Obstetric violence informed by theories of intersectionality, oppression, and power dynamics—a Ghanaian’s perspectives

Abstract

This essay explores obstetric violence (OV) from a Ghanaian perspective, applying theories of intersectionality, oppression, and power dynamics to critically analyze its causes and manifestations. OV, defined as mistreatment during childbirth, includes acts of physical abuse, nonconsensual care, discrimination, and breaches of privacy. Despite efforts to reduce maternal mortality in Ghana, systemic challenges persist, contributing to a high prevalence of OV, particularly among vulnerable groups such as adolescents, the socioeconomically disadvantaged, and ethnic minorities. The essay highlights that midwives, while essential to maternal care, often operate within oppressive healthcare systems characterized by poor resourcing, rigid hierarchies, and systemic gender bias. Through the lens of intersectionality, the study reveals how overlapping social identities—such as age, ethnicity, and socioeconomic status—influence women’s vulnerability to mistreatment. Oppressed group theory explains how midwives, themselves marginalized within patriarchal and medically dominated structures, may internalize oppression and perpetuate violence toward patients. Foucault’s theory of power and knowledge is used to illustrate how institutional norms and knowledge hierarchies empower midwives to exercise control over birthing women, often compromising women’s autonomy and dignity. The essay further discusses how systemic issues, including underinvestment in healthcare infrastructure, inadequate training on respectful maternity care, and normalization of abusive practices, contribute to the persistence of OV. It calls for comprehensive reforms such as empowering midwives through education and leadership training, decentralizing healthcare authority, promoting respectful maternity care practices, and addressing systemic inequities. Raising awareness, fostering accountability, and embedding patient-centered care principles into healthcare institutions are critical steps toward eliminating OV. Ultimately, the essay argues that addressing OV in Ghana requires not only confronting individual behaviors but dismantling the deeper structural and institutional forces that sustain power imbalances and systemic oppression. Empowering both midwives and birthing women is essential for transforming maternity care and advancing equitable, respectful maternal health outcomes in Ghana.

AJOG Global Reports at a Glance.

Why was this study conducted?

This essay investigated how intersectionality, the oppressed group theory, and power and knowledge dynamics shape obstetric violence (OV) during Ghanaian midwives’ practice.

Key findings

Tackling OV demands systemic reforms, confronting deeply rooted power imbalances and institutional practices.

What does this add to what is known?

It provides valuable insights into systemic shortcomings within the healthcare system and socio-cultural norms that may legitimize OV.

Introduction

Obstetric violence (OV) denotes the abuse of parturient women by healthcare professionals during parturition.¹ It often manifests as acts of disrespect, dehumanization, misuse of medical interventions, and various forms of physical harm.^2,3 OV is established through breaches of privacy, physical mistreatment, stigmatization, discrimination, the absence of culturally appropriate care, verbal harassment, and unjustified detention in healthcare facilities.^4,5 The factors contributing to OV are complex and multifactorial. Healthcare-related contributing factors may include inadequate resources, excessive workloads, the hierarchical role of healthcare professionals, including midwives, power dynamics, and the type of healthcare facility. Patient-related factors relate to socioeconomic status, such as the age of mothers (adolescents), women’s inability to pay illicit incentives or hospital fees.^5,6

The critical role of midwives, safeguarding the health of both mother and baby, in reducing maternal mortality is undeniable,⁷ while abuse during parturition significantly impacts maternal health outcomes.² A pivotal global study highlighted the substandard care many women endure during parturition, including corporal abuse, nonconsensual practices, and discrimination by healthcare providers.⁸ A study across four low- and middle-income countries (LMICs) reported 41.6% of women (vulnerable groups of younger, economically disadvantaged, unemployed with limited literacy, or unmarried) experienced corporal or verbal abuse, stigma, or discrimination during parturition.⁹ Mistreated women risk increased maternal complications, such as obstructed labor and postpartum haemorrhage.¹⁰ Fear of disrespect and abuse in healthcare facilities discourages women from seeking hospital-based care (Kane et al,¹¹ further contributing to maternal mortality. OV is not an isolated event but is deeply embedded within historical, cultural, and systemic factors,¹² making it an urgent matter that requires focused attention, especially in LMICs such as Ghana.

