Abstract
The pivotal concern of this study is to investigate how age, social status, language, and cultural background interact to affect women’s control over and susceptibility to disrespect during birth setting in Jharkhand, India. Women, particularly, belonging from tribal community were directly impacted by disrespect during birth settings, which happens during pregnancy, labor, and the first few weeks following delivery. Hence, the article aims to uncover the effects of disrespect during birth setting on patient’s trust in birth setting facilities and health care teams. Besides, this study also adds to challenge the culture of silence that currently surrounds this issue. The study was conducted in the Sisai block of Jharkhand’s Gumla district, where focus group discussion (FGD) with the assistance of 18 public health midwives (PHMs) and 24 individuals with prior parturition experience were involved. The qualitative data was categorized and analyzed using an intersectional framework, which facilitated the identification of significant themes and patterns. The results show that power dynamics and repressive institutions associated with gender, ethnicity, social, linguistic, and cultural inequality were intertwined with disrespect during birth setting, especially with tribal women. In conclusion, the standard of birthing treatment in India needs to be improved, especially in tribal regions.
Introduction
Nobody wants to be subjected to physical or verbal abuse by medical personnel, especially during childbirth… At such delicate time, we demand to be loved and cared. It is essential to educate the medical team about these difficulties… Even though I’m not sure of the exact strategy… raising their knowledge appears to be the only way to influence their behavior… I never meant to tell anybody else about my experience, but I’m sharing it with you now because I want to help others stay away from similar uncomfortable circumstances. (Bajanti, 39 years, tribal woman)
The global endeavors to achieve the fifth Millennium Development Goal have led to the formulation and execution of health policies along with improvements that hope to increase the use of healthcare facilities for childbirth and mitigating maternal mortality rates (Vogel et al., 2015). On a global scale, there has been advancement in enhancing maternal and infant health outcomes, which were accompanied by a reduction in maternal mortality ratios (Bale et al., 2003; Black et al., 2016). Even so, making sure patients have been safe and giving them better maternity care is still an ongoing and unfinished task. An increasing literature indicates that women encounter various forms of abusive and aggressive conduct while receiving during the process of childbirth healthcare team (Bohren et al., 2015; Mayra et al., 2022). The extant body of literature suggests women might experience ill-treatment and violence in their interactions with healthcare providers, as well as, due to systemic inadequacies within healthcare facilities and the broader medical services (Bohren et al., 2015; Togioka et al., 2023).
Furthermore, this encompasses intentional occurrences of different kinds of verbal and non-verbal violence including emotional and sexual violence; as well as several obstetric 1 procedures that could unintentionally cause discomfort to patients, such as refusing aid during delivery, needless episiotomies, an insufficiency of health care provider empathy, as well as lack of informed consent for involvement during childbirth procedures (Chattopadhyay et al., 2018; Perrotte et al., 2020). The phenomenon of mistreatment or violence toward women during birth settings in India has not been comprehensively investigated, despite the fact that nearly all (89%) of them deliver their babies in healthcare facilities (Sharma et al., 2019). Prior research (see Chattopadhyay et al., 2018; Sharma et al., 2019) encountered accounts from pregnant women who had suffered abuse from healthcare professionals, particularly during labor and delivery in state healthcare establishments. In addition, the obstetric care guidelines in India mandate that healthcare practitioners conduct screenings for domestic violence among pregnant women (Alvarez et al., 2017). Nevertheless, the consistent observance of these guidelines was not always maintained. Hence, the focal point of the study was to explore the association between discrimination and violence done by obstetric care provider’s and women’s inclination to confide in and rely on these practitioners regarding incidents of various forms of violence, especially among tribal women.
Instances of ill-mannered and rude conduct toward women during childbirth raised from inadequacies within the healthcare system, encompassing the knowledge and information healthcare providers receive during their training and the practices that were subsequently reinforced in their professional encounters (Scott & Johnson, 2017). Furthermore, biases prevalent in society might also play a role in such forms of maltreatment. This article opts for the framework of intersectionality theory to have better understanding of the root causes of the issue in Jharkhand, India. The notion of intersectionality, as introduced by Crenshaw (1994), theorizes that societal environments were molded through a confluence of various power structures (such as race, socio-economic status, gender, ethnicity, and sexual orientation) and types of subjugation (including bias, social stratification, and gender disparity). The concept of intersectionality had a significant impact on the understanding and attributes of violence, encompassing its subjective encounter and the manner in which it is comprehended by different individuals (Hancock, 2016). The statement underscores the potential personal and societal consequences of violence in public domains. Through the lens of gender studies, intersectionality as a conception has been widely used to assert that gender is interwoven and intersects with other factors of socio-cultural identity but is not limited to socio-economic, ethnicity, age and race (Veenstra, 2011). The concept of intersectionality posits that a thorough comprehension of the experiences of women could be achieved through a concurrent examination of various factors such as privilege, oppression, identity, positionality, and contextual elements.
The utilization of this framework facilitates a more all-encompassing comprehension of inequality by encompassing the intricacies of the actual world. The notion of intersectionality transcends the approach of examining social hierarchies in isolation, such as considering gender and ethnicity separately, or as a simple additive combination, where the combination of gender and ethnicity results in heightened disadvantage (Collins, 1998). The approach acknowledges the interdependence and reciprocal impact of social classifications, including but not confined to age, gender, age, ethnicity, and socio-economic status, which dynamically intersect as well as interact with one another (Conlon et al., 2014). It recognizes that an individual could encounter both advantages and disadvantages due to the intersection of multiple social hierarchies in diverse settings and across temporal dimensions (Hankivsky, 2022).
