English (pdf)
Article in xml format
Article references
Automatic translation
Send this article by e-mail
Cited by SciELO 
Cited by Google 
Similars in
SciELO 
Similars in Google 
Permalink
Introduction
The obstetric violence (OV) phenomenon has several titles, such as violence during labor, cruel treatment during delivery, disrespect and abuse, institutional violence, and violence in cases of abortion and post-abortion, among others 1. The concept’s framework is not only found in the medical area but also in human rights and in other health professions. Such significant complexity generates semantic and conceptual discussions 2.
Although a complex phenomenon, it is understood OV relates to the acts of violence committed during prenatal care, at delivery, in postpartum, and during the puerperium, in which there is disrespect for women’s physical integrity and mental health, as well as loss of autonomy in terms of choices, feelings, or both 3. Since 2014, the World Health Organization (WHO) has considered OV a public health problem directly affecting women and newborns 4.
Corroborating the WHO statement, a study carried out with 409 puerperal women at a specialized comprehensive hospital in the Amhara region, northwestern Ethiopia, evidenced that three out of four (75.1%) women reported having suffered at least one type of OV during labor and delivery. The OV types were as follows: non-consensual care -260 women (63.6 %); undignified care -226 women (55.3%); physical abuse -192 women (46.9 %); non-confidential care -132 women (32.3 %); neglected care -52 women (12.7 %), and discriminated care -38 women (9.3 %) 5. It is noted that these numbers can be significantly higher due to women’s lack of understanding to identify the acts of violence, which leads to the under- reporting of cases.
The need for changes in care during pre-delivery, delivery, and birth, as well as professional training regarding the phenomenon, are essential to combat, minimize, or eradicate OV, an increasingly growing action 3.
As essential players in a woman’s prenatal, delivery, and puerperium care, nurses should guarantee comprehensive care, emotional support, commitment to health, and exchange of knowledge and experiences, in addition to having scientific knowledge focused on the needs of each pregnant woman and evidence-based practices. To promote qualified, humanized, welcoming, and systematized assistance, it is indispensable to understand the OV phenomenon 6.
Knowledge about the concept of OV needs to be expanded and improved, considering that there is no precise definition in the scientific field 7, only complementary definitions, which makes it difficult to advance the knowledge of this phenomenon and its application.
Despite the high recurrence of the phenomenon, no studies indicate its antecedents, attributes, and consequents, which hinders the professionals’ understanding, with the possibility of triggering consequences in the clinical practice 7. Thus, it becomes indispensable to clarify the concept.
That said, the study presents the following guiding question: What are the essential attributes, antecedents, and consequents to determine the concept of OV in the Nursing context? In search of answers to the question, the study aims at identifying the essential attributes, antecedents, and consequents to determine the concept of OV in the Nursing context.
Materials and Methods
This conceptual analysis followed the method proposed by the Walker and Avant model 8, which consists of eight sequential or simultaneous stages. Six stages were used in this study, as they specifically contemplated the study object, with no need to build a model case or additional cases. Each stage is described below.
First stage: Selection of the concept - A concept that is important and useful to deepen the theoretical developments in the area of interest should be chosen.
Second stage: Delimitation of the analysis objectives - In this stage, the researchers should define the analysis scope 8.
Third stage: Identification of different uses of the concept in the literature - A broad literature review is done using dictionaries, thesaurus, available literature, and even friends and colleagues, identifying as many uses of the concept as possible. In this initial phase, the analysis is not restricted to a single concept aspect. There is the possibility of considering all uses of the term in question. The authors indicate that it is necessary not to limit the research merely to the medical or nursing literature, as this can influence their understanding of the true nature of the concept 8.
Forth stage: Determination of the essential attributes - In this phase, the researchers must determine the attributes, which are words or expressions that characterize the phenomenon. In other words, they are the defining characteristics that express the phenomenon’s essence 8.
Fifth stage: Identification of the concept’s antecedents and consequents - They are useful to further refine the attributes. The authors define ‘antecedents’ as events or incidents that must occur or be present before the occurrence of the concept and ‘consequents’ as events or incidents resulting from the occurrence of the concept. In other words, the results of the concept 8.
Sixth stage: Definition of the concept’s empirical references - It is the final stage of concept analysis. When a concept analysis is in its concluding phase, the question is how to measure this concept or determine its existence in the real world. They are categories or classes of observable phenomena that show the occurrence of the concept using an operational definition 8.
In the first stage, the OV concept was selected considering the relevance in the professional practice and research of the authors of this study who investigate violence and vulnerability. The second stage is in line with the research objective.
The third, fourth, fifth, and sixth stages were developed simultaneously. In the third stage -Identification of the different uses of the concept in the literature, a systematic scoping literature review was carried out, as proposed by the recommendations outlined in the Joanna Briggs Institute Reviewer’s Manual (JBI 9) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist (PRISMA-ScR 10). The review was registered in the Open Science Framework (OSF) platform at https://osf.io/682fr/.