Historically, Ghanaian maternal healthcare has transitioned from traditional midwifery to modern biomedical approaches.¹³ However, systemic challenges, rooted in colonial-era healthcare systems, persist in favoring urban centers, leaving a remnant of unequal access that remains to impact maternal care delivery.¹⁴

Geographically, Ghana’s diverse socio-cultural landscape significantly shapes maternal health practices nationwide. Urban areas generally benefit from better-resourced healthcare systems, while rural regions face pronounced disparities in maternal care quality¹⁵ resulting from shortages of skilled personnel, overcrowding, and inadequate infrastructure, conditions that can exacerbate the likelihood of OV.¹⁶ Working under high-pressure conditions and often with inadequate resources, midwives may be more prone to engaging in behaviors that lead to mistreatment.¹⁷

Examining Ghanian midwives, who serve as the primary caregivers during childbirth, as potential contributors to OV is important⁵ and would provide valuable insights into systemic shortcomings within the healthcare system and socio-cultural norms that may legitimize such behaviours.¹⁸ This essay critically examines and analyses OV-relevant literature, exploring theories of intersectionality, oppression, and power dynamics, including their practical applicability and significance to OV. It also highlights OV-related implications for Ghanaian healthcare practice.

Critical analysis, evaluation, and synthesis of OV literature—a Ghanaian’s perspective

Context analysis

Ghana has seen a decrease from 760 maternal mortality per 100,000 live births in 1990 to 310 in recent years (Ghana Statistical¹⁹). Despite Ghana’s substantial investment in various initiatives to reduce maternal mortality,²⁰ like the Safe Motherhood Programme, life-saving skills training, community-based health planning and services; exemption of maternity care costs, targeted antenatal care services, and the National Health Insurance Scheme, challenges persist (Ghana Statistical^19,21). Ghana’s maternal mortality rate exceeded the universal target of 70 deaths per 100,000 births.⁷ Ghana did not meet Millennium Development Goal target 5a to achieve a 75% decrease in the maternal mortality ratio (MMR).²² To achieve Sustainable Development Goal 3 (reducing the MMR to 70 per 100,000 live births) (United Nations Development²³) Ghana adopted the Emergency Obstetric and Newborn Care strategy.²¹

The occurrence of OV in Ghana highlights significant health facility quality of care concerns.^18,24,25 OV prevalence was 65.1% and 61%, respectively, among HIV-negative and HIV-positive women, with neglect, discrimination, and nonconsensual procedures frequently experienced by the latter.²⁶ Yalley et al,⁵ reported OV prevalence of 63.5%, abuse and mistreatment with breaches of confidentiality, discriminatory care, and detention for unpaid bills contributing to OV. Adolescent mothers were especially vulnerable to physical abuse compared to older women.⁵

Women’s hesitancy to seek institutional care often stems from personal experiences or shared accounts of mistreatment.²⁴ OV affects women’s physical and psychological health,²⁷ discouraging institutional care and increasing home births.^28,29 Poor attitudes among healthcare workers, such as shouting at women during delivery, impatience, negligence, disregard for traditional childbirth practices, and high hospital delivery costs, are prime factors driving home births.³⁰ OV heightens the risks of childbirth complications and postnatal depression^10,31 and limits women’s autonomy in sexuality,³² amplifying social and psychological impacts.

Health system factors, including resource shortages, excessive workloads, a culture of blame for maternal mortality, insufficient skilled personnel, and poor hygiene, perpetuate OV.^25,33,34 Conversely, Yalley,¹⁸ emphasized the normalization of OV, with midwives using it as a strategy during delivery, reinforcing the need for systemic reforms. The manifestation of Ghanaian OV is summarized in Table. Despite its longstanding presence in various forms, OV is an increasingly recognized issue within global health discussions.⁵

Table.

