Perspectives The art of medicine Obstetric violence in historical perspective Although improvements in perinatal care have helped save many lives worldwide, reproductive health inequities remain rife. Racial, geographical, and class-based disparities shape divergent maternal and infant health outcomes, as well as unequal access to vital forms of health care such as abortion. Present-day reproductive injustices are contextualised by many factors, including the underrecognised history of obstetric violence. Obstetric violence refers to harm inflicted during or in relation to pregnancy, childbearing, and the post-partum period. Such violence can be both interpersonal and structural, arising from the actions of health-care providers and also from broader political and economic arrangements that disproportionately harm marginalised populations. By focusing on obstetric violence, we centre the long and enduring history of biological reproduction as a site of social violence. In doing so, we elucidate how obstetric violence has reflected and amplified different forms of social and political discrimination, oppression, and exclusion. The connection between obstetric violence and social inequity reaches back centuries, as suggested by examples from the early modern period. In 16th-century papal Rome, for instance, Roman Catholic authorities in houses of catechumens (institutions for non-Christians) sequestered Jewish women’s babies unless they consented to Christianisation via baptism. Here obstetric violence arose from and perpetuated religious discrimination, since women were forced to choose between religious conversion and family separation in the post-partum period. Obstetric violence also occurred during colonisation by the Spanish Empire in the Americas, especially in the late 18th-century viceroyalties of New Spain and Peru. There, priests performed forced caesarean sections on some women who struggled to give birth. Crown officials made the operations obligatory and emphasised that the priority was to save the souls of fetuses and not the lives of their mothers. Again theological mandates shaped women’s childbearing experiences, while the broader contexts of Christianisation and colonisation conditioned this specific form of obstetric violence. Reproduction in the 16th century through to the 19th century was also shaped by the institution of slavery. Obstetric violence lay at the heart of slavery in the Americas, which relied on the exploitation of Black women’s reproductive labour for economic profit. In the system of hereditary slavery, enslaved women’s childbearing was appropriated to enrich their oppressors, and women faced violent punishment and abuse for failing to conceive and give birth to healthy offspring. Additionally, enslaved women were forced to undertake www.thelancet.com Vol 399 June 11, 2022 strenuous physical labour throughout their pregnancies, and they were frequently denied care and recovery time after giving birth. Enslaved childbearing women also faced violence from the growing medical fields of obstetrics and gynaecology. Antebellum physicians in the USA developed new medical procedures by continually experimenting on the bodies of enslaved women—and other individuals marginalised on the basis of race, class, and citizenship status—while denying them the standards of care afforded to other patients. The accelerated medicalisation of birth during the late 19th and 20th centuries also led to broader forms of gendered violence, as the male-dominated specialty of obstetrics sought to displace traditional female birth attendants and establish authority over childbearing. Positioned as subordinate to their physicians, women were subjected to needlessly aggressive interventions and routinely denied the ability to make decisions about their own bodies and health. The expansion of obstetrics was marked by discriminatory practices in the assessment and treatment of childbirth pain. 19th-century physicians in multiple regions claimed that middle-class and upper-class white women experienced more pain in childbirth, and they focused their efforts of pain relief on this subset of patients. Even today racial disparities persist in obstetric pain management, with practitioners in the USA providing less pain treatment to Black and Latina obstetric patients than to their white counterparts. Another recurrent form of obstetric violence involved coercive sterilisation by medical practitioners to prevent future childbearing. In the early 20th century, eugenic movements in multiple countries promoted the involuntary sterilisation of those deemed hereditarily “unfit”, which disproportionately impacted disabled, impoverished, and racially marginalised women. Sterilisation abuse persisted later in the century, even after most eugenic laws were formally repealed. In the USA, thousands