“Invisible wounds of childbirth”; women’s experiences of obstetric violence: a phenomenological qualitative study

Abstract

Introduction and Aim

Obstetric violence includes physical, verbal, emotional and sexual abuse against women during on labor process, and other negative practices such as violation of privacy, non-consensual interventions and discriminatory care. There are few studies on women’s experiences of obstetric violence during on labor process. The aim of this study is to investigate the feelings, thoughts and experiences of women who reported being exposed to obstetric violence at any stage of labor.

Methods

Data were collected using a constructivist qualitative research design. The interview data were transcribed and then subjected to qualitative content analysis in accordance with Standards for Qualitative Research Reporting (SRQR) using Graneheim and Lundman’s content analysis method. The qualitative research software package ATLAS.ti 9 was used for the analysis.

Results

The study interviewed 21 women. The analysis of the interviewees’ narratives revealed four distinct categories and 13 sub-categories. The four categories were obstetric violence, prevention of participation on labor process, inability to meet professional standards of care, and the woman’s emotional state after obstetric violence.

Conclusion

The study revealed that women in Turkey are exposed to obstetric violence during the the labor process and that this experience can be addressed in various dimensions. Having experienced obstetric violence, the women reported postpartum emotional reactions such as trauma, fear, anger and frustration. However, despite these negative experiences, some women expressed the joy of motherhood and the happiness and gratitude of being reunited with their baby. Better quality assurance is needed to protect the rights of women in labor and ensure a positive birth experience.

Highlights

• Obstetric violence significantly undermines women's autonomy, violating both human rights and health standards.

• Psychological abuse is the most frequently reported form of obstetric violence during childbirth, highlighting urgent needs for improved caregiver-patient communication.

• Systemic inadequacies and routine practices contribute substantially to women's negative birth experiences, emphasizing the necessity of health system reforms.

• Women experience profound emotional trauma, fear, anger, and frustration following obstetric violence, potentially impacting long-term maternal and infant well-being.

• Policy initiatives, caregiver training, respectful care practices, and legal frameworks are essential to combat obstetric violence and safeguard women's reproductive rights.

• Childbirth is an important experience for women, with both emotional and physical effects.

• This study has highlighted some of the considerations that need to be taken into account and some that should be avoided in order to provide effective care for women in normal labor.

• There is a need for high-quality studies on obstetric violence and its prevention.

Introduction

The World Health Organization (WHO) has emphasized the importance of addressing, assessing and eliminating obstetric violence against women during the labor process [1]. The term obstetric violence, which was first coined in South America in 2007, encompasses a range of forms of violence, including mistreatment during the labor process [2]. Obstetric violence can be defined as the appropriation of the human body and reproductive processes by health care personnel, leading to loss of autonomy and ability through inhumane treatment, abuse of drugs and the transformation of natural processes into pathological ones [3]. Similarly, the concepts of disrespect and abuse in the labor process include international obstetric violence, and institutional or structural violence in maternity care. As another dimension of gender-based violence, obstetric violence can include neglect, verbal, emotional, physical and sexual abuse, negative practices such as secrecy and non-consensual care, and inappropriate use of medical interventions such as episiotomies, inductions and unnecessary caesarean sections [2].

Obstetric violence violates women’s rights and puts their physical and mental integrity at risk. Hence, as well as being a public health problem, it is also a violation of human rights that damages women’s physical and mental health [1]. Such violence denies autonomy to women, prevents them from freely deciding on reproductive and sexual behaviors and reduces their quality of life [4]. Seven categories of obstetric violence during the birth process have been defined: physical abuse, care without consent, care without privacy, undignified care, discriminatory care, neglected care and detention in a health center [5].

The WHO emphasizes that all women, without exception, have the right to respectful, dignified health care and freedom from violence during pregnancy and childbirth [6]. However, women are exposed to various forms of violence during the labor process, such as hitting, bumping, pinching, unnecessary episiotomy and vaginal examination, insulting, shouting and mistreating [7–9]. Other forms of violence include disregard for their privacy, disrespect of their dignity and self, neglect, discrimination, ignoring their health service preferences, and conducting medical interventions without adequate information and consent [10, 11]. Studies on the prevalence, causes and consequences of obstetric violence during the birth process or women's experiences of such violence are limited [12–14].