Forms of OV in Ghana

Forms of obstetric violence	Examples
Verbal abuse	•Shouting •Use of offensive language •Threat of death or poor outcome of delivery
Physical abuse	•Striking and pinching during delivery
Psychological abuse	•Detention at the hospital following the inability to settle the hospital bill. •Stigma and discrimination •Neglect and abandonment •Lack of supportive care •Breast genitalia exposure
Financial	•Bribery •Extortion
Professional misconduct	•Nonconsented care including surgical procedures and episiotomy. •Sharing patient confidential information •Lack of privacy during procedures (vaginal examination) •Refusal to give analgesics during a painful procedure
Resources	•Lack of skilled midwives. •Inadequate resources •Competence of healthcare workers •Poor hygienic condition
Traditional practices	•Nonconformity to traditional customs during surrounding childbirth (preventing women from assuming a squatting position during labor) •Prohibiting women from retaining the placenta after childbirth •Absence of family members during delivery

Adopted from Yalley et al.⁵

Senkyire. Obstetric violence informed by theories of intersectionality, oppression, and power dynamics. AJOG Glob Rep 2025.

Theoretical perspectives and justification for a critical analysis of OV

The frameworks of intersectionality, oppressed group theory (OGT), and power and knowledge theory (PKT) provide valuable insights into understanding midwives’ OV. Intersectionality examines the impact of intersecting social identities (such as race, gender, class, and sexuality), creating layered experiences of oppression, thus emphasizing the inseparability of social identities, as shaped by the interaction of social processes and structures over time and place.³⁵ Intersectionality suggests a comprehensive lens to explore how systems of marginalization and privilege combine to shape unique individual and communal experiences.³⁶ Intersectionality presents an outline for analyzing how overlapping social elements (gender, race, and socioeconomic status) shape the care, including OV, that women receive during childbirth.³⁷ Women from marginalized racial or economic groups, for example, may face heightened vulnerability to coercive or abusive practices due to systemic biases and stereotypes that undermine their autonomy and prioritize medical authority over their needs.³⁸ Intersecting identities thus contribute to unequal treatment, with certain groups disproportionately experiencing healthcare-related OV.^35,39

Freire,⁴⁰ introduced the OGT, which was adapted to nursing by Roberts,⁴¹ OGT explains how, historically, marginalized groups may internalize oppression and reproduce dominant behaviors. OGT regarding midwives, traditionally subordinate to medical professionals, like doctors, suggests that midwives might exert control, or even violence, over patients to reclaim a sense of power.⁴⁰ Furthermore, positioned within a medical hierarchy that often undervalues their role, midwives may assert control over birthing women to compensate for their limited agency in the broader healthcare system.⁴² OGT illuminates how, in the absence of systemic support and recognition, midwives, consequently considered an oppressed group, can inadvertently perpetuate oppression themselves.⁴¹ From an OGT notion, midwives’ marginalization fosters internalized oppression, leading to the exercise of authority and control over pregnant women receiving care.⁴⁰

Foucault’s theory of PKT offers another theoretical perspective on OV to examine how power dynamics influence midwives’ healthcare practices, including obstetric care. Foucault⁴³ posited that knowledge and power are interconnected, with those controlling knowledge exerting authority over others. In OV, midwives may use their medical knowledge to assert authority over birthing women, often at the expense of the women’s autonomy and bodily integrity.⁴⁴ As both caregivers and enforcers of medical norms, midwives exercise power through their control of knowledge and decision-making during childbirth.⁴⁵ Institutional practices that prioritize medical expertise over women’s lived experiences reinforce these power imbalances, enabling coercive interventions or neglect.⁴⁶

