, Reference Storeng and Béhague2014). Additionally, skilled attendance at birth has been promoted since 2006 through the Janani Suraksha Yojana (JSY) scheme – a cash transfer programme that provides monetary incentives to women to attend institutions for delivery (Ng et al., Reference Ng, Misra, Diwan, Agnani, Levin-Rector and De Costa2014). As a result of these efforts, there has been a substantial increase in the number of institutional deliveries in India, especially after the launch of the National Health Mission (NHM) in 2013 (National Health Mission, 2017). However, this has not resulted in commensurate improvements in key maternal and newborn health indicators, especially the UN SDG of reducing maternal deaths. One reason for this is that the overemphasis on increasing institutional delivery has concealed women’s negative experiences with the health system in terms of the poor quality of their interaction with institutional health care staff (Jha et al., Reference Jha, Christensson, Skoog Svanberg, Larsson, Sharma and Johansson2016).

Health care providers often behave rudely with pregnant women (National Health Mission, 2017). Evidence of poor, often violent behaviour towards women during labour has been found in high- and low-income settings alike (Bowser & Hill, Reference Bowser and Hill2010; Bohren et al., Reference Bohren, Vogel, Hunter, Lutsiv, Makh and Souza2015; Ishola et al., Reference Ishola, Owolabi and Filippi2017). This can include physical and verbal abuse, violations of privacy, actions that promote stigma and discrimination, and neglect and abandonment (WHO, 2017). Thus, even though delivery in institutional facilities in India rose from 26.0% of total deliveries in 1992–93 to 72.0% in 2009, the quality of maternal care has remained a major concern (UNDP India, 2019).

Violence against women (VAW) is a well-recognised public health issue (Consultation on Violence against Women & WHO, 1996). Violence against women by health care providers during childbirth has been called ‘obstetric violence’, and has instead been variously described as ‘mistreatment’ (Bohren et al., Reference Bohren, Vogel, Hunter, Lutsiv, Makh and Souza2015), ‘disrespect and abuse’ (DA) (Bowser & Hill, Reference Bowser and Hill2010) and ‘dehumanized care’ (Misago et al., Reference Misago, Kendall, Freitas, Haneda, Silveira and Onuki2001) by other researchers. Although these different concepts have distinct definitions and systems of classification of VAW, they all highlight the connection between mistreatment and other forms of gender-based violence: the medicalization of the natural process of childbirth; the roots of VAW in gender inequality; and the threat to women’s rights and health (Savage & Castro, Reference Savage and Castro2017). Moreover, Sadler et al. (Reference Sadler, Santos, Ruiz-Berdún, Rojas, Skoko, Gillen and Clausen2016) suggested that ‘obstetric violence’ is reflective of other forms of marginalization of women, contingent on their location within the larger political economy.

Initially, the movement against ‘obstetric violence’ grew out of a focus on quality of care (Williams et al., Reference Williams, Jerez, Klein, Correa, Belizán and Cormick2018). In 1993 in Brazil, the ground-breaking and influential Network for the Humanization of Labour and Birth (Rehuna) in its founding charter recognized ‘the circumstances of violence and harassment in which care happens’ (Diniz & Ayres, Reference Diniz and Ayres2001). However, the network deliberately did not talk about ‘violence’ and instead favoured terms such as ‘humanizing childbirth’ and ‘promoting the human rights of women’ because it feared a hostile reaction from professionals if it specifically mentioned violence. It was legislation in Venezuela that used the term ‘obstetric violence’ for the first time, describing it as ‘the appropriation of the body and reproductive processes of women by health personnel’ (República Bolivariana de Venezuela, 2007). Here, it was defined as dehumanized treatment and an abuse of medication which converts natural processes into pathological ones, bringing with it a loss of autonomy of women and their ability to decide freely about their bodies and sexuality, negatively impacting their quality of life. Since then, a significant amount of research has been carried out globally on ‘obstetric violence’ and its multiple descriptions (Bowser & Hill, Reference Bowser and Hill2010; D’Gregorio, Reference D’Gregorio2010; Freedman et al., Reference Freedman, Ramsey, Abuya, Bellows, Ndwiga and Warren2014). While attempts to identify what constitutes VAW during childbirth by health care providers have been cognisant of the historical, social and cultural settings, doing so remains complex.