Maternal and infant health indicators focus on essential processes and their outcomes, such as prenatal care, health service delivery by health professionals trained in childbirth, and reduction of maternal morbidity and mortality rates. The maternal mortality rate in Turkey is 13.6 per 1000 live births; the infant mortality rate is 8.7 per 1000 live births [15]; and 98% of births take place in hospitals. Nurses and midwives are actively involved in both prenatal and postnatal care, while midwives and physicians are more involved in the management of the labor process itself. However, existing health indicators and data are not considered sufficient to reflect women’s perceptions of care and their experiences in areas such as communication, respect and emotional support [4]. Therefore, research is needed to investigate the care experiences of women exposed to obstetric violence during pregnancy, labor and the postpartum period.

Method

Purpose and design

The purpose of this study was to understand the feelings, thoughts, experiences, and problems of women who reported experiencing obstetric violence at any stage of the labor process. A qualitative research design drawing on a constructivist paradigm was used to generate new knowledge on this subject. Constructivist qualitative research is generally used to explore participants’ subjective experiences and perspectives and thoughts about the phenomenon at hand and to construct meaning.

Data collection procedures

Data were collected through face-to-face semi-structured interviews designed to explore women’s feelings, thoughts, and experiences regarding obstetric violence during any stage of the labor process. Two main tools were used during data collection: a descriptive information form and a semi-structured interview form.

Descriptive Information Form: This form, developed by the researchers, included questions on age, employment status, educational status, income status, chronic disease status, gestational week, number of pregnancies, number of children, number of abortions, number of prenatal care visits, and indicators of obstetric violence. The development of the form was guided by previous studies on obstetric violence and maternal care practices [16–19] as well as national guidelines and expert opinions to ensure content validity.

Semi-Structured Interview Form: This form, which included seven open-ended questions, was used to achieve the research aims, explore the women’s experiences in more depth, and guide the interviews. To assess their clarity and comprehensibility, the interview questions were first piloted with two women not included in the study, who had given birth and experienced at least one of the indicators of obstetric violence during the labor process (Table 1).

Table 1.

Interview questions

1. How was your birth?

2. Do you think your birth went the way you preferred? Can you describe it?

3. Were there any interventions that you think facilitated the labor process? How did you feel in this situation? Can you explain?

4. Were there any interventions that you think made the labor process difficult? How did you feel in this situation? Can you explain?

5. Were you informed about the interventions made/to be made during the labor process?

6. What did you experience and how did you feel after the birth? Can you explain?

7. How did you feel when you saw your baby?

All interviews were recorded with a voice recorder, and detailed field notes were taken by the researchers. The data collection process followed the Standards for Reporting Qualitative Research (SRQR) checklist [20].

Participants

This study was conducted with women who experienced obstetric violence during the labor process between July 1, 2023 and June 31, 2024. The study was conducted in a training and research hospital in Turkey. The study population comprised women exposed to obstetric violence during the labor process. A sample of 21 women from this population were identified using purposive sampling. Potential participants were reached by applying to the institution.

To identify women subjected to obstetric violence, indicators of obstetric violence were identified based on a comprehensive literature review [16–19]. These indicators encompass a wide range of mistreatment and violence, including abnormal examinations requiring consent, restricted movement during labor, withholding of food and water, physical or verbal abuse, lack of privacy, and exclusion of support persons. A total of 52 postpartum women were screened based on these indicators and established criteria. Of these, 21 women who reported experiencing at least one of the symptoms of obstetric violence were eligible and agreed to participate in the study.

Those women who voluntarily participated in the study were given an informed consent form on which they declared that they agreed to participate. The inclusion criteria were as follows: (1) age > 18 years; (2) ability to communicate in Turkish; (3) having given birth within the last six weeks; (4) reporting experience of at least one of the indicators of obstetric violence during the labor process; (5) having vaginal delivery; and (6) agreeing to participate in the study. The number of participants was determined according to the principle of data saturation [21]. More specifically, after the interview with the 19th participant provided no further new information, we interviewed two more participants, which confirmed that no new information about the research topic was obtained. This indicated that enough data had been collected and that there was data saturation. Therefore, we decided to terminate the interviews.

Data collection

To determine participants, women who met the inclusion criteria were informed about the study. In-depth interviews were conducted with women who agreed to participate in the study. The indicators of obstetric violence during the labor process were determined from the literature review [10, 22, 23]. Of the 52 women included in the screening process, 21 women who met the inclusion criteria and had experienced at least one of the indicators of obstetric violence during the labor process were included in the study.