Critical application of theoretical perspectives on midwives-related OV—a Ghanaian’s perspective

Interactions of intersecting identities between women receiving care and behaviors of Ghanian midwives providing care influence both experiences, meriting an intersectionality theory perspective to possible OV.⁴⁷ Lower socioeconomic Ghanian women are disproportionately affected by OV, often feeling powerless in healthcare settings and facing mistreatment due to their financial vulnerability.⁴⁸ Midwives may exploit these disparities by taking bribes from birthing women, leading to biased and unequal care,⁴⁷ reinforcing a hierarchical system that marginalizes impoverished women.⁵ Ethnic minority women experience additional discrimination, with stereotypes and biases leading to dismissive treatment or verbal abuse when midwives belong to different cultural, ethnic or language groups.^47,49 Ghanaian adolescents or unmarried women accessing maternity services often endure immoral, verbal and physical abuse due to societal stigmas linking early and premarital pregnancy with promiscuity and poor parental upbringing¹⁸ which exacerbates their trauma during childbirth.^5,50

Midwives in LMICS experience systemic oppression within male-dominated healthcare structures, poor working conditions, and are accused of causing death, contributing to stress and burnout that can manifest as hostility toward patients.⁵¹ Ghanaian midwives from the Ashanti and Western regions had similar experiences when blamed for adverse delivery outcomes. They risked disciplinary actions, including license revocation. To protect themselves, they resorted to abusive and forceful practices during childbirth.¹⁸

Ghana’s guidelines regarding respectful maternity care (Ghana Health⁵²) fail to address intersectional factors adequately. A standard approach was adopted, overlooking the unique vulnerabilities of groups such as adolescent mothers and women from rural areas. Midwifery training programs prioritize clinical skills versus addressing systemic biases and interpersonal dynamics, neglecting the intersectional factors shaping care delivery.⁵³

In midwifery, OGT theory draws attention to how healthcare workers, especially women in subordinate roles, internalize their oppression and may redirect it toward those they care for.^40,54 OGT applied to Ghanaian OV uncovers how the systemic marginalization of midwives positions them as both victims of institutional oppression and perpetrators of mistreatment within the healthcare system.⁴⁷ Ghanaian midwives are restricted from pursuing further education after basic training. This deprives them of acquiring modern delivery skills, forcing them to rely on outdated methods, which often include resorting to violence to ensure successful childbirth.⁴⁷

Ghanaian midwives, predominantly women, often navigate dual marginalization within patriarchal societal structures and hierarchical healthcare systems. They frequently find themselves devalued, disrespected, and demeaned by male physicians, which can foster feelings of disempowerment and frustration.^13,47 This systemic marginalization can contribute to a culture where midwives, constrained by limited upward mobility and autonomy, redirect their frustrations toward patients, perpetuating OV.⁴⁷

Midwives face challenging working conditions, including insufficient remuneration, resource shortages, and overwhelming patient workloads.^13,47 Ghanaian midwives earn an average monthly salary of ₵2000 ($138), less than 30% of a doctor’s salary, with some resorting to extortion and in-hospital trading, often neglecting or abandoning women in labor. Patient customers, unable to pay for purchased items, are sometimes delayed during discharge.⁴⁷ Ghana’s midwife-to-patient ratio is 1:560,⁵⁵ a 140-fold higher ratio than the WHO recommended ratio of 1:4.⁵⁶ Thus, midwives experience significant challenges, in managing multiple deliveries simultaneously, which are both dangerous and unfeasible. These systemic inequities amplify feelings of powerlessness among midwives, prompting some to assert control in ways that compromise respectful maternity care.⁴⁷ Acts such as verbal abuse or neglect often stem from internalized oppression rather than intentional malice.¹⁸