The research question -What are the essential attributes, antecedents, and consequents to determine the concept of OV in the Nursing context?- was determined through the PCC mnemonic, in which ‘P’ refers to participants (pregnant, parturient, and postpartum women). The first ‘C’ refers to the concept (OV, attributes, antecedents, and consequences) and the second one to the context (Nursing), following the PRISMA-ScR recommendations 10.
As for the eligibility criteria, all types of studies related to pregnant, parturient, and puerperal women addressed the theme of OV. Its attributes, antecedents, and consequents linked to the Nursing area were included. In addition, studies of any nature, available in full without a time frame and in any language, were considered, excluding duplicates indexed in more than one database.
The search followed the recommendations proposed by the JBI 9 through three stages: the first corresponds to the initial search, developed in the Theses and Dissertations Catalog of Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), using the following health descriptors (DeCS): gestantes (pregnant women), parto (parturition), período pós-parto (postpartum period), violência (violence), and enfermagem (nursing) with crossings using the OR and AND Boolean operators.
The second stage corresponds to the secondary search. It was conducted in the databases grouped according to the characteristics of each database, namely: LILACS (BVS), MEDLINE (PubMed), Scientific Electronic Library Online (SciELO), American Psychological Association PsycInfo and Institute of Education Sciences (ERIC), grouping the previously defined keywords. Therefore, the initial search string was as follows: (“saúde da mulher” OR parto OR “trabalho de parto” OR “parto humanizado” OR “mulheres” OR “parto obstétrico”) AND (“violência contra a mulher” OR “violência” OR “obstetrícia” OR “violações dos direitos humanos” OR “exposição à violência”) AND (“enfermagem” OR “assistência à saúde” OR “humanização da assistência” OR “enfermagem obstétrica”).
Subsequently, in the third stage, which consists of the list of references, the bibliographic references were analyzed and selected to choose the documents to be included and excluded from the study, as well as incorporating additional information.
The selection of the relevant documents was carried out by two reviewers in a paired, thorough, and independent manner. Initially, the titles and abstracts were read, excluding those papers that were incomplete or did not answer the questions established. Subsequently, the studies selected were read in full, excluding those that did not substantially portray the concept, antecedents, attributes, and consequences of OV in the Nursing context.
Any and all divergences between the reviewers were discussed to reach a consensus, considering the study eligibility criteria and methodological rigor. The selection of the corresponding words in the databases resulted in 22 final articles according to the respective crossing strategy (Figure 1).
After selecting the studies included to comprise the sample, the extracted data were analyzed according to the stages of determining the essential attributes, identifying the antecedents and consequents of the concept, and defining the empirical references of it.
The essential antecedents and consequents were critically analyzed and distributed according to what was addressed in the articles. The attributes were classified according to the OV typification.
Only in the last stage the OV concept was extracted from the manuscripts and transformed into a textual corpus for processing and analysis in the R Interface pour les Analyzes Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ) software. This program clearly structures the distribution of the vocabulary. By employing the similarity analysis, the results indicate the connection between the words, also distinguishing the common parts and the specificities, resulting in a maximum tree 11. Consequently, it was possible to observe the terms that operationally define the concept of OV.
It is worth noting that, as it is a review, it was not necessary to submit this study to any research ethics committee.
Results
The sample comprised 22 studies from the national and international literature published in journals devoted to Nursing or other related areas between 2013 and 2021 (Table 1).