Bohren et al. (Reference Bohren, Vogel, Hunter, Lutsiv, Makh and Souza2015) conducted a systematic review of VAW during childbirth by health care providers and produced a broad, comprehensive categorization with a pressing caveat that there is a lack of standardized, comprehensive and agreed-on typology, identification criteria and operational definitions of the mistreatment of women during facility-based childbirth. The major types of mistreatment by providers outlined in their systematic review were: (1) physical abuse, (2) sexual abuse, (3) verbal abuse, (4) stigma and discrimination, (5) failure to meet professional standards of care, (6) poor rapport between women and providers, and (7) health system conditions and constraints.

Despite increased global inquiry into VAW during childbirth by health care providers, henceforth referred to as ‘obstetric violence’, the literature in the Indian context has remains scattered, and a critical analysis of the existing literature is called for. This integrative review aims to collate and analyse the extant literature on ‘obstetric violence’ in India and analyse the results of empirical research using the comprehensive typology of Bohren et al. (Reference Bohren, Vogel, Hunter, Lutsiv, Makh and Souza2015). The aim is to also highlight results that do not align with any of the Bohren et al. categories, to identify all types of ‘obstetric violence’ in India and compare these with global findings. In summary, the aim is to develop a framework to address the pernicious yet evasive issue of ‘obstetric violence’ in India from a rights-based perspective within the existing structural and social determinants of health.

Literature search

Strategy and selection criteria

PubMed, Google Scholar and JSTOR were searched for peer-reviewed studies on the quality of treatment that women receive during childbirth in health facilities in India. The database search was carried out using the terms ‘mistreatment’, ‘obstetric violence’, ‘disrespect and abuse’ and ‘dehumanized care’, as these all denote the concept of poor treatment of women in childbirth by health care providers. However, a consensus was reached about using the term ‘obstetric violence’ for the review based on the way the Indian movement against this form of VAW has taken shape, in a manner similar to that of Latina midwives effectively resisting medicalization and harmful medical procedures as well as abusive and dehumanizing practices deployed against economically and socially marginalized women in Latin America (Dixon, Reference Dixon2015). For the purpose of this review, therefore, ‘obstetric violence’ refers to any of the terms mentioned above, and all these terms denote the same concept of VAW during childbirth by health care providers. The search was limited to the period 2003–2019 to focus on current operational definitions and methodologies of VAW during childbirth. The last search was carried out on 2nd July 2019.

From the initial database search, 67 potentially relevant articles were identified. A secondary supplementary search was conducted where the reference lists of identified articles were checked manually, as well as the ‘grey literature’. A combined total of 75 articles were identified through this process. After removing duplicates, 67 titles were reviewed to check their relevance to VAW during childbirth, on the basis of which 30 articles were excluded. Next, the abstracts of 37 articles were assessed for inclusion criteria, which formed the basis for eligibility. The inclusion criteria comprised qualitative or quantitative empirical research characterizing women’s experience of childbirth in health facilities, written in English, and limited to India. The following outcomes pertaining to VAW during childbirth were examined in each of the articles: the prevalence of ‘obstetric violence’, forms of ‘obstetric violence’, interventions for ‘obstetric violence’, implications for maternal mortality and morbidity, effect on facility-based childbirth, the legal aspects of ‘obstetric violence’ and Respectful Maternity Care (RMC). Abstracts that did not cover at least one of the above-mentioned outcomes were excluded, and 20 articles were finally arrived at for full-text review. Of these, the full text was not available for three articles, and hence they were removed from further analysis. All remaining papers were downloaded, organized and reviewed in Mendeley. The studies were assessed keeping in mind the need to record all explicit and implicit and symbolic and tangible forms of ‘obstetric violence’. One article that focused on measuring disrespect and abuse during antenatal care was excluded. After analysing the full texts for eligibility, sixteen articles were ultimately included in the review, as listed in Table 1. The integrative review process is depicted in Figure 1.