After obtaining informed consent from the participants, the dates and times of the interviews were determined according to their preferences. To ensure the participants’ privacy and comfort, the semi-structured interviews were conducted face-to-face at the health institution in a quiet and isolated interview room, free from external distractions, using the semi-structured form for data collection. The participants were informed about the purpose of the study, that the interview would be kept completely confidential, that the information they provided would only be used for research purposes and that they could discontinue participating whenever they wished. After the participants’ consent was obtained, each interview was recorded using a voice recorder and by taking notes.

The interviews were conducted by one researcher (D.S.G.), while the other researcher (E.Ö.) participated as an observer to support objectivity and minimize interviewer bias. The researchers (E. Ö. and D.S.G.) have academic backgrounds in gynecology and obstetrics and research experience using qualitative research methods [16, 24, 25]. They are also specialized in women’s health and post-traumatic psychosocial support. The recordings of the interviews enabled changes in the interviewees’ expressions, behaviors and non-verbal reactions to be captured. To minimize bias, one researcher conducted the interviews while the other participated as an observer. During the interviews, techniques such as questioning, repetition and responding were used to facilitate uninterrupted and non-judgmental in-depth communication. Regular team meetings were held after the interviews to evaluate the interview processes and share experiences.

The interviews were conducted using seven general questions (Table 1). An interview guide was developed specifically for this study, which comprised open-ended questions about women’s problems and experiences during the labor process. The interviews lasted between 24 and 38 min, with an average of 28 min.

Ethical considerations

Ethics committee approval and institutional permission were obtained before conducting the study (No: 13/22.01.2024). As already outlined, the participants were informed that their participation was voluntary and that audio recordings would be taken. They were also informed that they could withdraw from the study at any time if they felt uncomfortable, that the data would be kept confidential and would only be used for study purposes. Verbal and written informed consent were obtained from all participants.

Data analysis and reporting

Graneheim and Lundman’s content analysis method was used to analyze the interview data [26]. Content analysis is a method of analyzing written, oral or visual communication in a systematic way [27]. Qualitative content analysis is a structured but non-linear process that requires researchers to move back and forth between the original text and parts of the text throughout the analytic process [28]. The analysis was conducted in collaboration with the researchers.

The analysis process involved six main steps. First, the audio recordings were transcribed and combined with written and visual notes, resulting in an 82-page raw data document. Second, the narratives were read carefully several times to fully understand their content. Third, sentences from each narrative were carefully analyzed to identify contextual clues and thematic connections. This identification process involved examining shared concepts, emotions or events that showed thematic relevance. Fourth, codes were created to represent condensed units of meaning. These codes were phrases that captured the essence of the content in order to categorize and organize the data. Fifth, similar codes were then clustered into categories, resulting in fourteen subcategories and four categories that contained the emerging findings. Finally, the subcategories and categories were distilled to form coherent subthemes and overall themes. The identified categories, subcategories and codes are shown in Table 3. The researchers discussed the analysis and consensus was reached by adopting a different view in cases of disagreement. The transcripts were analyzed using the qualitative research software package ATLAS.ti 9 (Scientific Software Development GmbH, Berlin, Germany).

Table 3.

Categories, sub-categories and examples of codes

Categories	Sub-categories	Code examples
Obstetric Violence	Physical Violence	Physical interventions that directly harm the woman’s body or that she does not want (hitting, pinching, etc.), interventions made without her consent (episiotomy, interventional action), vaginal examinations with excessive force, harsh interventions that increase pain (fundal compression, manual perineal applications, etc.)
	Psychological Violence	Derogatory statements and shouting, intimidation or threats, ignoring women’s questions and feelings, failure to communicate, verbal violence
	Sexual Violence	Vaginal examination without information, procedures without consent, violation of privacy and disregard for confidentiality
	Social Violence	Excluding the support person (spouse or family member) from the delivery room, disregarding the woman’s religious or cultural sensitivities (male personnel present at the birth despite the fact that male personnel were not requested), emotionally isolating the woman by leaving her alone
	Systemic/Structural Severity	Lack of resources (lack of staff, lack of rooms), women’s decisions about childbirth being ignored by the system, standard practices that disregard their privacy
Prevention of Participation in the Labor Process	Not Included in the Decision Process	Disregard for women’s opinions, unilateral medical decisions
	Loss of Control over the Body	Not allowing choice of position, giving orders like: push now”, not allowing the woman to give birth at her own pace
Failure to Meet Professional Care Standards	Lack of Professional care and treatment	Lack of necessary follow-ups, lack of education about the labor process, lack of pain relief
	Routine Practices	Painful vaginal examinations, prolonged fasting and dehydration, absence of a partner or supporter during the labor process, frequent vaginal examinations, continuous supine positioning of the patient, frequent electronic fetal monitoring
	Inadequate Information	Not answering the mother’s questions, lack of interest, giving inconsistent information, not providing information about interventions and procedures
Women’s Emotional State after Obstetric Violence	Trauma and Fear	Bad thoughts about childbirth, fear of the next birth or not wanting to give birth, feeling helpless
	Anger and Frustration	Loss of trust in health personnel, anger against the system, self-blame
	Happiness and gratitude after violence	Joy of motherhood, gratitude and acceptance, love and attachment