Table 1 Classification of the Articles Included in the Review
| Author | Title (in its original language) | Year | Type of study |
|---|---|---|---|
| Aguiar JM, D’Oliveira AFPL, Schraiber LB (12 | Violência institucional, autoridade médica e poder nas maternidades sob a ótica dos profissionais de saúde | 2013 | Qualitative research |
| Silva MG, Marcelino MC, Rodrigues LSP, Toro RC, Shimo AKK (13 | Violência obstétrica na visão de enfermeiras obstetras | 2014 | Experience report |
| Souza AB, Silva LCS, Alves RN, Alarcão ACJ (14 | Fatores associados à ocorrência de violência obstétrica institucional: uma revisão integrativa da literatura | 2016 | Integrative literature review |
| Antunes TCS (15 | Violência obstétrica expressa no contexto das enfermeiras de uma maternidade pública do município do Rio de Janeiro | 2017 | Descriptive, exploratory, and qualitative |
| Oliveira VJ, Penna CMM (16 | O discurso da violência obstétrica na voz das mulheres e dos profissionais de saúde | 2017 | Interpretive, with a qualitative approach |
| Zanardo GLP, Calderón M, Nadal AHR, Habigzang LF (17 | Violência obstétrica no Brasil: uma revisão narrativa | 2017 | Literature review |
| Marrero L, Brüggemann OM (18 | Violência institucional durante o processo parturitivo no Brasil: revisão integrativa | 2018 | Integrative review |
| Moura RCM, Pereira TF, Rebouças FJ, Costa CM, Lernades AMG, Silva LKA et al. (19 | Cuidados de enfermagem na prevenção da violência obstétrica | 2018 | Integrative literature review |
| Perera D, Lund R, Swahnberg K, Schei B, Infanti JJ (20 | ‘When helpers hurt’: Women’s and midwives’ stories of obstetric violence in state health institutions, Colombo district, Sri Lanka | 2018 | Field work |
| Miranda FL, Velloso GS, Lima PO, Rangel SC, Almeida HF, Pinheiro MLP et al. 21 | Violência obstétrica: percepções de enfermeiros obstétricos em uma maternidade de Minas Gerais | 2019 | Descriptive and exploratory, with a qualitative approach |
| Nascimento SL, Pires VMMM, Santos NA, Machado JC, Meira LS, Palmarella VPR (22 | Conocimiento y vivencias de violencia obstétrica en mujeres que han vivido la experiencia del parto | 2019 | Descriptive and of a qualitative nature |
| Souza ACAT, Lucas PHCS, Lana TC, Lindner SR, Amorim T, Felisbino-Mendes MS (23 | Obstetric violence: Integrative review | 2019 | Integrative review |
| Campos VS, Morais AC, Souza ZCSN, Araújo PO 24 | Conventional practices of childbirth and obstetric violence under the perspective of puerperal women | 2020 | Qualitative, descriptive, and exploratory |
| Castro ATB, Rocha SP 25 | Violência obstétrica e os cuidados de enfermagem: reflexões a partir da literatura | 2020 | Literature review |
| Menezes FR, Reis GM, Sales AAS, Jardim DMB, Lopes TC 26 | O olhar de residentes em enfermagem obstétrica para o contexto da violência obstétrica nas instituições | 2020 | Descriptive and exploratory, with a qualitative approach |
| Mena-Tudela D, Gasch- Cervera A, Alemany-Anchel MJ, Andreu-Pejó L, Gonzálzes-Chordá VM (27 | Design and validation of the PercOV-S Questionnaire for measuring perceived obstetric violence in nursing, midwifery and medical students | 2020 | Instrumental design |
| Pascoal KCF, Filgueiras TF, Carvalho MA, Candeia RMS, Pereira JB, Cruz RAO (28 | Violência obstétrica na percepção de puérperas | 2020 | Field study |
| Paula E, Alves VH, Rodrigues DP, Felicio FC, Araújo RCB, Chamilco RASI et al. (29 | Obstetric violence and the current obstetric model, in the perception of health managers | 2020 | Descriptive and exploratory, with a qualitative approach |
| Ribeiro DO, Gomes GC, Oliveira AMN, Alvarez SQ, Gonçalves BG, Acosta DF (30 | Obstetric violence in the perception of multiparous women | 2020 | Qualitative, of a descriptive and exploratory nature |
| Silva MI, Aguiar RS (31 | Knowledge of nurses of primary care about obstetric violence | 2020 | Descriptive-exploratory, with a qualitative approach |
| Texeira PC, Antunes LS, Duamarde LTL, Velloso V, Faria GPG, Oliveira TS (32 | Percepção das parturientes sobre violência obstétrica: a dor que querem calar | 2020 | Descriptive and exploratory, with a quali-quantitative approach |
| Zancheta MS, Santos WS, Souza KV, Pina VR, Hwu H, Stahl H et al. (33 | Amplifying voices on obstetric violence: Recommendations for advocacy by an obstetric nurse | 2021 | Exploratory research |
Source: Own elaboration.
Regarding the analysis of the empirical indicators, the term ‘woman’ was identified as the most prevalent in the documents, followed by ‘autonomy,’ ‘body,’ ‘reproductive processes,’ ‘delivery,’ ‘natural process,’ ‘medicalization,’ ‘abusive,’ ‘unnecessary,’ ‘pathologization,’ ‘medication abuse,’ ‘body appropriation,’ ‘dehumanized,’ ‘postpartum,’ ‘assistance,’ ‘ability,’ ‘decision,’ ‘health professionals,’ ‘loss,’ and ‘physical integrity’ (Figure 2).
The antecedents related to OV were organized (Table 2), representing the main risk factors that led to the occurrence of these instances. Antecedents associated with the women themselves, health professionals, institutions, and legislation were identified. The most frequent elements were ‘unfavorable financial conditions,’ ‘black-skinned women,’ and ‘lack of knowledge about the theme.’
