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Obstetric violence has returned to the public agenda. Spain’s Health Minister Mónica García Gómez said in a recent parliamentary question time session that care during labor and the postpartum period has improved in recent years. “Today we have more protocols that promote respectful childbirth, reduce interventions that provide no benefit, encourage skin-to-skin contact and ensure a companion is present at all times,” she said. Hospitals are expanding patient education and informed-consent practices — including birth plans and shared decision-making — to ensure women understand options and are supported throughout pregnancy and the postpartum period.

She stressed the need to strengthen the training and clinical skills of staff who care for pregnant women. “We want to eliminate obsolete practices through tools such as ‘not-to-do’ guidelines and maximize the safety of the mother and baby,” she said.

Concept of Obstetric Violence

The Spanish Society of Gynecology and Obstetrics (SEGO) does not use this term. “We prefer to speak of ‘malpractice,’ arguing that the vast majority of interventions are performed with the aim of ensuring maternal-fetal safety,” Pere Brescó Torras , MD, president of SEGO, told El Médico Interactivo, part of the Medscape’s Professional Network.

The group El Parto es Nuestro, a nonprofit feminist association dedicated to improving care for mothers and children during pregnancy, uses the United Nations (UN) (whose human-rights bodies issue guidance and findings that help shape national laws and healthcare policies worldwide). “The UN, through its special rapporteurs and committees, such as the Committee on the Convention of the Elimination of All Forms of Discrimination against Women, It defines obstetric violence as a distinct form of violence against women and pregnant people, carried out by healthcare providers in reproductive health,” Teresa Escudero , physician and partner at El Parto es Nuestro, told El Médico Interactivo.

Escudero added that there are similar definitions in Venezuelan and Argentine legislation. “And recently Catalan legislation — Law 17/2020, which amends Law 5/2008 on women’s rights to eradicate gender-based violence — explicitly recognizes and defines obstetric violence as a form of gender-based violence and a violation of sexual and reproductive rights. It defines disrespectful practices, excessive medicalization and lack of informed consent during pregnancy, childbirth, or the postpartum period,” she said.

Between Clinical Judgment and Perceived Experience

This conceptual debate opens different interpretations about what happens in clinical practice during childbirth care, especially when it comes to differentiating between an obstetric complication, malpractice, or actions that could be improved, as well as the woman’s own perception of her experience.

SEGO’s president laid out three distinct categories. An obstetric complication is an unavoidable adverse event that can occur even when clinical care follows evidence-based standards. Malpractice describes care that strays from established protocols or best practices. And an “area for improvement” refers to care that is clinically appropriate but could be better — for example, clearer communication with the patient, better timing of interventions, or more shared decision-making.

From El Parto es Nuestro’s perspective, there can be violence without malpractice and malpractice without violence. “The person who defines the violence is the woman who suffers it. We are aware that, in general, health professionals do not consider themselves to be exercising violence because their intention is not to be violent — we understand they want to care for the woman and her baby. But overriding the woman, not taking her wishes into account, not explaining what is being done or why — even if it is the right clinical action — is violence. And there may be women who felt very well treated and respected during an induction or a cesarean that, nevertheless, were not clinically indicated; that would be malpractice without violence,” Escudero said.

Informed Consent

“In life-threatening emergencies, the absolute priority is to preserve the patient’s life and safety, so it is not always possible to obtain explicit informed consent. In these cases, care is provided under the principle of implied consent, assuming the patient would accept the interventions necessary to save her life or prevent serious harm. As soon as possible, the patient — or, if necessary, her family — should be informed,” SEGO’s president said.

Escudero said, “Generally, what we see in obstetrics is too much verbal informed consent, without the woman being able to ask whether there are alternatives to those being presented and without time for the woman to think it over. We understand there are emergencies in which rapid action is crucial, but options should be considered beforehand. That is why El Parto es Nuestro recommends preparing a birth plan that outlines as many options as possibleand that the plan be agreed upon between the woman who will give birth and the team that will care for her.”

Problematic Interventions

SEGO noted that the interventions most often debated — episiotomy, induction of labor, cesarean delivery, and instrumental delivery (forceps or vacuum) — are those whose use varies with clinical context. They are not inherently problematic, the society’s president said; when they’re needed to protect maternal-fetal safety, their use should be justified, grounded in evidence and tailored to each patient’s circumstances.

Escudero reminded readers: “Episiotomy should be a last resort; the World Health Organization considers exceeding 5% episiotomy rates could indicate malpractice, and 15% cesarean rates likewise. Medication should be used as little as possible. Childbirth is a natural process and a highly specific neurohormonal event, in which what the mother wants and needs should be respected and physiology encouraged whenever possible. The Kristeller maneuver has been formally discouraged for decades. It simply should not be performed.” (The Kristeller maneuver is a fundal pressure technique that is widely discouraged because of safety concerns.)

Factors That Influence Clinical Practice

SEGO noted that day-to-day protocol use is shaped by workload, resource availability and how facilities are organized. Still, the overarching goal is to deliver safe, high-quality care adapted to each clinical setting. The society prioritizes ongoing professional training, evidence-based practice, clearer communication with patients, and more individualized care. Its president also urged better organization and resource optimization to support that quality of care.

El Parto es Nuestro insists that improving care depends critically on training and the structural conditions of the system. At the same time, they noted that many professionals work under high pressure, with long on-call shifts, shortages of staff and limits on time and space. “Many professionals fight every day within a system that mistreats them, where they have 24-hour shifts and exhausting schedules, with scarce human resources and insufficient space and time to provide proper care,” Escudero warned.

On midwives she said, “There has long been a shortage of midwives, and that only makes things worse. The professional who should attend physiological births is the midwife, and she should do so with one-to-one support; the woman giving birth should have her midwife accompanying her whenever she needs. It is unacceptablefor a midwife to have to attend five women in labor at once — that should not be allowed.”

How Childbirth Care Should Be

SEGO conveys that childbirth care should strike a balance between clinical safety and respect for the woman, fostering trust, good communication and shared decision-making between professionals and patients. “The current approach is moving toward more individualized care that considers each woman’s needs, preferences, and circumstances. This implies encouraging her active participation in decision-making by offering clear, understandable information so she can choose in an informed way. At the same time, maternal-fetal safety remains the priority, integrating the patient’s preferences with evidence‑based recommendations and the clinical judgment of professionals,” SEGO’s president said.

El Parto es Nuestro believes every professional who cares for pregnant women should receive specific training in respectful care, preferably including real testimonies from women who have suffered violence. “Professionals must listen to the women they care for and stop denying the evidence. Obstetric violence exists in Spain, as it does in all countries around the world. Only by accepting that there is a problem can we begin to solve it,” Escudero concluded. She also said that continuous evaluation of hospital practices would be useful and that making statistics on cesarean rates, instrumental deliveries and episiotomies public would help.

This article was translated from El Médico Interactivo on Univadis, part of the Medscape Professional Network.