Table 1. Studies included in the review

Figure 1. Process of selecting studies for this integrative review on ‘obstetric violence’ in India.

Findings

Overview

‘Obstetric violence’ has been described as having taken place when routine medical or pharmacological procedures associated with labour are conducted without allowing the woman to make decisions regarding her own body (D’Gregorio, Reference D’Gregorio2010). Such treatment is antithetical to the Universal Rights of Childbearing Women charter, which states that every woman has the right to dignified, respectful sexual and reproductive health care, including during childbirth (White Ribbon Alliance, 2011).

This integrative review of the existing literature found that, although the selected studies reported a high prevalence of ‘obstetric violence’ in health care facilities in India, the nature of the violence was highly variable. A study among labouring women in public and private facilities in Uttar Pradesh found that all women in the study reported at least one indicator of mistreatment (Sharma et al., Reference Sharma, Penn-Kekana, Halder and Filippi2019). A community-based study in Uttar Pradesh found that 84.3% of women reported some kind of disrespect and abuse (Nawab et al., Reference Nawab, Erum, Amir, Khalique, Ansari and Chauhan2019). While the prevalence of women reporting any form of ‘obstetric violence’ was about the same in the studies of Patel et al. (Reference Patel, Makadia and Kedia2015) (57.7%), Sudhinaraset et al. (Reference Sudhinaraset, Treleaven, Melo, Singh and Diamond-Smith2016) (57.0%) and Diamond-Smith et al. (Reference Diamond-Smith, Treleaven, Murthy and Sudhinaraset2017) (50.0%), other studies in Uttar Pradesh found a much lower prevalence of women reporting any kind of obstetric violence – namely, 28.8% (Bhattacharya & Sundari Ravindran, Reference Bhattacharya and Sundari Ravindran2018) and 15.1% (Goli et al., Reference Goli, Ganguly, Chakravorty, Siddiqui, Ram, Rammohan and Acharya2019). The latter were closer to the findings from a facility-based survey by Dey et al. (Reference Dey, Shakya, Chandurkar, Kumar, Das and Anthony2017), where observational data by health care providers showed that 22.4% of women reported being mistreated during delivery. The same study, however, found a much lower prevalence of self-reported mistreatment of women by health care providers, at 9.1%. Similar variability has been observed in other low- and middle-income countries, wherein the prevalence of self-reported disrespect and abuse ranges from 20% in Kenya (Abuya et al., Reference Abuya, Warren, Miller, Njuki, Ndwiga and Maranga2015) to 43% in Ethiopia (Wassihun & Zeleke, Reference Wassihun and Zeleke2018) to 98% in Nigeria (Okafor et al., Reference Okafor, Ugwu and Obi2015).

A possible explanation for these contrasting results could be the use of different definitions for each kind of abuse (Bhattacharya & Sundari Ravindran, Reference Bhattacharya and Sundari Ravindran2018). There is a lack of global standard measures of abuse, which may partially account for the highly varied reported prevalences of mistreatment (12–98%) across different populations and national contexts (Freedman & Kruk, Reference Freedman and Kruk2014; Freedman et al., Reference Freedman, Ramsey, Abuya, Bellows, Ndwiga and Warren2014). Moreover, the sampling of participants may affect the reported prevalence of ‘obstetric violence’; for instance, the higher prevalence of any form of disrespect and abuse found by Nawab et al. (Reference Nawab, Erum, Amir, Khalique, Ansari and Chauhan2019) may be due to the fact that only 4- to 6-week post-partum females were included, which greatly reduced the reporting bias (inability to recall).