Oppressed groups often replicate oppressive behaviors within their limited spheres of influence.⁴⁰ This dynamic is exacerbated in resource-limited environments where midwives feel unsupported and undervalued.⁴⁴ Ghanaian healthcare institutions frequently prioritize efficiency over patient-centered care, fostering a hierarchical culture that pressures midwives to conform rather than advocate for patients’ rights. This institutional environment reinforces internalized oppression, normalizing OV as a routine aspect of care.¹⁸ The marginalized status of both groups further compounds the power imbalance between midwives and laboring women. Women, especially those from disadvantaged backgrounds, are less likely to challenge mistreatment due to fear of repercussions, perpetuating a cycle of silence and abuse.^44,57

Ghanaian maternity care is dominated by the biomedical model, aligned with Foucault’s⁴³ PKT framework, and positions doctors and institutional protocols as ultimate authorities.^58,59 Midwives are thus often subordinated despite their professional training.⁶⁰ This marginalization may lead midwives to assert authority over patients to navigate their position, sometimes resulting in coercive or abusive practices.⁶¹ Furthermore, Ghanaian maternity care often prioritizes midwives’ beliefs and preferences over women-centered care. The perception is that women are ignorant and unable to make decisions about their bodies.⁴⁷ Consequently, fostering a delivery room power dynamic that undermines birthing women’s autonomy.

Foucault’s concept of biopower (control and regulation of bodies and populations) is evident in OV.⁶² Ghanaian midwives act as enforcers of institutional authority, managing women’s reproductive processes under the disguise of medical necessity.^63,64 Examples include performing nonconsensual episiotomies, strict monitoring of protocol compliance or using verbal coercion (⁶⁵; International Confederation of⁶⁶).

As holders of specialized medical knowledge (PKT framework) midwives occupy a position of power over patients, who often lack equivalent understanding.⁵⁷ Ghanaian midwives uphold the concept of “obedience,” enforcing women’s subordination and asserting their authority as healthcare providers as evident during the second stage of labor when women seek confirmation on how to push.⁴⁷ This imbalance in knowledge can lead midwives to disregard patients’ preferences and concerns, fostering a healthcare environment where women feel disempowered and silenced during childbirth.⁶⁷

Foucault’s concept of normalization sheds light on how certain behaviors become legitimized through institutional practices.⁶⁸ In Ghanaian maternity wards, mistreatment is often rationalized as disciplinary or corrective, thereby normalizing actions like scolding or physically restraining laboring women,¹⁸ thus creating institutionalized violence as accepted routine care. Although midwives may contribute to OV, some challenge the power structures that oppress midwives.⁶¹ For instance, rural Ghanian midwives may deliberately diverge from rigid protocols to offer compassionate and empathetic care, thereby resisting institutional norms.^65,61

Executive actions to eliminate OV and develop wholesome future Ghanaian midwife practices

Empowering Ghanaian midwives is key to improving maternity care in Ghana, irrespective of historic and continued systemic challenges. Ultimately, adopting an intersectionality framework would let Ghanaian midwives feel less oppressed and bring Ghana closer to achieving respectful and equitable maternity care.

Actions to interrupt OV among Ghanaian midwives would ultimately require substantial investment, including a commitment from the Ghanaian government. However, these are crucial for creating a healthcare system that protects women’s rights and ensures safe, respectful maternity care for all. Furthermore, the implementation process must involve consultation and collaboration with midwives, women’s groups, and other key stakeholders to ensure its effectiveness and sustainability.

Several key organizational systems-related actions are highlighted.

Organizational system-related actions

• 1.Empowering midwives

Policies granting midwives greater autonomy in decision-making and professional responsibilities can reduce burnout caused by rigid hierarchies. Improving working conditions, such as adequate staffing, access to equipment, and fair pay, is essential to alleviating stressors and enhancing compassionate care.

• 2.Respectful maternity care

To promote respectful maternity care, midwifery education should prioritize informed consent, and shared decision-making. Midwives can act as transformative agents in healthcare, championing the rights and well-being of patients.