Rigor

Qualitative rigor, which encompasses the strategies and methods used to ensure the credibility and trustworthiness of research findings, aims to increase confidence in the results of the study. The study followed Guba and Lincoln’s criteria: reliability, transferability, dependency and verifiability [29]. The study was enriched by the fact that the researchers were from different disciplines, namely women’s health and diseases, nursing and midwifery. To enable a more objective perspective towards the data, the first author was the main analyst but did not participate in the interviews. Reliability was ensured through long-term data interaction, allowing sufficient time for data collection and analysis, and member checking. Member checking involved the research team members’ reading the interviews several times and checking the coding of two interviews with the participants, who were asked to verify the text’s accuracy. Verifiability was supported by the use of quotations to illustrate the basis of the study findings. To increase credibility, all authors discussed the interpretation of the data during the coding sessions, thereby enabling moderation of the analysis. To confirm the accuracy of the data analysis, portions of the interview transcripts with accompanying codes and categories were sent to two psychologists and a social worker for their approval. To ensure reliability, two independent researchers were involved in analyzing the data and discussing the results until consensus was reached. Transferability was supported by detailed descriptions of the research process, while confirmability was ensured by presenting accurate direct quotes from the interviews. Transferability of the research findings was strengthened through purposive sampling and in-depth interviews. In addition, maximum diversity in sampling was used. Finally, verifiability was ensured through careful record keeping, including original notes, transcription and analysis.

Unlike many other studies, this qualitative study examined the problems and experiences of women who have personally experienced obstetric violence during the labor process. The study aimed to provide valuable information for developing interventions that can address the problems faced by these women. It draws attention to obstetric violence and includes the most important examples of the effects of obstetric violence on women, especially during the labor process.

Findings

Sociodemographic profiles

Table 2 presents the participants’ descriptive information. The mean age was 28.7 years, gestational week at birth was 39 and mean gravida was 2.1. The majority of participants were private sector employees, had finished primary education, reported an income equal to expenditure, had no chronic diseases, one child, no abortions and nine or more antenatal care contacts. All participants reported experiencing at least one of the indicators of obstetric violence.

Table 2.

Descriptive information

		Frequency	Percentage
Age (years)	18–24	8	38.1
	25–31	6	28.5
	32–38	4	19.1
	39–45	3	14.3
Employment status	Unemployed	7	33.3
	Public sector	5	23.8
	Private sector	9	42.8
Education status	Primary education	6	28.5
	High school	5	23.8
	Associate degree	3	14.3
	Graduate	5	23.8
	Postgraduate	2	9.6
Economic status	Less than expenses	7	33.3
	Equal to expenses	10	47.6
	More than expenses	4	19.1
Has a chronic disease	No	17	80.9
	Yes: (Please explain)**	4	19.1
	Hypertension	1	4.8
	Diabetus Mellitus	1	4.8
	Hyperthyroidism	2	9.6
Gestational week at birth	38	8	38.1
	39	6	28.5
	40	5	23.8
	41	2	9.6
Gravida (number)	1	8	38.1
	2	7	33.3
	3	1	4.8
	4	4	19.1
	5	1	4.8
Number of children	1	10	47.6
	2	7	33.3
	3	2	9.6
	4	2	9.6
Number of abortions	0	17	80.8
	1	2	9.6
	2	2	9.6
Number of times antenatal care received	7	3	14.3
	8	6	28.5
	9	12	57.2
Indicators of obstetric severity	No	0	0
	Yes: (Please explain)**	21	100
	Consent for vaginal examination was not obtained during or after admission to the hospital	14	66.6
	The room used during the labor process was not mine alone	4	19.1
	I could not move freely during the labor process (walking, etc.)	12	57.2
	I couldn’t eat during the labor process	19	90.4
	I couldn’t drink water during the labor process	17	80.8
	My privacy was not respected in the delivery room	15	71.4
	I was not informed about medical practices during the labor process	10	47.6
	Multiple vaginal examinations (more than 1 in 4 h)	13	61.9
	Medical staff pressed my abdomen with their elbow because the labor was not progressing	12	57.2
	Health personnel did not meet my needs during my labor process	16	76.2
	When my baby was born, I could not hold him/her immediately	16	76.2
	Medical staff shouted at me	8	38.1
	Medical staff used physical force	6	28.5

^**Multiple responses

Based on the participants’ statements in the interviews, we identified 13 subcategories that fell into four main categories: dimensions of obstetric violence, impeded participation in the labor process, inability to meet professional standards of care, and the woman’s emotional state after obstetric violence. Table 3 presents the categories and associated subcategories. The following sections report the findings for each category.