Table 2 Concept Analysis Antecedents
| Antecedents of the OV concept | ||
|---|---|---|
| Elements | Numbers of the references | Frequency |
| Unfavorable financial conditions | 12,15,17,18,20,23,26,27,29,30 | 10 |
| Black-skinned women | 12,15,17,18,20,23,26,30,32,33 | 10 |
| Lack of knowledge about the theme | 15-18,22,25,26,28,31,32 | 10 |
| Inadequate infrastructure | 13-16,20,21,23,26 | 8 |
| Lower schooling levels | 15,17,20,23,26,27,32 | 7 |
| Unqualified professionals | 14,15,21,22,26,27,29 | 7 |
| Naturalization and perpetuation of the practices | 12,15,17,24-26 | 6 |
| Precariousness in terms of materials and resources | 12,14,15,23,26,33 | 6 |
| Women’s lack of knowledge in relation to their sexual and reproductive rights | 20,22,23,30,32 | 5 |
| Ethnic minorities | 15,18,20,27,32 | 5 |
| Adolescents | 12,15,20,30 | 4 |
| Work overload | 14,20,23,26 | 4 |
| Non-existence of specific legislation addressing OV | 17,23,24 | 3 |
| Lack of knowledge about own body and the delivery-physiological processes | 15,24,25 | 3 |
| Impunity of acts | 12,16,21 | 3 |
| Stress/Authoritarianism on the part of the professionals | 15,23,30 | 3 |
| In abortion situation | 15,26 | 2 |
| Homosexuals | 15,32 | 2 |
| Inmates | 15,30 | 2 |
| High number of children | 12,30 | 2 |
| Immigrants | 15,20 | 2 |
| Professionals’ low wages | 14,16 | 2 |
| Sex workers | 30 | 1 |
| Drug users | 30 | 1 |
| Living on the street | 30 | 1 |
| Protestants | 32 | 1 |
| Single women | 15 | 1 |
| Unwanted pregnancy | 15 | 1 |
| HIV-positive women | 15 | 1 |
| Family culture | 25 | 1 |
| Women with no companion | 30 | 1 |
Source: The authors’.
The attributes identified were organized according to the typologies (Table 3). The following terms stood out in physical violence: ‘episiotomy/episiorrhaphy,’ ‘unwarranted cesarean sections,’ ‘oxytocin use;’ in psychological/emotional violence, the most prevalent attributes highlighted were ‘humiliations’ and ‘providing false information or omitting information.’ In turn, institutional violence had the following as its main attribute: ‘not allowing the presence of a companion;’ the sexual violence typology had ‘repetitive vaginal touch examination’ as an attribute; finally, the ‘lack of human and material resources’ attribute stands out in structural violence.
Table 3 Concept Analysis Attributes
| Attributes of the OV concept | ||
| Physical violence | ||
| Elements | Numbers of the references | Frequency |
| Episiotomy/episiorrhaphy | 13,14,17,18,20,22-26,28,32 | 12 |
| Unwarranted cesarean sections | 12,13,15,17,18,20,22,25,26,28,32,33 | 12 |
| Oxytocin use | 13,15,18,22,23-26,32 | 9 |
| Kristeller maneuver | 15,18,22,23,25,26,27,32 | 8 |
| Lithotomy position at birth | 17,18,23-25,28,29,32 | 8 |
| Unnecessary interventions or procedures or performed without due consent | 14,15,17,21,27,28,30,33 | 8 |
| Denial of any type of pain relief | 14,17,18,25,29,30,32 | 7 |
| Restriction to the bed | 18,23-25,26,29,30 | 7 |
| Trichotomy | 17,22,23,25,26,30,32 | 7 |
| Not using analgesics when indicated | 12,15,16,21,27,31,33 | 7 |
| Aggressions | 12,14,15,18,24,27 | 6 |
| Performance of enema | 15,17,22,25,28 | 5 |
| Prohibition of eating or drinking | 23,25,32 | 3 |
| Excessive medicalization | 14,17,21 | 3 |
| Amniotomy | 23,24,32 | 3 |
| Preventing skin-to-skin contact | 15,17,32 | 3 |
| Trivialization of pain | 20,30 | 2 |
| Use of forceps | 25,32 | 2 |
| Prolonged bed rest | 22,32 | 2 |
| Valsalva maneuver | 23,24 | 2 |
| Causing pain | 12,18 | 2 |
| Walking in the last stage of delivery | 30 | 1 |
| Not allowing immediate mother-infant contact immediately after birth | 29 | 1 |
| Invasive procedures performed on newborns that show good vitality | 15 | 1 |
| Psychological/Emotional violence | ||
| Elements | Numbers of the references | Frequency |
| Humiliations | 14,17,18,23,25,27,28,31,32 | 9 |
| Providing false information or omitting information | 15,18,19,23,24,29,30,32 | 8 |
| Threats | 16,18,25,28,30,31 | 7 |
| Yelling | 14,16,18,25,31,32 | 6 |
| Abandonment | 18,20,24,26,32 | 5 |
| Disrespect | 12,26,27,28,30 | 5 |
| Reproaches | 14,16,18,31,32 | 5 |
| Imposition of decisions/values | 15,18,19,26 | 4 |
| Rude manners | 12,30,31,32 | 4 |
| Curses | 14,18,25 | 3 |
| Disqualification of the woman’s choices | 18,30 | 2 |
| Denial of care | 18,26 | 2 |
| Trivialization of the woman’s suffering or needs | 18,20 | 2 |
| Teasing | 15,17 | 2 |
| Devaluation of women complaints | 15,24 | 2 |