None of the studies included in this review recorded any incidence of sexual abuse. However, it is possible that, due to perceived stigma and discrimination, sexual abuse might not have been reported by women. This is in line with the findings of Bohren et al. (Reference Bohren, Vogel, Hunter, Lutsiv, Makh and Souza2015), who found evidence of sexual abuse only from their quantitative synthesis and not their qualitative one. Hence, it is possible that women are uncomfortable reporting sexual abuse, and further quantitative inquiry is needed for sensitive data on this topic to emerge. This does not in any way undermine the strength of qualitative inquiry in obtaining information of such a sensitive nature.

Another important finding from this review was a significant association between mistreatment and maternal complications (Dey et al., Reference Dey, Shakya, Chandurkar, Kumar, Das and Anthony2017; Raj et al., Reference Raj, Dey, Boyce, Seth, Bora and Chandurkar2017; Bhattacharya & Sundari Ravindran, Reference Bhattacharya and Sundari Ravindran2018). Moreover, the reviewed studies found an association between type of provider and the experience of ‘obstetric violence’ (Dey et al., Reference Dey, Shakya, Chandurkar, Kumar, Das and Anthony2017; Bhattacharya & Sundari Ravindran, Reference Bhattacharya and Sundari Ravindran2018). This is important because women reporting the use of an unskilled provider rather than a staff nurse for delivery were more likely (AOR = 8.32; 95% CI = 2.50–27.60; p < 0.01) to report delivery complications (Raj et al., Reference Raj, Dey, Boyce, Seth, Bora and Chandurkar2017). This relationship between ‘obstetric violence’ and complications is a critical finding because the reduction in maternal complications is a high-priority goal for programmatic efforts to improve maternity care, and any such finding should be considered carefully, whether causal or not (Dey et al., Reference Dey, Shakya, Chandurkar, Kumar, Das and Anthony2017). Moreover, maternal stress of any kind slows down the labour process, thereby increasing the chances of complications (Freedman et al., Reference Freedman, Ramsey, Abuya, Bellows, Ndwiga and Warren2014). Further ahead in the chronology, post-partum depression has also been found to be significantly associated with a negative childbirth experience (Gausia et al., Reference Gausia, Ryder, Ali, Fisher, Moran and Koblinsky2012).

One of the consequences of ‘obstetric violence’ that emerged from this review was that some women perceived institutional delivery as being threatening, particularly if they had prior experience of pregnancy-related hospitalization (Barnes, Reference Barnes2007). Nawab et al. (Reference Nawab, Erum, Amir, Khalique, Ansari and Chauhan2019) found that, when women were asked about their willingness to attend a facility for childbirth in the future, of those who said ‘no’, 93.8% reported experiencing some form of disrespect and abuse. Of those who were indecisive, 91.7% had experienced disrespect and abuse. This association between experiencing any disrespect and abuse and the decision to attend a facility in the future was statistically significant (χ² = 11.188, df = 2, p < 0.05). Therefore, keeping in mind the government’s goal of increasing institutional delivery in order to reduce maternal mortality in India, the aforementioned findings underscore the need to prevent ‘obstetric violence’ and promote Respectful Maternity Care.

This review has highlighted evidence of a practice of suppressing women’s pain, or rather their expression of pain, during childbirth. Some women were asked to keep quiet when they shouted out in pain, or were abused, both physically and verbally. This finding was reinforced by a health care provider who said that many women screamed during labour, not out of ‘real pain’, but because the screams of a woman on another bed compelled women in the labour ward to join in communal screaming, ‘whether or not there’s real pain’ (Chattopadhyay et al., Reference Chattopadhyay, Mishra and Jacob2017). Such explanations are not uncommon in other parts of the world, as the disciplining of labouring women by suppressing their screams is one of the more insidious, yet common, forms of ‘violence’ inflicted through biomedical institutionalization (Shabot, Reference Shabot2016; Chadwick, Reference Chadwick2017).