Dimensions of obstetric violence

The participants’ reports on the dimensions of obstetric violence they were exposed to during the labor process were grouped under five subcategories: physical violence, psychological violence, sexual violence, social violence and systemic/structural violence. The most frequently and least frequently mentioned subcategories were psychological violence and sexual violence, respectively (Table 4).

Table 4.

Frequency and percentages of statements about obstetric violence during the birth process according to subcategories (n = 21)

Categories	Sub-categories	N	%
Dimensions of Obstetric Violence	Physical Violence	17	80.9
	Psychological Violence	18	85.7
	Sexual Violence	4	19.1
	Social Violence	12	57.1
	Systemic/Structural Severity	10	47.6
Prevention of Participation in the Birth Process	Not Included in the Decision Process	9	42.8
	Loss of Control over the Body	12	57.1
Failure to Meet Professional Care Standards	Failure to Provide Professional Care and Treatment	11	52.4
	Routine Practices	14	66.6
	Inadequate Information	16	76.2
Women's Emotional State after Obstetric Violence	Trauma and Fear	18	85.7
	Anger and Frustration	8	38.1
	Happiness and Gratitude after Violence	4	19.1

Participants reported various forms of psychological violence by health care workers, such as using derogatory expressions, shouting, intimidating or threatening, ignoring the questions and feelings experienced, not communicating and verbal violence, as in the following:

“I can’t stop laboring anymore. I put my head on the thing, you can’t put your head on the table, those who are afraid of childbirth shouldn’t come, we don't have to take care of them. My labor started. I didn’t make a sound in case they didn’t take care of me or if I was scared. Then I went in, after connecting to the Non-Stress Test (NST), they said you will give a urine test, go to the box and urinate. When I was going to the toilet, I fell down for a moment, but I couldn’t tell them because they were shouting a lot. It was my first delivery and I was very scared that they would say something.” (P1)

“They kept trying to rush me, shouting at me to push. It was a shift change. They thought I would cause problems for the next team. At one point they said, ‘Why did you come here if you cannot give birth?’ At that moment, I was so ashamed and upset that I thought I would not be able to give birth. I both cried and forced myself to give birth.” (P16)

In our study, participants reported facing various forms, such as physical interventions that directly harmed their bodies or that they did not want (hitting, pinching, etc.), non-consensual interventions (episiotomy, interventional action), vaginal examinations with excessive force and harsh interventions that increase pain (fundal compression, manual perineal applications, etc.).

“My birth process was difficult. You know, I did not have any pain. They gave artificial labor, they gave me suppositories (Propess, vaginal pessary containing prostaglandin E2). Then I couldn’t give birth. I was devastated for a while. It was very difficult; it was not a normal process. The staff there said ‘Don’t shout, don’t shout too much, what are you doing?’ So I said, ‘I am giving birth for the first time, of course it will happen.’ I mean, I couldn’t stand it anymore, I was yelling and screaming to let me go. It was a difficult process. They put pressure on my abdomen; one staff member pressed on my abdomen with his arm, I couldn’t push much, I had to force myself to give birth.” (P14)

“They were so harsh during the examination that I screamed in pain but no one paid any attention. My doctor hit my leg and told me to open my leg. I thought I was being treated like an object, not like a human being. Even after the intervention was over, I could not recover. I just gritted my teeth because of the pain.” (P15)

In our study, participants reported situations that meet the definition of sexual violence, such as vaginal examination without information, vaginal interventions without consent, violation of privacy and disregard of confidentiality during the labor process.