| Impatience | 26,30 | 2 |
| Embarrassment | 18 | 1 |
| Hostile treatment | 17 | 1 |
| Irony | 17 | 1 |
| Coercion | 17 | 1 |
| Disrespect towards beliefs and cultures | 15 | 1 |
| Judgment | 26 | 1 |
| Lack of welcoming | 29 | 1 |
| Coldness | 15 | 1 |
| Harshness | 15 | 1 |
| Ironic phrases | 26 | 1 |
| Harsh speeches | 26 | 1 |
| Authoritarian behaviors | 16 | 1 |
| Derogatory words | 16 | 1 |
| Mockery | 28 | 1 |
| Moralistic speeches | 30 | 1 |
| Changes in the tone of the voice | 23 | 1 |
| Coarse treatment | 18 | 1 |
| Offenses | 27 | 1 |
| Pejorative comments | 26 | 1 |
| Institutional violence | ||
| Elements | Numbers of the references | Frequency |
| Not allowing the presence of a companion | 12,14,15,17,23-26,28,29,32,33 | 12 |
| Pilgrimage in search of assistance | 15,18,25 | 3 |
| Refusal of admission to health institutions and retention of women and their newborns in the institutions | 27,32,33 | 3 |
| Not allowing breastfeeding | 15,32 | 2 |
| Not having the opportunity to get to know the maternity ward and the professionals who will assist them | 19 | 1 |
| Difficulty accessing prenatal services or poor-quality care | 15 | 1 |
| Sexual violence | ||
| Elements | Numbers of the references | Frequency |
| Repetitive vaginal touch examination | 15,18,22,25,28,32 | 6 |
| Invasion to the woman’s privacy | 17,26,27,33 | 4 |
| Sexual abuse | 17,30-32 | 4 |
| Sexual harassment | 17 | 1 |
| Unnecessary exposure of intimacy | 30 | 1 |
| Breast clinical examination without due consent and without information | 15 | 1 |
| Structural violence | ||
| Elements | Numbers of the references | Frequency |
| Lack of human and material resources | 18 | 1 |
| Inadequate infrastructure | 18 | 1 |
| Insufficient number of beds | 18 | 1 |
| Imposition of institutional routines | 18 | 1 |
| Shortage of professionals | 12 | 1 |
Source: The authors’.
The main OV consequences found in the literature were organized (Table 4). It was observed that the interventions performed caused significant physical and psychological sequelae for women’s life and marital and maternal relationships, as well as traumas. In addition, they had consequences for the newborns, which could lead to their death. The following stand out among the consequents: ‘maternal and child morbidity and mortality,’ ‘loss of the woman’s autonomy at delivery,’ ‘emotional and psychological harms,’ and ‘physical harms.’
Table 4 Concept Analysis Consequents
| Consequents of the OV concept | ||
|---|---|---|
| Elements | Numbers of the references | Frequency |
| Maternal-child morbidity and mortality | 13-17,19,25,26,28,30 | 10 |
| Loss of the woman’s autonomy at delivery | 15-17,23-26,29,32 | 9 |
| Emotional and psychological harms | 12,14,22,25-28,32 | 8 |
| Physical harms | 12,14,26,27,28,30,32 | 7 |
| Pain | 15,26,27,32 | 4 |
| Repercussions for the woman’s sexual and reproductive health | 14,15,27,32 | 4 |
| Negative influence on the pregnancy and delivery physiological process | 21,29,31 | 3 |
| Third- and fourth-degree perineal laceration | 14,15,22 | 3 |
| Infection | 14,15,22 | 3 |
| Hemorrhage | 14,15,22 | 3 |
| Trauma | 16,32 | 2 |
| Depersonalization of the woman | 29,30 | 2 |
| Urinary and fecal incontinence | 14,22 | 2 |
| Fetal distress | 24,32 | 2 |
| Fear | 15,18 | 2 |
| Insecurity | 15,18 | 2 |
| Negative effects on the mother-child bond | 15,25 | 2 |
| Negative impact on women’s quality of life | 25 | 1 |
| Discrediting women and their physiological ability to give birth | 21 | 1 |
| Loss of privacy | 16 | 1 |
| Child’s developmental inability | 28 | 1 |
| Early hospitalization of women | 32 | 1 |
| It can lead to surgical delivery | 32 | 1 |
| It impairs blood flow and oxygen to the infant | 32 | 1 |
| It hinders and increases duration of labor and pain intensity during contractions | 32 | 1 |
| Low self-esteem | 32 | 1 |
| Loss of trust in the professionals | 32 | 1 |
| Tachysystole | 24 | 1 |
| Hypertonia | 24 | 1 |
| Uterine hyperstimulation, uterine rupture or both | 24 | 1 |
| Loneliness | 18 | 1 |
| Loss of the uterus | 27 | 1 |
| Stress | 27 | 1 |
| Edema | 15 | 1 |
| Episiorrhaphy endometriosis | 15 | 1 |
| It makes it difficult to initiate breastfeeding, as well as duration of exclusive breastfeeding | 15 | 1 |
| Respiratory problems for the newborn | 15 | 1 |
| Difficulty in the care targeted at the newborns and their development | 15 | 1 |
| Intensification of the difficulty to access health services | 14 | 1 |
Source: Own elaboration.