A unique finding that emerged from this review of the Indian experience was the persistence of some harmful traditional practices and beliefs during childbirth in certain parts of rural India, which result in the misperception of risks to the mother and child. Studies have noted that a lack of acceptance of certain post-partum beliefs by institutional facilities results in women in rural India preferring home births (Van Hollen, Reference Van Hollen2003; Barnes, Reference Barnes2007). In addition, the adoption of dangerous ‘modern’ practices during home deliveries, in particular the use of oxytocin injections, was also noted. It was important to highlight these practices in this review, even though they do not adhere to the classification provided by Bohren et al. (Reference Bohren, Vogel, Hunter, Lutsiv, Makh and Souza2015), because India is a vastly diverse country with entrenched forms of ‘obstetric violence’ that are not necessarily limited to formal facilities. They are also extant in traditional birth practices and birth centres where trained village women health workers conduct deliveries. This is pertinent for India because, on the one hand, women are encouraged to give birth in institutions where they are often met with ‘obstetric violence’, while on the other hand, women from rural areas who are reluctant to access institutional care during childbirth due to fear of such ‘violence’ and being subjected to harmful practices that may jeopardise their health. These results pertain to the unique web of home births, institutional births and those carried out in quasi-institutional settings in India. Their inclusion is necessary and important because they are an impediment to the chances of many women of having a safe childbirth experience.

An element of ignorance among women about what constitutes a harmful practice was observed. The occurrence of ‘obstetric violence’ among women with no mass media exposure was found to be approximately five times higher (OR = 4.7; 95% CI = 1.7–12.8) than among those with mass media exposure in a study by Goli et al. (Reference Goli, Ganguly, Chakravorty, Siddiqui, Ram, Rammohan and Acharya2019). However, this review also found evidence of women normalizing acts of ‘obstetric violence’ that were evidently harmful, such as physical abuse and applying unnecessary force during delivery. Nawab et al. (Reference Nawab, Erum, Amir, Khalique, Ansari and Chauhan2019) found that 89.1% of women who experienced disrespect and abuse answered ‘no’ to the query about any treatment that they perceived as humiliating, and this association was statistically significant. This finding is consistent with previous reports of treating disrespectful maternal care as ‘normal’ and part of an age-old practice by health providers and by women undergoing such treatment (Bowser & Hill, Reference Bowser and Hill2010; Sando et al., Reference Sando, Ratcliffe, McDonald, Spiegelman, Lyatuu and Mwanyika-Sando2016). This normalization not only helps increase the prevalence of the problem but also renders it part of the ‘iceberg phenomenon’ by way of non-recognition and under-reporting (Nawab et al., Reference Nawab, Erum, Amir, Khalique, Ansari and Chauhan2019).

Madhiwalla et al. (Reference Madhiwalla, Ghoshal, Mavani and Roy2018) noted that their study participants acknowledged that the mistreatment of women in the form of shouting and physical coercion existed, although this was not necessarily perceived as abuse. Furthermore, Bhattacharya and Sundari Ravindran (Reference Bhattacharya and Sundari Ravindran2018) found that, although statistically insignificant (p = 0.31), there was a high prevalence (25.0%) of reported abuse in private health facilities. Other studies recorded evidence of significant ‘obstetric violence’ in private facilities (Nawab et al., Reference Nawab, Erum, Amir, Khalique, Ansari and Chauhan2019; Sharma et al., Reference Sharma, Penn-Kekana, Halder and Filippi2019). This shows that abusive provider behaviour has become a norm and is not restricted to government facilities where the providers are over-worked and have to work with limited resources (Bhattacharya & Sundari Ravindran, Reference Bhattacharya and Sundari Ravindran2018). For example, nurses working in New Delhi maternity homes attributed impolite and disrespectful treatment of impoverished women to long working hours, poor pay and overcrowding of facilities (Singh, Reference Singh2010). Thus there appears to be evidence of a normalization of obstetric violence in private hospitals in India. Further research is needed to assess this.