of Native American women were sterilised in Indian Health Service (IHS) hospitals during the 1970s, many under abusive and coercive circumstances; a study by physician Connie Pinkerton-Uri, of Choctaw and Cherokee heritage, estimated that IHS hospitals sterilised around a quarter of Native American women of childbearing age during this period. The 1974 case of Relf v Weinberger exposed the forced sterilisation of low-income African American patients; in the 1978 case of Madrigal v Quilligan, ten Mexican immigrant women brought a class-action lawsuit against the Los Angeles County Hospital for a pattern of coercively sterilising Latina patients. In many of these instances, medical practitioners misled patients Further reading Abuya T, Warren CE, Miller N, et al. Exploring the prevalence of disrespect and abuse during childbirth in Kenya. PLoS One 2015; 10: e0123606 Bowser D, Hill K. Exploring evidence for disrespect and abuse in facility-based childbirth: report of a landscape analysis. Boston, MA: Harvard School of Public Health and University Research Co, LLC, 2010 Caffiero M. Cochrane L, trans. Forced baptisms: histories of Jews, Christians, and converts in papal Rome. Berkeley, CA: University of California Press, 2012 Davis D-A. Reproductive injustice: racism, pregnancy, and premature birth. New York, NY: New York University Press, 2019 Equal Justice Initiative. Shackling of pregnant women in prisons and jails continues. Jan 29, 2020. https://eji.org/news/shacklingof-pregnant-women-in-jailsand-prisons-continues/ (accessed May 19, 2022) Grobman WA, Sandoval G, Rice MM, et al. Prediction of vaginal birth after cesarean delivery in term gestations: a calculator without race and ethnicity. Am J Obstet Gynecol 2021; 225: 664.e1–64.e7 Gurr B. Reproductive justice: politics of health care for Native American women. New Brunswick, NJ: Rutgers University Press, 2015 Lawrence J. The Indian Health Service and the sterilization of Native American women. Am Indian Q 2000; 24: 400-19 Lira N. Laboratory of deficiency: sterilization and confinement in California, 1900–1950s. Berkeley, CA: University of California Press, 2021 Montesinos-Segura R, Urrunaga-Pastor D, MendozaChuctaya G, et al. Disrespect and abuse during childbirth in fourteen hospitals in nine cities of Peru. Int J Gynaecol Obstet 2018; 140: 184–90 2183 Perspectives Morgan JL. Laboring women: reproduction and gender in New World slavery. Philadelphia, PA: University of Pennsylvania Press, 2004 Morgan LM, Roberts EF. Reproductive governance in Latin America. Anthropol Med 2012; 19: 241–54 O’Brien E. Pelvimetry and the persistence of racial science in obstetrics. Endeavour 2013; 37: 21–28 Ocen PA. Punishing pregnancy: race, incarceration, and the shackling of pregnant prisoners. California Law Rev 2012; 100: 1239–311 Cooper Owens D. Medical bondage: race, gender, and the origins of American gynecology. Athens, GA: University of Georgia Press, 2018 Few M, Tortorici Z, Warren A. Baptism through incision: the postmortem cesarean operation in the Spanish Empire. University Park, PA: Penn State University Press, 2020 Quattrocchi P, Magnon N, eds. Violencia obstétrica en América Latina: conceptualización, experiencias, medición y estrategias. Buenos Aires: Instituto de Salud Colectiva, 2020 Ricardo Ceppi Stringer/Getty Images Rich M. The curse of civilised woman: race, gender and the pain of childbirth in nineteenthcentury American medicine. Gender Hist 2016; 28: 57–76 about the nature of the procedure being performed; women were also pressured into signing sterilisation consent forms while in labour or while heavily sedated after caesarean sections. In some cases, impoverished women were told they would lose social support services or custody of their children if they did not agree to be sterilised. A pattern of sterilisation abuse also occurred in Peru, where between 250 000 and 300 000 women were sterilised between 1996 and 2001. These operations were explicitly racialised, with the country’s president at that time Alberto Fujimori referring to them as a solution for the country’s “Indian problem”. These histories reveal how widespread coerced sterilisation has been within medical practice, and illustrate how obstetric violence historically reinforces vulnerabilities along lines of gender, race, poverty, disability, and nationality. In mid-to-late 20th century Latin America, certain kinds of obstetric violence happened in the context of organised political terror. Military dictatorships in Argentina, Brazil, and Chile were notable for repression against political opposition. Government regimes during this period abducted, tortured, disappeared, or killed thousands of people, claiming that they were enemies of the state. Military officials committed acts of sexual violence against those detained; infants born to detainees were almost