Discussion
The expressions or terms presented using the similarity analysis evidence that the phenomenon can occur during prenatal care, delivery, the puerperium, in case of abortion, and when there are violations of the woman’s human rights and integrity, loss of autonomy and decision-making. The findings of this research point to empirical indicators that operationally define the concept of OV, which contributes to clarifying the phenomenon and providing theoretical support for nurses to timely identify the occurrence and intervene appropriately.
The category of the antecedents identifies that, for the occurrence of OV, several factors involved are related not only to the woman but to the entire pregnancy-puerperal process. The following stand out, unfavorable financial conditions, skin color, schooling level, lack of knowledge about the theme, inadequate infrastructure, precariousness in terms of materials and resources, and unqualified professionals.
Black-skinned women 12,15,17,18,20,23,26,30,32,33 with unfavorable financial conditions 12,15,17,18,20,23,26,27,29,30, lower schooling levels 15,17,20,23,26,27,32, and ethnic minorities 15,18,20,27,32 are targets more prone to violent practices, mainly routine interventions and absence of a companion. In addition, many women of low socioeconomic status with low schooling levels had limited access to prenatal consultations, which further led to disinformation about labor and delivery 34.
In a study carried out with nine low-income and black-skinned women in northeastern Brazil, physical, verbal, and institutional OV instances were reported. There were practically no reports of respect for women during delivery and minimal obstetric interventions 2.
The greater a woman’s vulnerability, the ruder and more derogatory the treatment she was offered 35. Secondly, adolescents 12,15,20,30, sex workers 30, drug users 30, homeless women 30, homosexuals 15,32, and inmates 15,30 are more prone to negligence and omission of care 30.
A research study conducted with Chilean women evidenced that those with low schooling levels, minors, homosexuals, and indigenous reported more OV cases, mainly those treated in the public health system 36.
Lack of knowledge about the theme 15-18,22,25,26,28,31,32 was a significant finding of an OV antecedent. A study conducted in India with 305 women identified that 257 suffered some disrespect and abuse; of this total, 89.1 % answered “no” when asked about any treatment they considered humiliating. This reveals that this type of violence is seen as something normal when knowledge is inadequate 37.
However, when understanding the act, the answers were notably different, as revealed by a survey carried out in Spain, in which 17,541 questionnaires were delivered, 38.3 % realized that they had suffered OV and 44.4 % perceived that they were subjected to unnecessary or painful procedures, of which 83.4% were not asked for their due informed consent 7.
Naturalization and perpetuation of the practices 12,15,17,24-26, an OV antecedent, such as pain related to delivery 38, is also associated with a lack of knowledge on the topic. It is believed that delivery is a painful process, naturalizing the unfavorable situations experienced by the women and not recognizing some procedures as violence but common and routine situations 39.
Knowledge about the body and the physiology of delivery favors the reduction of vulnerability, the fight against OV and women’s empowerment, ensuring their rights and autonomy and counteracting abusive actions performed by professionals.
The following stand out among the antecedents related to health professionals and institutions: unqualified professionals 14,15,21,22,26,27,29, work overload 14,20,23,26, the professionals’ low wages 14,16, stress/authoritarianism on the part of the professionals 15,23,30, inadequate infrastructure 13-16,20,21,23,26, precariousness in terms of materials and resources 12,14,15,23,26,33 and impunity of acts 12,16,21. Due to a lack of training and adequate working conditions -especially associated with insufficient materials and resources, obstetric care quality becomes increasingly dehumanized, causing emotional stress and overload in professionals 40.
The professionals’ inability to offer qualified assistance, which allows for predicting violence and intervening, reflects a society that has always naturalized violent behaviors and procedures as non-violent. In addition, the professional-user hierarchy, with unilateral authority, tends to lead professionals to verbalize and perform violent techniques or both without noticing that they are, in fact, violent 41. Therefore, it is fundamental that professionals know the OV antecedents, attributes, and consequents to provide good quality care throughout the pregnancy-puerperal process.
The attributes, which are essential characteristics of the phenomenon, were grouped according to the type of violence into physical, psychological or emotional, institutional, sexual, and structural, which allowed for a better understanding of OV.