The present study explores the correlation among age, social class, cultural and linguistic background so as to understand the changing degrees of power and susceptibility experienced by tribal women with regard to birth settings in government health institutions located in Sisai block, Gumla district, Jharkhand, India. The author utilizes a multifaceted approach, incorporating the viewpoints of both public health midwives (PHMs) and tribal women who reported experiencing extreme pain, anxiety, shame, or loss of self-worth during their birth settings. The observation could be made that akin to healthcare providers globally, a significant proportion of healthcare providers in Jharkhand have devoted to provide proper care of patient while upholding moral principles. Conversely, the reality of gaps in the provision of such care, coupled with the absence of transparency concerning this type of gender-related violence, presents a significant obstacle to guaranteeing the safety of patients. The occurrence of birth settings had a negative impact on relationship quality between patients and healthcare providers, and could also diminish patient confidence in the healthcare system.
The subsequent sections delineate the fundamental conceptions and related factors that underpin current investigation. The following section outlines the research context, methodology and presents significant findings pertaining to the perceptions or experiences of violence during pregnancy among childbirth among PHMs and tribal women. The author proceeds to engage in a thorough discourse regarding the intersection of birth-setting violence with diverse factors, such as age of patient, social status, linguistics, and background. The present study investigates the manner in which these intersections is evident in the healthcare system, as well as on a personal and at community level.
Conceptual Framework for Understanding Birth Setting Disrespect and Violence
The analysis of intense acts perpetrated by healthcare professionals has been tackled through diverse terminologies and conceptual frameworks, including patient contentment, obstetric aggression, ethical violations by personnel, and maltreatment within healthcare settings (Hou et al., 2022). The aforementioned studies provide significant empirical evidence that patients commonly encounter episodes of aggression or incivility across diverse healthcare contexts and in various patient-provider interactions on a global scale (Rocque & Leanza, 2015). However, there exists a dearth of information pertaining to birth settings in India. As the global investigation into instances of disrespect during birth settings care advances, it is imperative to scrutinize the prevalence of similar violence in India, especially focusing on tribal women.
The term birth settings has been utilized by the author in this article to encompass the mistreatment that women undergo during the phases of pregnancy, childbirth, and the immediate postpartum period. Sadler et al.’s (2016) perspective that the mistreatment of women at the time of childbirth could be interpreted as a form of structural violence. Further, Diaz-Tello (2016) opined notion about the birth settings as the practice of healthcare providers bullying and coercing pregnant women during childbirth. The systemic issue at hand had been acknowledged as being deeply entrenched in institutionalized gender-related violence. Hence, the author’s argument aligned with their assertion that the notion of birth setting functions as a valuable analytical framework for tackling disrespect and violence in the realm of obstetric healthcare.
Research Context
The study area was designated as the state of Jharkhand, given its sixth-place ranking in India with a total tribal population of 26.3% (Census, 2011). Jharkhand is home to 32 distinct tribal communities, with Santhal comprising the largest proportion of the population at 31.7%, followed by Oraon at 19.8%, Munda at 14.2%, and Ho at 10.7% (ibid). They primarily inhabit the state of Jharkhand, with the district of Gumla having the highest proportion of tribal population in the state at 68.90%.
According to the National Family Health Survey (NFHS-5) (2019–2020), Jharkhand surpassed all other states in terms of total fertility rate, which contributes to the yearly increases in capacity required for maternity services. According to the study, the overall fertility rate for women in Jharkhand between the ages of 15 and 49 was 2.3% children per woman. The rate in urban areas was lower, at 1.6 children per woman, while the rate in rural regions was higher, at 2.5% children per woman (People Archive Rural India, 2021). According to the most recent NFHS-5 (2019–2020), 32% of the women interviewed were already married when they were 18 years old.
The study was conducted in the Sisai block of Jharkhand’s Gumla district, 64 km from Ranchi, the state capital. According to the Census (2011), the Sisai block is a poorly developed location in Jharkhand that has a low literacy rate. Women and girls in this area typically have less access to education and job possibilities, which lowers their social standing in their families and communities. Regarding, tribal women encounter additional challenges and lack chances as a result of their ethnic identity and cultural and linguistic distinctions. As a result, these cultural hindrances deter tribal women from getting medical care.
The number of births taking place in hospitals in the Sisai block has significantly increased as a result of the adoption of government initiatives, such as the Janani Suraksha Yojana (JSY) and good condition referral system for emergency obstetric treatment. The JSY has implemented an incentive scheme for rural women and Accredited Social Health Activists (ASHA) to encourage facility-based deliveries in order to maintain this trend. The utilization of prenatal and postnatal care, which continues to be among the lowest in the nation, has only slightly improved. Despite the focus on improving the quality of care, the Government of India has implemented strategic initiatives like Labor Room Quality Improvement Initiative (LaQshya) to improve the quality of care in labor rooms. However, these interventions have limited effectiveness in enhancing maternity care in a respectful manner in comparison to other recommendations like the World Health Organization (WHO) recommendations for intrapartum care. 2
Research Design
The study’s fieldwork was carried out over two distinct periods, specifically from February to August in 2022, and subsequently in October of 2022. The study’s fieldwork was carried out in four ANC clinics. The clinics cater to a population with an average size of 10,000. The selection of the Sisai block was based on its ability to represent the multifaceted socio-economic, religious, and ethnic (tribal) composition of Jharkhand. Invitations were extended to the health care team operating within the district to partake in Focus Group Discussions (FGDs). Additionally, expectant women who had been registered by healthcare team were also invited to attend separate FGDs.