Providers set expectations and norms around what is acceptable behaviour during delivery, while women are often misinformed and may have low expectations of care. This was corroborated by a facility-based study that showed under-reporting of disrespectful and abusive behaviour by women who delivered at public health facilities (Dey et al., Reference Dey, Shakya, Chandurkar, Kumar, Das and Anthony2017). While 9.1% of women self-reported mistreatment during delivery, the directly observed mistreatment rate was much higher, at 22.4%. A study of women who recently gave birth at public health facilities in Uttar Pradesh indicated that one in five experienced mistreatment by their provider during delivery. This did not differ for women whose deliveries were observed or conducted by a mentored nurse (Raj et al., Reference Raj, Dey, Boyce, Seth, Bora and Chandurkar2017). Another study from Uttar Pradesh found a significant difference in mistreatment with the timing of admission, such that a greater proportion of mistreatment was observed in cases admitted during working hours compared with those observed outside regular working hours (p = 0.02) (Sharma et al., Reference Sharma, Penn-Kekana, Halder and Filippi2019).

The review’s findings suggest that mistreatment practices may not only be common, but are sufficiently acceptable that observation does not deter them. Hence, culture plays an important role, and its effect is further highlighted by a study in Uttar Pradesh, which found that lack of ‘cultural health capital’ disadvantages women during delivery care in India (Sudhinaraset et al., Reference Sudhinaraset, Treleaven, Melo, Singh and Diamond-Smith2016). Thus, when poorer women, and those of lower social standing, are subjected to ‘obstetric violence’, they are unable to recognize and describe the low quality of care or discrimination. Diamond-Smith et al. (Reference Diamond-Smith, Treleaven, Murthy and Sudhinaraset2017) assessed the association between women’s empowerment and mistreatment during childbirth and found that dimensions of empowerment related to social norms about women’s values and roles were associated with their experiences of mistreatment during childbirth.

The review found an association between socio-demographic factors and ‘obstetric violence’. Among the various determinants of disrespect and abuse, socioeconomic status was found to be significant (Diamond-Smith et al., Reference Diamond-Smith, Treleaven, Murthy and Sudhinaraset2017; Goli et al., Reference Goli, Ganguly, Chakravorty, Siddiqui, Ram, Rammohan and Acharya2019; Nawab et al., Reference Nawab, Erum, Amir, Khalique, Ansari and Chauhan2019). Other significant factors were caste (Dey et al., Reference Dey, Shakya, Chandurkar, Kumar, Das and Anthony2017; Diamond-Smith et al., Reference Diamond-Smith, Treleaven, Murthy and Sudhinaraset2017; Goli et al., Reference Goli, Ganguly, Chakravorty, Siddiqui, Ram, Rammohan and Acharya2019) and religion (Goli et al., Reference Goli, Ganguly, Chakravorty, Siddiqui, Ram, Rammohan and Acharya2019). In previous literature from other countries, socio-demographic factors such as higher parity, lower SES and HIV-positive status have been reported to predispose women to disrespect and abuse during childbirth in a facility (Bowser & Hill, Reference Bowser and Hill2010; Diniz et al., Reference Diniz, Salgado, Andrezzo, de Carvalho, Carvalho, Aguiar and Niy2015).

Study limitations

This review has certain limitations. First, the research was limited to seven states in India, hindering generalization about the results of these studies to other parts of the country. Second, the sample sizes of the included studies failed to give a sense of the actual magnitude of ‘obstetric violence’ in India. Third, only one study (Chattopadhyay et al., Reference Chattopadhyay, Mishra and Jacob2017) in the review looked at intentionality as defined by Freedman and colleagues, i.e. that the definition of disrespect and abuse should include actions that the provider intends to be harmful, but that such intent should not be a requirement of disrespect and abuse (i.e. unintended should also be included) (Freedman & Kruk, Reference Freedman and Kruk2014).