Among the attributes included in the category of physical OV, interventions and procedures that are unnecessary or performed without due consent 14,15,17,21,27,28,30,33 stand out, as well as oxytocin use 13,15,18,22-26,32, episiotomy and episiorrhaphy 13,14,17,18,20,22-26,28,32, Kristeller maneuver 15,18,22,23,25-27,32, constant use of forceps 25,32, denial of any type of pain relief 14,17,18,25,29,30,32 whether by means of non-pharmacological methods or not, restriction to the bed 18,23,24-26,29,30, prohibition of eating or drinking 23,25,32, enema 15,17,22,25,28, trichotomy 17,22,23,25,26,30,32, which includes unnecessary removal of pubic hair, and mandatory lithotomy position at birth 17,18,23-25,28,29,32, which causes increased pain and slows down the delivery process.
These attributes are mentioned in several interviews with women in maternity hospitals in the Czech Republic 42. In another research study carried out in a hospital in Azuay, Ecuador, the women also reported these attributes they characterized as types of physical violence 43. These studies corroborate the results found in the current one, validating the essence of the phenomenon.
Some women point out another perception about the Kristeller maneuver and oxytocin administration. In a research study carried out with 57 puerperal women in the central area of the Huasteca region of San Luis Potosí, Mexico, it was reported that these procedures are an act of gratitude towards the mothers at delivery, as they help the infant to descend more quickly and minimize moments of prolonged suffering 44.
However, when episiotomy and episiorrhaphy were mentioned 44, the women’s reports of actually feeling OV were unanimous, mainly in cases where they were not informed. This agreement is observed in several pieces of scientific evidence 16,43,44.
Despite the efforts to seek humanization in obstetric care, the following is clearly noticeable: predominance of interventional procedures such as excessive medicalization 14,17,21, trivialization of the pain felt by the women 20,30, not using analgesics when indicated 12,15,16,21,27,31,33, forcing parturient women to walk in the last stage of delivery 30 without their consent, prolonged bed rest 22,32, aggressiveness 12,14,15,18,24,27, and performing an amniotomy 23,24,32 and the Valsalva maneuver 23,24, which refers to encouraging voluntary push, with unequal power relations between professionals and women prevailing 16.
Physical violence is more prevalent because it is more easily identifiable among women, as shown by a research study carried out at a public hospital in North Shewa, Amhara, Ethiopia. It was pointed out that 100% (435) of the women identified some of these attributes that characterize OV related to physical characteristics 45.
The following attributes stand out in the psychological OV category: humiliation 14,17,18,23,25,27,28,31,32, teasing 15,17, providing false information or omitting information 15,18,19,23,24,29,30,32, yelling 14,16,18,25,31,32, threats 16,18,25,28,30-32, disqualification of women’s decisions 18,30, denial of care 18,26, abandonment 18,20,24,26,32, embarrassment 18, imposition of decisions/values 15,18,19,26, trivialization of women’s suffering or needs 18,20, reproaches 14,16,18,31,32, ironic phrases 17, and coldness 15.
The harms caused by psychological OV go beyond the physical aspect, leaving emotional and psychological scars for a long time, undermining the emotional realm and bringing about consequences that negatively interfere with the puerperal period, a delicate moment for puerperal women 46. It should be noted that these problems can lead to postpartum depression 47.
In an analysis of the notifications of pregnant women in Brazil between 2011 and 2018, with 2,033,026 cases, the type of violence with the highest incidence was physical (61.9 %), followed by psychological (31.2 %) and lastly, sexual (27 % 48).
The incidence of reports that mention the essential characteristics of the phenomenon, that is, the attributes, is considerably high. A multicenter survey carried out in the United States with 2,138 women indicates that one out of six (17.3 %) mentions some type of abuse, such as yelling, disrespect, unknown or erroneous information, denial of care, embarrassment, and loss of decision-making autonomy. It is believed that more women have suffered psychological violence, although they could not identify it 49.
From the institutional category perspective, the attribute with the highest incidence was not allowing the presence of a companion 12,14,15,17,23-26,28,29,32,33. Brazilian women are supported by the Companion Law (Law 11,108) of April 7th, 2005, which allows for the presence of a companion during delivery, childbirth, and the immediate postpartum period, either in private or public health services 50.
Although supported by law, qualitative studies 51,52 still notice reports of Brazilian women who claimed they were not allowed to have a companion and accepted so due to lack of information, even with distress.
In the sexual OV category, the most characteristic attributes were a repetitive vaginal touch 15,18,22,25,28,32, invasion of privacy 17,26,27,33, sexual abuse 17,30-32, and unnecessary exposure of intimacy 30.
Repeatedly touching the vagina can cause harm, such as inciting premature birth and infection in the infant 53 and inducing pain and discomfort. In a study, Mexican women mentioned that they feel unnecessarily invaded in their privacy and exposed, with several touches practically at the same time, reporting that there seems to be no communication between the health professionals 44.