Following the FGDs, a subsequent phase of research involved conducting individual interviews in-depth with ten tribal pregnant women who had earlier taken part in the FGDs. The researchers conducted face-to-face interview with prospective participants approximately 1 month prior to the FDGs, during which they orally communicated the study’s objectives. The author obtained written informed consent from the participants who voluntarily agreed to take part in the FGDs involving midwives and pregnant women on the specified day.
The participants were provided with reassurance regarding the high value placed on their information, and emphasis was placed on the potential contribution of the research findings toward enhancing birth-setting services for women across the country. In order to maintain confidentiality and minimize interference with regular operations, FGDs were carried out in secluded spaces within the antenatal care (ANC) clinics or outside of regular clinic hours for both participant groups. During the process of data collection, the author adhered to the ethical and safe research protocols as prescribed by the WHO for investigating instances of violence against women. The participants were given clear instructions to refrain from revealing any personally identifiable information, including their names, while being interviewed.
The research encompassed the involvement of 18 PHMs who possessed previous experience in government labor rooms and were currently involved in Maternal and Child Health (MCH) programs within the Sisai block district. The input of PHMs was deliberately solicited due to their pivotal function in detecting, intervening, and directing expectant mothers who encounter discrimination and leading to violence in Sisai block. The FGDs were carried out in the native language, that is, Sadri and later translated into English by the author.
The study also utilized six distinct FGDs comprising a cumulative total of 24 expectant mothers, with an estimated six to seven participants in each group, to gather data. The process of selecting participants was a collaborative effort between the author and the PHMs, with due consideration given to the pregnant women’s availability and willingness to participate. For attaining a comprehensive scope of viewpoints, the expectant tribal women were classified into seven distinct categories: women under the age of 25, women over the age of 35, women residing in block areas, women residing in village areas, a group of well-educated women (possessing a minimum of secondary school education), and a group of Sadri-speaking women as well as a group of Hindi-speaking women. The formation of the groups was designed to encompass a diverse range of socio-demographic backgrounds and experiences among the pregnant women participating in the study.
A cohort of expectant mothers was screened, and four individuals who self-reported instances of mistreatment during labor and delivery were chosen to partake in subsequent one-on-one, comprehensive interviews. The author, in collaboration with the PHMs, carried out the selection procedure with the objective of incorporating women with varied attributes, such as age, ethnicity, and block or village origins. The FGDs and face-to-face interviews conducted with tribal pregnant women were carried out in either Sadri or Hindi languages. The sessions were audio recorded, while notes were taken to ensure precise documentation of the discussions.
The author transcribed the audio recordings of the sessions in a precise manner and subsequently rendered them in the English language. Throughout the translation procedure, all data that had the potential to disclose the identity of individual participants was eliminated and pseudo names were used to maintain confidentiality. A segment of the translated text was subjected to scrutiny by an uninvolved colleague to verify linguistic precision and uniformity.
The qualitative study’s data coding and analysis were performed by the author, with the objective of conducting a comprehensive and detailed investigation of the information gathered. The data analysis was accompanied utilizing an intersectional framework, which facilitated the classification of the information into three primary factors, namely individual, health system, and socio-cultural factors. The themes such as age, social status, cultural and language background were identified within the aforementioned categories. In addition, the analysis was strengthened through the implementation of observational techniques and site visits to multiple clinics and hospitals located within the Sisai district. Informal discussions were conducted with the healthcare team, such as nurses, doctors and medical officers, to obtain further insights and contextualize the findings.
Findings
Viewpoints of Primary Health Midwives (PHMs)
Historically, the primary duty of PHMs has been to facilitate childbirth in community-based settings. The present tendency of childbirth predominantly taking place in healthcare facilities has broadened the responsibilities of PHMs. Presently, a diverse array of services is being provided beyond the scope of maternal and neonatal care.
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The services provided encompass aid with family planning, immunization administration, and counsel on matters of development and nutrition. The choice of midwifery in Sisai has been broadened to encompass supplementary public health obligations, which comprise the administration of contagious ailments besides furnishing aid to those who have suffered from domestic abuse. As a component of the study, the author interacted with health care team to investigate their level of cognizance regarding instances of violence perpetrated by healthcare practitioners in the realm of maternal and pediatric
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healthcare. A significant proportion of the respondents recognized the presence of the aforementioned violence and deemed it to be widespread.
I will refrain from endeavoring to safeguard my fellow professionals. The phenomenon is indeed taking place. Furthermore, this phenomenon is not limited solely to the hospital environment. Even individuals employed in the respective discipline bear responsibility for certain occurrences of maltreatment (Somanti, 40 years, PHMs)
Several healthcare teams asserted that violence in the birth setting is prevalent, and they also recounted instances from their personal acquaintances who had undergone what they perceived as violent acts during their tenure as patients.