always confiscated and raised by families who supported the regimes in power. In this context, authorities used obstetric violence to terrorise childbearing women and sever their kinship ties. Some of these historical forms of obstetric violence have persisted during the 21st century, often enabled by new contexts. Mass incarceration in the USA facilitates obstetric violence including the forced separation of mothers and infants after birth as well as coercive sterilisation, which was documented in the California prison system between Activists celebrate the legalisation of abortion in Argentina in December, 2020 2184 2006 and 2013. In addition, many jails and prisons still shackle incarcerated women during pregnancy and childbirth, inflicting both physical and psychological harm. The obstetric violence faced by incarcerated people— who are disproportionately likely to be Black or Latina in the USA—represents another instance in which obstetric violence both reflects and perpetuates systemic racism. Although its impacts are unevenly distributed, obstetric violence today is a global phenomenon. There have been reports of abusive maternity care in facilities across numerous countries. In their 2010 framework, Diana Bowser and Kathleen Hill identified seven categories of disrespect and abuse in childbirth: physical abuse, nonconsented care, non-confidential care, non-dignified care, discrimination, abandonment, and detention in facilities. Drawing on this approach, studies in 2015 from Kenya, Ethiopia, Tanzania, and Nigeria found the prevalence of reported disrespect and abuse varied between 15% and 98% among childbearing women in the different countries. Similarly, a 2017 study of 1528 women in Peruvian hospitals found that about 97% of the women had encountered at least one category of disrespect and abuse during childbirth, with non-dignified and nonconsented care the most common. About 55% of the women experienced four or more concurrent categories of mistreatment. Discrimination was most frequent in regions with large Indigenous populations, who have marginal access to state-based rights. Another widespread form of contemporary obstetric violence involves the denial or obstruction of access to legal abortion, resulting in harms associated with forced childbearing and unsafe illegal abortion. Although some countries have recently expanded access to abortion, including Argentina in 2020, Mexico and Benin in 2021, and Colombia in 2022, abortion is illegal or heavily restricted in numerous locations. In May, 2022, a leaked draft of a Supreme Court majority opinion by Associate Justice Samuel A Alito, Jr revealed plans to reverse the legalisation of abortion in the USA. Lack of access to safe abortion results in medical harms, such as increased rates of preventable death from sepsis and haemorrhage, and economic and political harms related to exclusion and loss of autonomy. The criminalisation of abortion thus bolsters patriarchal norms that punish women for rejecting motherhood. These broad-ranging harms illustrate how obstetric violence can be enacted through what Lynn Morgan and Elizabeth Roberts have called reproductive governance, which refers to the way authorities exert influence and control over reproductive behaviours through legislative, economic, moralistic, and physical means. Both historically and in the present day, activists play a crucial role in naming and addressing obstetric violence. Latin American activists popularised the term obstetric violence in the 1990s, using it to call attention to human www.thelancet.com Vol 399 June 11, 2022 rights abuses that occurred in the context of medicalised childbirth. In the USA, the category of obstetric violence has garnered increasing attention from activists in recent years, drawing on insights from Dorothy Roberts, Loretta Ross, and others into the pervasive violence that has shaped Black women’s experiences of reproduction. The framework of reproductive justice, developed by a group of Black feminists in the 1990s, reoriented the conversation around reproductive rights to encompass both the right not to reproduce and the right to have children, which includes the ability to bear and raise those children in healthy environments safe from myriad forms of structural and interpersonal violence. Within this framework, addressing obstetric violence is an imperative for those seeking reproductive justice. Birthing justice activists have brought widespread attention to racial disparities in birth outcomes, and have called for greater use of doulas and midwives as well as changes in obstetric practice. In the past few years, advocates have successfully challenged the inclusion of race and ethnicity as variables in a clinical algorithm known as the Vaginal Birth After Cesarean (VBAC) calculator. The calculator promoted the disproportionate