• 3.Addressing institutional power structures

Institutional reforms are vital for fostering inclusivity and equity in maternity care. Decentralizing authority and involving midwives and patients in decision-making ensures that services reflect the needs of those directly impacted. Establishing safe reporting mechanisms for mistreatment promotes accountability and trust. Collaborative care models reduce rigid hierarchies, fostering mutual respect among healthcare professionals and improving teamwork and shared responsibility.

• 4.Building knowledge

Leadership training programs can further equip midwives to advocate for patient-centered care and foster a respectful and equitable healthcare environment. Continuous education on ethical power management equips midwives to navigate their roles responsibly, respecting patient autonomy and dignity. Curricula must address cultural norms and systemic inequities to improve midwives’ ability to deliver empathetic and inclusive care. Training in human rights advocacy empowers midwives to challenge unjust practices and align their roles with dignity and equity.

• 5.Promoting organizational changeOrganizational changes within maternity care institutions can embed respect, dignity, and collaboration into their ethos. Leveraging technology, such as digital feedback systems, helps monitor practices and address deviations. Recognizing and rewarding respectful care reinforces positive behaviors, creating a culture of excellence.

Raising awareness

Building self-awareness among midwives through reflective practices can address internalized oppression and unconscious misuse of power. Raising community awareness about women’s rights during childbirth empowers patients to advocate for better treatment, fostering mutual respect and ethical care practices.

Advancing research and evidence-based practice

Advancing research on power imbalances and systemic oppression in maternity care provides evidence for policy reforms. Including midwives and patients in intervention, design ensures solutions are practical and representative of lived experiences. Disseminating evidence through workshops and seminars fosters continuous learning and drives efforts toward compassionate care.

Conclusion

This essay investigated how intersectionality, the OGT, and power and knowledge dynamics shape OV during Ghanaian midwives’ practice. The application of OGT to OV reveals the systemic and institutional drivers behind midwives’ dual roles as victims and perpetrators. Addressing the root causes of their oppression and promoting a culture of respect and empowerment could disrupt this cycle of violence and excessive power control over women, ultimately enhancing maternity care outcomes in Ghana. Furthermore, social hierarchies such as gender, class, and ethnicity intersect to create systemic inequities, positioning midwives as both victims of structural oppression and agents of violence within healthcare.

The essay critically examined how knowledge and power (PKT) are exercised in maternal healthcare, shedding light on the unfortunate perpetuation of harmful practices and their impact on women’s autonomy and dignity during childbirth. PKT underscores the intricate relationship between institutional hierarchies, knowledge systems, and interpersonal dynamics that contribute to the perpetuation of OV. Addressing these challenges demands comprehensive systemic reforms to dismantle entrenched power structures, establish accountability, and empower both midwives and patients.^43,69 Reimagining power dynamics within maternity care is crucial for Ghana to achieve equitable and respectful childbirth experiences.

Tackling OV demands systemic reforms, confronting deeply rooted power imbalances and institutional practices. Empowering midwives, prioritizing respectful maternity care, and establishing robust accountability mechanisms can transform Ghanaian maternal healthcare to uphold dignity, equity, and trust. Such changes will elevate the standard of care and improve maternal and neonatal health outcomes, paving the way for a more just and compassionate LMIC maternity care system.

CRediT authorship contribution statement

Ephraim Senkyire: Methodology, Software, Validation, Formal analysis, Investigation, Resources, Data curation, Writing – original draft, Writing – review & editing, Supervision, Project administration. Gloria Senkyire: Writing – review & editing, Writing – original draft, Methodology, Formal analysis, Data curation, Conceptualization. Ernestina Asiedua: Writing – review & editing, Writing – original draft, Methodology, Formal analysis, Data curation, Conceptualization. Victor Tawose-Adebayo: Writing – review & editing, Writing – original draft, Supervision, Methodology, Formal analysis, Data curation. Magdalena Ohaja: Writing – review & editing, Writing – original draft, Supervision, Formal analysis.