Conclusions and policy recommendations

There are clear systemic issues that allow ‘obstetric violence’ to occur: an insensitive medical education curriculum, constraints on provider time and resources, disempowerment of nurses and community health workers and a lack of accountability (Chattopadhyay et al., Reference Chattopadhyay, Mishra and Jacob2017). The political will to address the problem will need to be built among professionals as well as governments, and resources will need to be allocated (Jewkes & Penn-Kekana, Reference Jewkes and Penn-Kekana2015). The World Health Organization has been a pioneer in this, making recommendations for intrapartum care resulting in a positive childbirth experience (WHO, 2018). The focus of the global agenda has gradually expanded beyond just the survival of women and their babies, to ensuring they both thrive and achieve their full potential in terms of health and well-being.

In response to global efforts to tackle the poor treatment of women during childbirth (White Ribbon Alliance, 2011; WHO, 2015, 2018), recent efforts in India to improve quality of care during childbirth have focused on provider training and checklists to increase implementation of key clinical practices (e.g. washing hands with soap and checking vital signs) (Chaturvedi et al., Reference Chaturvedi, De Costa and Raven2015; Arora et al., Reference Arora, Shields, Grobman, D’Alton, Lappen and Mercer2016). In terms of executive measures, the National Health Policy 2017 set objectives to deal with gender-based violence and address the quality of care provided under reproductive, maternal, newborn, child and adolescent health (RMNCH+A) programmes (Ministry of Health and Family Welfare, 2017). Such measures have been supplemented by the recent Labour Room Quality Improvement Initiative (LaQshya) guidelines released by the Indian government (National Health Mission, 2017). These state that the delivery of transformed care not only needs the availability of adequate infrastructure, functional and calibrated equipment, drugs, supplies and human resources, but the meticulous adherence to clinical protocols by service providers at health facilities. A component of care that is almost universally absent due to infrastructural constraints in public facilities in India is the presence of a birth companion. While Tamil Nadu has identified the importance of this, and started a Birth Companionship Programme to improve maternal health (Department of Health and Family Welfare, 2005), other states are yet to follow suit. Evidence shows that women who receive any type of support from their husband or a health worker are significantly more likely to report lower mistreatment scores (Diamond-Smith et al., Reference Diamond-Smith, Sudhinaraset, Melo and Murthy2016).

In conclusion, this review provides a picture of the normalized nature of ‘obstetric violence’ in India. The included studies highlight the key socio-cultural, economic and systemic obstacles that deny women access to quality care during childbirth. Patriarchal societies and organizational hierarchy allow undemocratic power relations to develop between patients and providers. Combined with a historic normalization of gender-based violence, women in general, and those of lower social standing in particular, harbour lower levels of expectation of quality care during childbirth. Figure 2 illustrates a way forward for addressing ‘obstetric violence’ in India as a subset of violence against women. The factors that enable ‘obstetric violence’ are listed as social environment, harmful cultural practices, systemic barriers and historic normalization of violence against women. Hence, the areas of intervention to address ‘obstetric violence’ are based on the manifestations of these factors. Suggestions for future research include a wider geographical coverage that identifies a typology and prevalence of ‘obstetric violence’. A rights-based approach builds on the fact that results will be seen when the objective of Respectful Maternity Care is adopted as an extension of the elimination of ‘obstetric violence’, which includes respect for women’s autonomy, dignity, feelings, privacy, choices, freedom from ill treatment and coercion and consideration for personal preferences, including the option of companionship during maternity care (National Health Mission, 2017). Evidence-based policy and programmes are critical for achieving the reduction in maternal mortality that is envisioned in the SDGs. Redressal mechanisms should be enabled to generate support for women and accountability for health care providers. As a long-term goal, gender-transformative education and clinical practices should be developed and taught to future health care providers. Such education and practice promotes gender equality and equity in health with the aim of redressing health inequities that are a consequence of gender roles and unequal gender-relations in society (World Health Organization, 2007). Ultimately, the improvement in maternal mortality ratio requires a transformational change in the processes related to care during delivery, which essentially amounts to quality care without violence or coercion and the participation of women in decision-making while retaining agency over their own bodies.

Figure 2. Multi-pronged framework for addressing ‘obstetric violence’ in India.