A midwife recollected an incident that served as an example, wherein she acquired secondhand information regarding an act of violence perpetrated by a colleague midwife. Bimla recounted an instance in which a mother expressed interest in exploring the feasibility of acquiring a perpetual family planning method, specifically sterilization:
upon eliciting information regarding the woman’s rationale for pursuing a permanent method… she ultimately divulged a narrative that was rather disconcerting to learn. The individual disclosed that she had undergone physical abuse during her hospitalization, resulting in significant distress. As a result of the traumatic incident, her desire to have children was diminished (Bimla, 45 years, PHMs)
Despite the recognition of violence at birth setting as a prevalent issue in the FGDs, the majority of PHMs appeared to hold the perspective that it was a matter of relatively low significance. As per the professional midwifery, the provision of clear and confident directives pertaining to the conduct of women during the process of childbirth was deemed a crucial component of midwifery competence. Nonetheless, a limited number of individuals had taken into account the potential perception of patients toward such resolute conduct as inequitable, demeaning, incapacitating, or possibly as instances of aggression.
The PHMs also held the perspective that specific pregnant individuals exhibited increased susceptibility to violence in birth settings. They recognized the following groups as being particularly at risk:
patients who vocalize excessively without a valid reason patients who exhibit an unwillingness to endure discomfort neonates who fail to comply with directives to exert expulsive efforts during the birthing process patients who possess significant experience and demonstrate an attitude of expertise women who pose superfluous inquiries (Lali, 47 years, PHMs)
The health care team engaged in a discourse regarding multiple occurrences of unintended pregnancies, with a specific focus on women who had repatriated after working overseas, and adolescents. The individuals conveyed genuine apprehension for the well-being of these women and their offspring. The health care team underscored the obligation of community-based and institutional midwives to prioritize the well-being of tribal women, which occasionally required exhibiting resolute and assertive conduct.
Furthermore, the healthcare team observed that certain women may possess inadequate knowledge regarding potentially hazardous circumstances that may arise during pregnancy or delivery. The authors also emphasized cases in which women presented themselves at medical facilities during the advanced stages of labor but were ill-equipped due to their failure to bring essential attire and personal effects mandated by state institutions.
Furthermore, a significant proportion of healthcare teams conveyed their conviction that the clinical and hospital settings fostered circumstances that conceivably result in mistreatment of patients. The participants identified certain factors, namely deficient infrastructure, overcrowding, inadequate staffing, and onerous workloads, as significant contributors to their stressful professional circumstances.
Narratives by Women Regarding Violence at Birth Settings
The present study conducted FGDs with tribal pregnant women who had prior experience of childbirth in government health institutions revealed a significant number of instances of violence, particularly within labor rooms. Broadly speaking, the tribal women participants in this study made a conscious decision to refrain from disclosing these occurrences of inappropriate behavior. The individuals in question lacked awareness of established protocols for reporting the inappropriate conduct of healthcare professionals. Additionally, they harbored concerns that any form of complaint, even if informal, could potentially compromise the well-being of their infants. During each session of the FGDs, a select group of two or three female participants recounted their individual experiences of encountering unfavorable treatment from healthcare providers during the process of childbirth. Additionally, a number of other participants were cognizant of acquaintances, siblings, or relatives who had undergone comparable negative incidents.
The female participants in this study conveyed their appreciation toward the comprehensive healthcare system in Sisai and the healthcare practitioners who provided them with assistance in delivering their babies in a secure manner. The individuals in question exhibited a lack of inclination toward questioning the system or the healthcare providers upon whom they depended for their present and future medical needs. In addition, notwithstanding their adverse encounters, the women accorded the utmost priority to the secure delivery of their offspring as the most crucial consequence.
Frequently, individuals would justify the instances of violence they had experienced as an inevitable outcome or predetermined course of events in their lives. The aforementioned instances of mistreatment and abuse have played a role in fostering a sense of distrust among individuals toward obstetric health facilities and healthcare providers. Based on personal experiences and accounts of other women’s encounters at specific hospitals, these individuals devised strategies to seek medical care from alternative healthcare facilities in later pregnancies.
Phenomena of Violence—Verbal, Emotional, Sexual
During the FGDs, a significant number of tribal women recounted their utmost significant experiences of emotional or verbal mistreatment by healthcare providers while giving birth. Tribal women conveyed emotions of profound distress, offense, humiliation, inadequacy, astonishment, and confusion throughout their labor encounters:
throughout the duration of the encounter, the nurse persistently attributed fault to the speaker, frequently asserting that they were a source of inconvenience to her… the rationale behind the negative treatment was not comprehensible as they perceived their actions to be innocuous (Rohini, 27 years, pregnant tribal women)
The female participants demonstrated diverse reactions to these occurrences; nevertheless, on the whole, they seldom divulged them to anyone, including their non-formal sources of assistance encompassing acquaintances and relatives.