“My water broke around 2:00 a.m. My husband and I went to the emergency room of the gynecology hospital. They told me to lie down on a stretcher and made me take off my underwear. A male doctor started to examine me from below (vaginal examination) without saying anything. I was so unprepared that I didn’t even understand what was happening. There were a lot of people around me and I felt like I was on display naked. I asked them to cover me and no one helped me. They took notes of what the examining doctor said.” (P21)

“During the examination, they were so harsh and fast that I felt they didn’t respect my body as if it wasn’t mine. Everything was done as if it was a routine procedure. My feelings were not taken into consideration at all. Since it was a training and research hospital, there were many assistant doctors and almost all of them examined from below (vaginal examination) and confirmed it with the senior doctor (specialist doctor). I tried to feel like I was not there at that moment, but it was very difficult. If I could have gone to a private hospital, maybe it wouldn’t have been like that, but I didn’t have money.” (P16)

Participants also reported that such behaviors rendered their birth experience severely traumatic and deeply shook their trust in the health care system.

Participants reported experiencing forms of social violence during the labor process, such as not allowing the support person (spouse or family member) into the delivery room, disregarding religious or cultural sensitivities (male staff present at the birth although female staff were requested) and emotional isolation by being left alone.

“When my sister was forcibly removed at the moment of birth, it was bad to even think about her at that time. I mean, she could have stayed with me completely. This is what happens when labor starts. No one knows how fast your labor will go or how long it will take. They treat you the way they treat everyone else. For example, I give birth in one and a half to two hours. They leave me and go to the room. If I didn’t have a companion, I would be alone and I could have a nervous breakdown. They should not leave me. In my first birth, I was alone, no one was with me. I was trying to fight the pain alone. it was very bad, it was horrible.” (P9)

“We went to the emergency room because my water broke at night. They see that I am a covered (Muslim, hijab) woman. However, they assigned the male specialist doctor and the male assistant doctor in his team to examine me. I couldn’t choose at that moment. Yes, birth is an emergency, but there were many female specialists and midwives on duty that night. It is very important to respect religious beliefs and culture. Normally, a female doctor was monitoring me, but we had to apply to the emergency room.” (P21).

“I wanted my husband to be in the room because it was my first birth and I was very scared, but they wouldn’t let me. I was alone during the birth process; midwives would come by, do a vaginal examination and leave. When my contractions started to become more frequent, I begged them to let my husband be with me so that he could massage my waist; my waist was cracking. But they did not let me. I was completely alone during my labor process. I cannot give my second birth anymore.” (P5)

Participants also reported systemic/structural forms of violence in that they received inadequate care due to insufficient personnel during the labor process, that the rooms were inadequate due to the lack of separate rooms, that their decisions about birth were ignored by the system, and that there were standard practices that ignored their privacy.

“Right now my (episiotomy) stitches are very bad. I mean, I didn’t take enough painkillers. I’m in a lot of pain, so we’ll go to day two. I can’t sit, but I have to sit. I am waiting for my room to be changed because my bed is broken. Right now, I am sitting because I have to, I have to lie down, it hurts a lot. I gave birth and although it is the second day, I was not given a room with a proper bed.” (P10)

“There were so many people in the delivery room. Everyone was running around, but no one was looking at me. I think there were other births happening at the same time. It was like I was a routine case or a machine. No one realized how important that moment was for me. Everything progressed like a process and I was left completely alone during this process. I gave birth with commands such as Lie down! Get up! Push! Breathe in! Beathe out!” (P7)

Prevention of participation in the labor process

The participants’ reports about being prevented from participating in the labor process were grouped under two subcategories: not being included in the decision-making process and loss of control over the body. The second was mentioned more frequently (Table 4). The first was mentioned less frequently for several reasons: these women did not see themselves as decision-makers; they were not provided with information; and the hospital team did not include the woman in the process, despite her being the supposed focus of the birth.

Participants reported that their opinions were ignored during the labor process, medical decisions were made unilaterally and they were not informed during the implementation of medical procedures. By preventing their participation in the labor process, health care workers prevent women from taking an active role in the birth experience and exclude them from decision-making processes.

“My contractions were getting weak but we arrived at the hospital. They immediately took me to the delivery room. They started artificial labor. I didn’t want it at all, I had heard from my friends that labor lasted very long with artificial labor. I wanted to go home but they did not let me go.” (P20).

“When I was in labor, the cleaning staff pressed on my abdomen as I tried to push. I couldn’t breathe; I was so tired that I stopped pushing. They forced me to give birth by pushing. I could have pushed.” (P18)

Participants reported that they were not allowed to choose their position during the labor process, that they were given orders such as “Push now!” and not allowed to give birth at their own pace, indicating that they lost control over their own body.