use of caesarean sections for patients identified as African American or Hispanic; research and advocacy-based efforts spurred the development of an updated VBAC calculator in 2021. Activism against obstetric violence in Latin America often occurs through formal legal channels. Countries including Venezuela (2007), Argentina (2009), Chile (2015), Colombia (2017), and Ecuador and Uruguay (2018) have passed legislation defining and outlining sanctions against obstetric violence, which is categorised as gender violence, and which in many places is punishable by law. Human rights commissions and working groups have sought recompense for situations spanning injury, mistreatment, and neglect during childbirth. Many who have filed obstetric violence complaints over the past decade have been Indigenous women. Activists have suggested the need for interventions at policy and community levels, including expanded public resources and infrastructure. Recent Latin American efforts to define, sanction, and punish obstetric violence have provoked backlash from some medical providers. But since 2014 some women who endured obstetric violence have been met with sympathy from national and international human rights courts that have awarded them monetary damages and benefits such as free schooling for their children. Activists recognise that obstetric violence is an imprecise semantic category, but argue for its value as a conceptual framework. Framing diverse violations under the umbrella of obstetric violence shifts the discourse away from individual cases and isolated medical malpractice and towards structural conditions—permitted or supported by some health-care systems—that infringe on the collective dignity and wellbeing of childbearing people. www.thelancet.com Vol 399 June 11, 2022 Los Angeles Times/Getty Perspectives Activists with the Committee to Stop Forced Sterilization march outside a hospital in Los Angeles, CA, USA, circa 1974 Drawing on a historical perspective reveals the scope of obstetric violence across time and place and illustrates its embeddedness within specific historical structures, including racism, patriarchy, religious persecution, colonialism, and ethnonationalism. This history compels attention to the social and political determinants of reproductive health outcomes, providing context for understanding and addressing the persistence of reproductive health inequities and reproductive injustice in the present. For clinicians, awareness of this history can deepen understanding of the ways in which past oppressions inflect interactions between health professionals and patients. This history can also underscore the importance of providing respectful reproductive care that supports patient dignity, autonomy, and wellbeing. More broadly, by illuminating the connections between reproductive experience and social inequity, attention to obstetric violence suggests that interventions to improve reproductive health must be informed by an awareness of larger social and political contexts. Furthermore, by naming harm related to childbearing as violence, the framework of obstetric violence insists on the severity of these harms and conveys an imperative to address them. The history of reproductive health care is mired in social and political injustice, but its future can be shaped by those who recognise and challenge its inequities. *Elizabeth O’Brien, Miriam Rich Department of the History of Medicine, Johns Hopkins University, Baltimore, MD 21205–2113, USA (EO’B); Society of Fellows and Department of History, Dartmouth College, Hanover, NH 03755–1808, USA (MR) eobrie19@jhmi.edu Roberts DE. Killing the Black body: race, reproduction, and the meaning of liberty. New York, NY: Vintage Books, 1999 Roniger L, Sznajder M. The legacy of human rights violations in the Southern Cone: Argentina, Chile, and Uruguay. New York, NY: Oxford University Press, 1999 Rosen HE, Lynam PF, Carr C, et al. Direct observation of respectful maternity care in five countries: a cross-sectional study of health facilities in East and Southern Africa. BMC Pregnancy Childbirth 2015; 15: 306 Ross L, Solinger R. Reproductive justice: an introduction. Oakland, CA: University of California Press, 2017 Sesia P. Naming, framing and shaming through obstetric violence: a critical approach to the judicialisation of maternal health rights violations in Mexico. In: Gamlin J, Gibbon S, Sesia P, Berrio L, eds. Critical medical anthropology: perspectives in and from Latin America. London: University College London Press, 2020 Stern AM, Novak NL, Lira N, et al. California’s sterilization survivors: an estimate and call for redress. Am J Public Health 2017; 107: 50–54 Vyas DA, Jones DS, Meadows AR, et al. Challenging the use of race in the Vaginal Birth after Cesarean Section calculator. Womens Health Issues 2019; 29: 201–04 2185