individuals tend to exhibit a tendency of infrequently expressing their apprehensions regarding these issues to others, and they abstain from registering grievances pertaining to such occurrences with any party. (Sonamati, 20 years, tribal women) notwithstanding the diverse experiences encountered, individuals opt to maintain reticence and evade involvement in disputes or clashes (Bajanti, 39 years, tribal women) I persevered through the acts of violence, resigning myself to the belief that it was predetermined for me (Nisha, 27 years, tribal women)
Through conducting individual follow-up interviews, the author acquired further comprehension regarding the diverse expressions of violence in birth settings, which encompassed occurrences of violence. Further, Bajanti, recounted her encounter of experiencing sexual violation by a male staff member of the hospital in the operating room while giving birth for the first time. Following her cesarean section,
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she was positioned on a medical cart within the surgical suite, awaiting transportation to the postpartum unit. At that particular juncture, the nurses were preoccupied with other duties, resulting in her being left unattended. The individual experienced a period of somnolence and was subsequently aroused by a peculiar sensation that was characterized as unusual physical contact. Upon awakening, she observed a male staff member in close proximity to her:
I experienced a state of surprise and disbelief… one of his hands was in contact with my mammary gland (Bajanti, 39 years, tribal women)
Bajanti recollected that she promptly responded by loudly summoning a nurse, resulting in the male individual hastily departing from the theater. Nonetheless, she opted against pursuing any additional grievance or discourse regarding the occurrence, as she experienced a sense of shame that deterred her from divulging the details of what had transpired.
Intersection of Violence, Social Class, and Societal Status
The tribal women in this study expressed shared viewpoint that the care they received during childbirth in public healthcare facilities was subject to fluctuations based on variables such as their economic status, linguistic and cultural backgrounds, plus social position. A participant highlighted the substantial influence of personal relationships in determining the caliber of obstetrical healthcare received. For instance, having a familial relation who was employed in the healthcare industry or possessing a connection to an individual acquainted with a healthcare provider sufficed in preventing unfavorable conduct:
there have been instances observed where staff members have attributed various issues to mothers. From a personal standpoint, I did not encounter any difficulties as a result of my sibling’s employment at the identical medical facility. Nevertheless, it must be acknowledged that certain healthcare providers exhibit discourteous behavior toward their patients (Rohini, 39 years, tribal women)
One of the participants, Rewati, recounted an experience that underscores the influence of economic and social status on the incidence of discrimination in birth settings. The participant exhibited a restricted level of formal education and financial means, and experienced a lack of familial assistance during her gestational period. However, the individual conveyed appreciation for the assistance rendered by the midwife at the nearby ANC facility and the monetary aid extended by fellow expectant mothers at the clinic. Notwithstanding the aforementioned assistance, the individual reported experiencing emotional and physical violation at the hands of the nurse and midwife present in the delivery room:
upon my arrival to the labor room, the healthcare providers conveyed their discontentment with my attire. The observers made remarks regarding the disproportionate size of the garments, without knowledge of the benevolent donor who had bestowed them upon me (Rewati, 23 years, lactating tribal women)
During the process of childbirth, Suniti inadvertently defecated on the bed. Upon being requested for an additional bed linen, she was clarified that she possessed only one and opted to reserve it for a later time. The midwife responded by hurling a bed sheet toward the individual and uttering derogatory comments, drawing a comparison between the individual and a toilet. The attending nurse assigned to her in the moments leading up to delivery attributed the disorderly state of the birthing area to her actions:
the individual utilized derogatory language and engaged in cursing directed toward me, insinuating that despite my financial limitations to purchase clothing, I participated in actions that resulted in my current state of pregnancy in a timely manner (Suniti, 29 years, tribal women)
During the critical moments of the final phase of childbirth, the woman, experiencing severe discomfort, inadvertently made contact with a nearby midwife. The midwife reacted by swiftly turning and delivering a forceful slap to the woman’s hands, while vociferously instructing her to desist from physical contact.
The subject’s cognitive appraisal of the obstetricians in the delivery room differed markedly from her appraisal of the midwife and nurse. The patient held the belief that the medical professionals provided her with adequate treatment and did not exhibit any discriminatory behavior toward her during the course of her medical care. Nonetheless, the individual conveyed dissatisfaction regarding the inadequate presence of medical practitioners in the delivery room throughout the entirety of the parturition procedure.
About the phenomenon of labor room… nurses and midwives are engaged in blaming patient and physical assault… whereas doctors tend to refrain from such conduct… The incidence of unfavorable conduct among nurses and midwives is higher in the absence of physicians in the delivery room… The presence of medical professionals, particularly consultant obstetricians, has been observed to have a positive impact on the conduct of nurses and midwives. Individuals exhibit a more amicable and benevolent demeanor, potentially with the aim of ingratiating themselves with their higher-ups and showcasing their empathetic disposition (Runa, 33 years, tribal women)
Gita refrained from filing any formal complaints regarding her treatment and conveyed her viewpoint by stating, “we belong to the economically underprivileged strata of society.” The availability of alternative childbirth services was restricted for them.