“Is inpatient delivery compulsory? I think it is not necessary. I mean, the process can go according to the patient. I would prefer to give birth sitting down rather than lying down because it doesn’t happen there. For example, I had a stiff back. For example, my mind was on my waist past the birth. It could have happened in a different way.” (P6)

“It was my second birth. The first one was also a normal delivery but without (episiotomy) stitches. I did not want stitches. It hurt a lot. I forgot the pain of labor. I think they were in a hurry, otherwise I would have given birth normally without stitches.” (P19)

Failure to meet professional standards of care

The category of failure to meet professional care standards included three subcategories: failure to provide professional care and treatment, routine practices and failure to inform. The most frequently and least frequently mentioned subcategories were inadequacy in informing and failure to provide professional care and treatment, respectively (Table 4).

Participants reported a lack of professional care and treatment, such as lack of necessary follow-ups during the labor process, lack of education about the labor process and lack of pain relief.

“For example, when I said I was in labor, they would close the door and leave. If I was giving birth, they wouldn’t look at me. They had that type of characteristics. You can’t say anything; it’s your first birth; you are scared of everything. I say, ‘I don’t know.’ They say, ‘If you don’t know, why are you giving birth to a child?’” (P1)

“I was in so much pain that I promised never to give birth again. I asked for painkillers and anesthesia but they refused. I said, ‘I’m going crazy, I don’t want to give birth.’ I’m in a lot of pain and no one paid attention. I will definitely not forget my labor process.” (P17)

Participants reported receiving painful vaginal examinations as a routine practice during the labor process, prolonged fasting and dehydration, absence of a partner or supporter during the labor process, frequent vaginal examinations, having to lie on their backs, and frequent electronic fetal monitoring.

“I lie down and they try to connect me to the NST. I say, ‘You know, let me move freely’ because I know myself. I tell them that I will give birth in less than half an hour. I had a lot of trouble when they connected me to the NST. They said, ‘Well, the doctor deemed it appropriate, so that’s why we are doing it.’ But I am not comfortable, I will give birth there. This was very bad. They forced me to do it even though I didn’t want to.” (P9)

“My labor lasted two days; I couldn’t give birth. I went into labor without food or water. They said they put an IV drip in me, but it was a labor drip. They only allowed me to rinse my mouth. I was exhausted, I had no strength to give birth.” (P4)

Participants reported that health care personnel did not answer their questions, were indifferent, gave inconsistent information, and did not provide information about interventions and procedures during the labor process.

“It was a very tiring and painful period because it was very short and fast. I mean, how can I put it, there were a lot of stitches and tears, it was difficult for me. I mean, not knowing what to expect made me very tired. I can say I was scared; it made me very sad to think about it.” (P8)

“When I had contractions, we went to the hospital. The doctor at the outpatient clinic said I had a 6 cm opening and I was admitted. When I came to the delivery room, they told me that I had a 3 cm opening and they would not take me to the delivery room with this opening. When the doctor from the outpatient clinic came to the delivery room, they had to take me. I don’t understand what kind of situation this is. Is it something that can change, or don’t they know how to examine?” (P2)

The woman’s emotional state after obstetric violence

The category of women’s emotional state after experiencing obstetric violence was derived from the combination of three subcategories: trauma and fear, anger and frustration, and happiness and gratitude after violence. The most frequently and least frequently mentioned subcategories were trauma and fear, and happiness and gratitude after violence, respectively (Table 4). In addition, a few participants stated that although they were exposed to obstetric violence, giving birth was miraculous, they were grateful for being able to give birth to their baby, and they accepted obstetric violence because they their baby was delivered in good health.

Participants reported that they had bad thoughts about birth, feared the next birth, did not want to give birth and felt helpless during the labor process.

“It hurt during the vaginal examination and I was in a lot of pain afterwards, but I kept quiet because I was scared. At that time, I preferred to keep quiet instead of asking for help because I thought that what was done to me was for my own good so I should not question it. I felt like something bad would happen to me or my baby if I spoke out.” (P13)

“As I gave birth, I was no longer in pain. My mouth was dry, my legs were shaking. I was unable to get up from the table, let alone take care of the child I gave birth to. I stared at the ceiling and wondered what happened to me.” (P12)

Participants also reported anger and frustration during the labor process, such as loss of trust in health personnel, anger towards the system, and self-blame.

“My birth was very difficult. My pain never stopped; nobody did anything. They waited for the baby to come out. I would have given birth like this at home. Aren’t these women mothers themselves? Haven’t they given birth? Why didn’t they help me?” (P11)

“I tried to be patient with my aches and pains. I was very inexperienced because it was my first birth. I asked about everything. They asked me if I had never read anything. They didn’t want to answer. Such a beautiful meeting should not be so troublesome” (P18).