A shocking report in a research study conducted in northern Brazil reveals that the health professional performed the vaginal touch examination and asked all the students present to repeat the procedure, causing discomfort, invasion of privacy and exposure of the woman’s intimacy 53. This scenario proves to be totally inhuman to the woman.
That is a reality not only in Brazil but also in other countries, such as Iran, where the prevalence of sexual OV stands out in relation to the other types. This assertion is indicated in a study conducted with 725 women, in which 14.8% suffered sexual violence, 9.9 % were victims of psychological violence, and 6.5 % of physical violence. Domestic sexual abuse was also very evident 48.
Finally, the structural OV attributes refer to precarious assistance or omission to the detriment of the infrastructure 18, lack of human and material resources 18, lack of beds 18, imposition of institutional routines 18 and shortage of professionals 12. This is more likely to occur in public institutions before the woman’s hospitalization, affecting both her and the professionals, which entails overload and undignified working conditions 18.
These attributes are proven through diverse evidence in practice. During data collection, nurse-researchers noticed a deficit in terms of equipment and a lack of necessary maintenance, especially in the public sector, in addition to communication difficulties between professionals and the absence of adequate signs in the environment 14.
In the category of the OV phenomenon consequents, resulting events or incidents were detected, such as loss of women’s autonomy, emotional and psychological harms, and maternal and child morbidity and mortality.
When a woman loses her autonomy during delivery 15-17,23-26,29,32, her primary role is obliterated, in addition to her decision-making power. For this gap, it is recommended that women look for a support network during prenatal care to acquire knowledge 54.
The formation of groups of pregnant women in southern Brazil showed that those who regularly participated in the meetings were able to enjoy significant autonomy and were willing to argue and impose their wishes, showing greater awareness of the delivery moment 55.
Other terms presented as OV consequents were emotional and psychological harms 12,14,22,25-28,32, fear 15,18, insecurity 15,18 and loneliness 18.
These terms corroborate a research study conducted in northeastern Brazil, in which the puerperal women mentioned having suffered emotional and psychological consequences, resulting in frustration, anger, anguish, and impotence. In the interviews, it is possible to see hints of postpartum depression and trauma after the episiotomy procedure. Consequently, the same women reported that these problems affected their sex lives 52.
In the findings of the current study, episiotomy, an OV attribute, refers to the following consequences: third- and fourth-degree perineal laceration 14,15,22, infection 14,15,22, intense bleeding 14,15,22, urinary and fecal incontinence 14,22, edema 15, and episiorrhaphy endometriosis 15. Although uncommon, episiorrhaphy endometriosis is more prevalent in women who have undergone at least one episiotomy and in cases of vaginal deliveries with curettage to avoid hemorrhages and uterine subinvolution 56.
Procedures considered routine and standardized in health services, without indication, can cause or intensify pain 15,26,27,32, physical harm 12,14,26-28,30,32, and unnecessary suffering. In view of this, the importance of dialogue between professionals, especially nurses, and pregnant women is emphasized, in addition to providing fundamental information about the pregnancy-puerperal process and encouraging self-knowledge about their bodies, role, and decision-making power 57.
An important OV consequence is maternal and child morbidity and mortality 13-17,19,25,26,28,30 during labor and the puerperium, mainly due to cesarean sections without indication, which intensifies the likelihood of respiratory problems for the newborn 15 and triples the mother’s mortality risk, in addition to the possibility of also causing loss of the uterus 27.
OV can lead to maternal morbidity and mortality due to several factors, such as adverse events related to aggressive management of vaginal and cesarean deliveries, neglect to perceive the suffering experienced by the woman, hostility, negligence, and delay in assisting women who are having an abortion -spontaneous or desired- and not allowing the presence of a companion 51.
Finally, it is crucial that nurses are aware of the OV phenomenon and duly trained and able to identify it and intervene in a timely manner, offering humanized, comprehensive, empathetic, and qualified assistance.
It is believed that this concept analysis contributes to Nursing science, research, and clinical practice, considering that it provides scientific support with a deep discussion of the phenomenon, presenting the OV antecedents, attributes, and consequents in detail. This enables nurses to recognize the empirical indicators of the concept; thus, it is likely that they will have a greater knowledge that will lead them to more precise Nursing care in the clinical practice.
As a limitation, we cite non-elaboration of the model case and additional cases; however, there was an in-depth analysis of empirical bases and compliance with methodological rigor.
Conclusions
In this research, it was possible to analyze the OV concept, identifying 76 related attributes, 31 antecedents, and 39 consequents. The study made it possible to contribute greater clarity to the phenomenon, offering theoretical and scientific support for nurses to identify OV cases and contributing to the evolution of Nursing epistemology.
The multidimensionality of the topic studied was comprehensively observed, as it presents several typifications, each with their respective essential characteristics, in addition to their multiple antecedents and consequents in the scenario of OV during the pregnancy-puerperal period.