Correlation Between Violence and Teenage Pregnancy
The age of onset of pregnancy in women appears to have a significant influence on their susceptibility to obstetric care provider violence. In the course of the interviews, Sulekha, who was in her second gestation
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recounted her antecedent parturition
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encounter during her minority. The individual in question terminated her academic pursuits prematurely and proceeded to enter into matrimony at a tender age. Upon the occasion of her nuptials, her comprehension of family planning techniques was restricted, resulting in her expeditious conception. During the course of her pregnancy, she consistently attended the nearby ANC clinic and hospital, however, she did not receive sufficient instruction regarding the discomfort and procedures associated with parturition. Consequently, she experienced prolonged periods of severe labor discomfort prior to ultimately giving birth to her infant:
Recalling the events remains a source of distress for me… upon the arrival of the second physician, he promptly directed his gaze toward me and proceeded to issue a harsh command… instructing me to adjust the positioning of my legs in a particular manner to facilitate his assessment of the advancement of my labor…I acceded to his entreaty, albeit the experience was excruciating. The highest level of discomfort was encountered during the examination performed by the attending medical practitioner throughout the entirety of the labor process… The individual experienced a sense of utter powerlessness and emitted vocalizations of agony (Sulekha, 25 years, tribal women)
Sulekha was experiencing distressing sensations that caused her to shed tears, while the medical practitioner admonished her. During the course of labor, the patient was directed to engage in pushing during contractions. However, following a prolonged period of intense discomfort, she experienced a significant degree of fatigue and depletion, rendering her unable to adhere to the aforementioned instructions:
afterwards, the medical professional proceeded toward me and applied pressure to my shoulder in a vigorous manner, instructing me to exert force. Nevertheless, my physical state was weakened. As a reaction, he applied a significant amount of force to my thighs through a slapping motion. The remaining staff members maintained a state of silence (Sulekha, 31 years, tribal women)
Similar to numerous individuals encountered during the data collection process, the woman experienced a sense of powerlessness in response to the incident and opted against disclosing it to any parties. The individual lacked knowledge regarding the possible repercussions of the care providers’ inappropriate conduct and was uncertain about the existence of any formal mechanisms for reporting such occurrences, such as to law enforcement or healthcare regulatory bodies. The study revealed that a prevalent phenomenon among women was the incapacity to articulate their grievances or object to what they deemed as unjust treatment.
Interplay Between Violence, Language, and Cultural Background
As per findings, it was observed that tribal women also believed a perception that discrimination rooted in their language and cultural customs contributed to the maltreatment they encountered while receiving obstetric care. It was particularly evident in the expressed verbal and emotional abuse during the process of childbirth. The participants recounted incidents in which hospital personnel of tribal origin made derogatory remarks toward them. One such instance involved a tribal woman who was addressed in a disrespectful manner at the hospital:
You are the source of our difficulties... challenges are frequently encountered as a result of your actions... It is expected that you will continue to bear offspring annually from the age of 19 onwards, however, it is commanding that we address all of the concerns (Suniti, 29 years, tribal women)
The study conducted interviews with women who spoke in Sadri highlighted the importance of prevailing linguistic obstacles in healthcare facilities operated by the hospitals. The research findings indicate that Sadri-speaking women in Sisai reported a dearth of fundamental information in their native language at hospitals. As an example, the user made reference to the lack of comprehensive checklists outlining necessary items for childbirth and imperative instructions for labor in the Hindi language.
One of the participants with a high level of education, recounted an incident in which she was subjected to verbal abuse and disregard by a midwife during her stay in the antenatal ward of a governmental hospital in a previous pregnancy. Despite lacking fluency in reading Hindi, which was her second language, the individual in question demonstrates a commendable level of comprehension and speaking proficiency in the language. The midwife responded in an unprofessional manner when the patient made a request for a Sadri version of the childbirth preparation instructions to confirm her understanding in her native language.
the communication style employed by the individual toward me can be characterized as exhibiting a vocalization pattern akin to that of a canine’s bark. The individual in question exhibited impolite behavior toward me, inquiring as to whether my presence at the hospital was intended to effect alterations… The individual proceeded to use profanity toward me while asserting that their contributions toward the Oraon community had already been substantial (Rewati, 36 years, tribal women)
As per the account provided by Rewati, she was involved in a verbal altercation with the midwife due to her perception that there was no valid reason for being subjected to derogatory remarks. The individual held a strong conviction that healthcare providers engaging in discriminatory practices on the basis of culture and language were entirely intolerable:
while acknowledging our appreciation and respect toward these individuals, it is vital that certain modifications are implemented in their dispositions (Rohini, 27 years, tribal woman)
The present study reports the experiences of a highly educated tribal woman who was wedded to a financially secure individual and who encountered instances of discrimination on the basis of her language and culture at a local ANC clinic and government hospital.
In the course of my initial gestation period, I dwelled in a locality that lacked the presence of individuals adhering to my cultural faith. Nonetheless, in my present gestation, the preponderance of the inhabitants in the locality adhere to the tribal cultural faith, thereby implying that the medical practitioners and other healthcare providers are well-versed with our customs and way of life… In contrast, in the antecedent setting, there was a lack of initiative to provide me with education or even initiate discourse… I experienced significant distress when I was addressed as "the tribal mother," while other women were referred to by their names… It would have been preferable to have been addressed by one’s name. (Mrinal, 31 years, tribal women)
Upon admission to the antenatal ward of a government hospital for her initial childbirth, Singo was expeditiously admonished by a nurse who insisted that she modify her clothing:
Upon my arrival at the ward, I was met with a discerning gaze from the nurse due to my attire… In the presence of her female peers, she scolded me for my clothing and demanded that I alter it to a dress and a robe. She made a comment in a mocking tone, suggesting that it would be impossible for me to give birth while fully clothed from head to toe (Singo, 43 years, tribal women)
The female patient had abstained from articulating her emotional state of anguish and indignation to the healthcare professionals at her nearby medical facility. Participants ascribed their hesitancy to a subjective perception of insufficiency and apprehension, positing that they were deficient in the requisite fortitude to vocalize their thoughts.
Discussion
Confluence of Various Dimensions of Violence
The application of intersectionality in discussions surrounding violence against tribal women brought to the forefront issue of violence in birth settings. The aforementioned phenomenon was characterized by the intricate interplay of various power dynamics and systems of oppression, converge and reciprocally influence women’s encounters with mistreatment or violence in the context of childbirth. The concept of intersectionality underscores the insufficiency of gender inequality as a sole explanatory factor for gender-related violence, underscoring the significance of examining multiple facets of identity and oppression. The phenomenon of gender inequality has been molded by various systems of subjugation and power, rather than being solely determined by gender in isolation. The presented findings indicate that the prevalent systems of power and oppression in birth settings emerge from the crossing of diverse factors encompassing the healthcare system, individual encounters, and socio-cultural environments.
In the subsequent sections, the author analyzed these factors in isolation, scrutinizing each one individually. In the final section of the analysis, the author integrated the arguments through demonstrating the interplay and impact of multiple factors on experiences of disrespect and violence in birth settings.
Factors Related to the Healthcare System
The issue of tolerating discrimination and violence against women as a result of social and institutional norms holds a significant place in the extensive literature on abuse in healthcare. It pertains to the individual experiences of mistreatment faced by tribal women and their corresponding reactions, as well as the healthcare professionals’ restricted emotional empathy or understanding of their patients’ encounters with mistreatment. The findings of the present study indicate that a significant number of women tend to remain reticent regarding their encounters with disrespect and violence in healthcare environments, as they perceive such incidents to be commonplace occurrences. Furthermore, the comprehension of their entitlements as patients to obtain courteous treatment and medical attention within healthcare establishments was restricted.
The absence of disclosure by tribal women concerning their encounters with violence at birth settings was indicative of an asymmetrical distribution of power between patients and healthcare professionals, whereby the latter were able to exert dominance through the use of manipulative language and physical actions, with little to no accountability. Regarding this, Jewkes and Penn-Kekana (2015) advise against attributing responsibility to healthcare professionals as a homogeneous entity. The text underscores the arduous and unfavorable working circumstances that numerous birth setting providers encounter, including hospital overcrowding and staff scarcities, which might add to their discouragement. It is critical to acknowledge health system factors as a type of lack of respect and abuse (Sadler et al., 2016). Additionally, it is important to identify the impact of socialization within these systems, which might drive individuals to engage in violent behaviors.
The findings of the investigation demonstrate that conflict in birth setting care might stem from a disparity in viewpoints between medical professionals and their patients. Patients might perceive guidance on labor conduct as a type of aggression, while healthcare providers might regard such ethical guidance as a crucial component of competent nursing or midwifery care. Additionally, it is authoritative to take into account that midwives’ interpretations of patients’ non-adherence to their recommendations might originate from authentic apprehensions regarding the well-being of the women. Midwives might express concern that women may lack awareness of potentially hazardous situations and thus prioritize certain instructions to promote their safety.
Policy deliberations in the future that aim to improve birth setting care in Sisai must consider the aforementioned health system factors. When tackling matters of accountability between healthcare providers and their patients, it is vital to take into account these factors. The identification and implementation of suitable measures for enforcing the responsibility of healthcare practitioners is of utmost importance in safeguarding the welfare and entitlements of patients.
It is unavoidable upon the state to assume the responsibility of remedying the current dearth of accountability pertaining to inappropriate conduct within care-based relationships. The implementation of improved observation, policies, and training that prioritize ethical manner and safety of patient is crucial in the realm of birth setting care. It is domineering to establish and implement appropriate measures to guarantee the maintenance of optimal standards of care. The societal beliefs surrounding entitlement to healthcare, healthcare practitioners, and the preferred obstetric healthcare system within the nation warrant critical analysis and reassessment. These convictions form the basis for the establishment of more equitable, gender-conscious, and suitable care protocols. Active participation in such discussions is imperative for promoting constructive transformations in the healthcare domain.
Individual Factor
The experience of obstetric violence was influenced by the age of the women in the current study. Young mothers were identified as a population that is particularly vulnerable to experiencing violence in birth settings. This susceptibility might be attributed to their limited exposure to the healthcare system and insufficient comprehension of the childbirth process. Comparable results have been documented in research carried out across states.
The acknowledgment of women’s financial vulnerability has been recognized as a notable aspect that contributes to violence in birth settings. Individuals who possess the necessary financial resources to avail themselves of private hospital births tend to encounter enhanced privacy and receive care that is more accommodating to their needs. Patients were provided with the opportunity to have companions present in distinct delivery rooms, who may act as advocates or witnesses to safeguard their rights and welfare.
Nonetheless, the vast majority of women in Sisai who deliver babies in government-run facilities were compelled to relinquish control and depend entirely on their obstetric careers for their well-being. In situations where distrust arises within the patient-provider dynamic, women frequently resort to seeking care at an alternative state and private hospital with a more favorable reputation for their subsequent pregnancies as their sole feasible and satisfactory recourse.
The relationship between poor socio-economic position and discrimination in birth settings has been acknowledged as a risk factor in several nations. In Sharma et al. (2019) study impoverished women residing in rural areas frequently abstain from accessing healthcare services during pregnancy owing to the maltreatment they encounter in healthcare establishments. This study has confirmed that individuals with limited educational attainment and low economic status are at a higher risk of experiencing mistreatment in healthcare settings. Healthcare providers are cognizant of the fact that women belonging to this demographic were more inclined to acquiesce to suboptimal care, even if it failed to meet the minimum standards.
Socio-cultural Factors
The present investigation identified three socio-cultural determinants that have a noteworthy impact on the birth-setting experiences of women. The determinants encompass factors such as the impact of patriarchy, hierarchies between patients and providers, and the cultural-linguistic backgrounds of patients. The interconnectivity of these factors results in a restricted focus on obstetric violence within the nation. The consent of women to ill-treatment and violence during birth setting care, coupled with their incapacity to articulate their encounters even among their casual support systems, could be ascribed to the power differentials and socio-cultural norms linked to hierarchal structures and the relationships between patients and providers.
The influence of the patriarchy society in Sisai was noted in tribal community. So, tribal women’s inclination toward submissiveness to men could potentially influence their attitudes and customary practices toward engaging with individuals they perceive as their “superiors,” including female healthcare professionals. The deeply rooted gender inequality and inequity that underlies violence in birth settings is a result of the intricate interplay between patient-provider hierarchies and patriarchy.
An increasing gap between the state and private sectors has emerged, which leads to the formation of an additional hierarchy of patients and providers in the country, particularly in town areas. Based on current research, it was observed that affluent tribal women residing in town regions often opt for private healthcare institutions to receive birthing care. The patient-provider relationship is influenced by the intersection of hierarchies and the language and cultural backgrounds of the individuals involved.
Studies carried out in diverse nations have demonstrated that there exists a correlation between violence in birth settings and the cultural backgrounds of women (Menjívar & Salcido, 2002). As exemplified by a scholarly investigation of indigenous women in Peru, this association was brought to the forefront (Rousseau & Hudon, 2016). Likewise, within the United States, race has been recognized as a noteworthy determinant of emotional maltreatment and bias in the context of birth-setting care (Bryant et al., 2010).
Through the conducted interviews, it was discovered that tribal women, particularly those who lacked proficiency or familiarity with the Hindi language, exhibited hesitation regarding the influence of their language and cultural customs on their treatment within birth care facilities situated in the Sisai. It is imperious to acknowledge that the conclusions drawn from this research were founded on a restricted and unrepresentative sample. Consequently, it is advisable to exercise prudence when attempting to apply these outcomes to the entire population.
Further research is needed to examine the potential influence of culture, that is, ethnic identity and native language and cultural background on the notion and encounter of disparate treatment in birth settings care in other parts of districts, as well as, across states of India.
Conclusion
The findings of the investigation indicate that violence at birth setting is frequently encountered by expectant mothers in Sisai. However, these occurrences are frequently left unreported or unvoiced, even within their informal support systems. According to PHMs, mistreatment and violence in birth settings could be attributed to women’s perceived non-compliance with medical advice or their behavior being perceived as assertive, uncooperative, unprepared, or lacking in knowledge. Insufficient resources at the institutional level have been identified by PHMs as a causative factor to the incidence of violence birth settings.
As per the interviews, the participants commonly attributed violence at birth settings to midwives, nurses and junior doctors. Nonetheless, the participants in this research also recognized and valued the attentiveness and interventions of specific healthcare practitioners belonging to these identical disciplines. The observers had noted instances where these service providers had taken measures to hold their peers responsible for fostering environments that were discriminatory or abusive. The perceptions and experiences of violence at birth settings were shaped by the intersection of the cultural identity and practices of women and healthcare providers.
Additionally, young women were consistently targeted in the healthcare system, being perceived as unprepared or uncooperative during childbirth. This suggests that some healthcare providers were making judgments about the perceived value or worth of patients, which in turn had effects on service quality provided.
As stated earlier, the primary aim of this study was to examine the prospective correlation between the mistreatment of tribal women during birth-setting care and their likelihood of reporting instances of domestic violence and other types of mistreatment to healthcare professionals. The data that has been gathered does not offer definitive proof on this matter. Nonetheless, it signifies a dearth of channels for recourse available to patients who experience maltreatment in birth-setting care environments, along with an absence of repercussions or liability for healthcare professionals implicated in abusive conduct.
Raising awareness about violence at birth setting represents an initial step toward implementing remedial actions aimed at improving the emotional and physical well-being of patients, as well as the general quality of care. Furthermore, it enables the initiation of a discourse between healthcare practitioners and patients that is founded on reciprocal regard, confidence, and comprehension. Therefore, the resolution of violence in birth settings necessitates a holistic strategy that focuses on the underlying structural factors at the individual, healthcare system, as well as socio-cultural levels. According to Sadler et al. (2016), a variety of strategies could be employed to document instances of violence during childbirth. These may involve implementing changes at the legal, financial, administrative, educational, and scientific levels. Expanding on the suggestions provided by the authors, current article presents a concise summary of pertinent recommendations for our current and future pursuits.
The proposed initiative involves the implementation in reforming and improving health system in Sisai with the objective of establishing professional accountability for the purpose of ensuring patient safety and well-being. This article entails the implementation of official protocols that enable patients to seek redress in cases of severe violence. It includes the establishment of patient advocates and impartial medical boards that have been specifically designed to receive and evaluate complaints in a just and impartial manner. Moreover, it is imperative to enhance the focus on the ethics of care during the professional education of obstetric healthcare practitioners. It is recommended that obstetric healthcare providers have access to periodic refresher training, which may be obligatory. The training program ought to prioritize the development of empathy toward patients by utilizing experiential learning approaches, such as the integration of theater techniques into the training syllabus.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author received no financial support for the research, authorship and/or publication of this article.