These quotations suggest that the subcategory of anger and frustration expresses the complex emotional reactions that these women developed towards the health system, health personnel, and themselves due to obstetric violence during what should have been a unique and special moment in their lives.

In contrast, a few participants also expressed positive emotions related to the moment of seeing and holding their baby, such as joy of motherhood, gratitude, and emotional attachment. These feelings were described as arising in spite of the obstetric violence they experienced—not as a result of it. Their joy was connected to the outcome of childbirth—the presence of a healthy baby—rather than the process they underwent. These statements highlight the emotional complexity of birth experiences and the psychological resilience shown by some women, even in traumatic circumstances.

“I felt that being a mother is very different. You know, you carry it inside you, but seeing it and looking at it is very different. Everything is erased in an instant. The world revolves only around her.” (P3)

“Everything was so bad that when my baby was born, I just wanted to hug him, smell him and cry, I couldn’t think of anything else.” (P8)

These quotations suggest that happiness and gratitude after obstetric violence expresses these women’s focus on the joy of motherhood and the positive feelings of having a healthy baby despite their negative experiences during childbirth. That is; despite having traumatic experiences, women may tend to accept the difficulties in the laboring process through their love for their babies, maternal bonds and a sense of gratitude for having a healthy baby.

Discussion

The study aimed to explore the feelings, thoughts, and experiences of women who reported being exposed to obstetric violence at any stage of the labor process. The results of this study show that the participants were exposed to various dimensions of obstetric violence, including physical, psychological, sexual, social and systemic/structural. Psychological violence was the most frequently reported violence dimension. Similarly, Beck (2018) reported that women were most commonly exposed to neglect and abandonment of care, which are the most common elements of psychological violence [30]. In contrast, Martínez-Galiano et al. (2021) reported that physical and verbal violence was more common than psychological violence during the labor process [31].

Previous studies have reported that women are exposed to various dimensions of physical violence during childbirth, such as hitting, beating, slapping, kicking, pinching, using force, physical restraint, surgical intervention without analgesia/anesthesia (episiotomy, etc.), frequent vaginal examination, unnecessary episiotomies and fundal compression during the labor process [30–36]. In parallel with these studies, the participants in our study reported various dimensions of physical violence, such as hitting, use of force, physical restraint, surgical intervention without analgesia/anesthesia (episiotomy, etc.), frequent vaginal examination, unnecessary episiotomies and fundal compression.

Our participants also reported sexual violence, which is one of the most sensitive and traumatic dimensions of obstetric violence. It includes practices that violate women’s physical and sexual integrity during the labor process and postpartum processes. In our study, participants reported vaginal examinations performed without information, interventions without consent, violation of privacy and disregard of confidentiality. These findings are line with those of previous studies [37, 38].

Obstetric violence is not only limited to individual practices but is also affected by structural deficiencies in health services. Our findings also indicated structural problems in the hospital’s health system, such as lack of resources (insufficient staff and room), disregard of women’s decisions about childbirth by the system and reporting of privacy violations. Obstetric violence can also lead to traumatic experiences related to organizational problems in the health system [39]. Our participants also reported social violence, such as excluding their partner or birth supporter from the delivery room or ignoring their religious or cultural sensitivities.

In our study, participants reported losing control over their bodies and that decisions about the labor process were not shared with them. Mena et al. (2020) also found that women are systematically excluded from decision-making processes related to their birth and that healthcare providers make decisions without consulting women [40]. Annborn and Finnbogadóttir (2022) reported that women want to be informed about decisions and measures related to the labor process [41]. Dwekat et al. (2021) found that health professionals reported that most women are unaware of their rights, such as the right to receive respectful care during childbirth [42], which tends to worsen women’s birth experiences.

One of the most common problems that women face during the labor process and delivery is a lack of professional care and treatment. In our study, women reported painful vaginal examinations, prolonged fasting and dehydration, frequent vaginal examinations by different people, frequent electronic fetal monitoring, lack of interest, lack of information about interventions and procedures, and lack of pain relief. Similarly, Martínez-Galiano et al. (2021) reported that women in Spain were subjected to frequent vaginal examinations by different people [31]. Women also perceive vaginal examinations as extremely uncomfortable or painful [4, 43, 44]. Unfortunately, however, women lack sufficient knowledge about care and treatment practices during the labor process [8, 32, 43].

Regarding emotional states, our participants most frequently reported trauma and fear, having experienced obstetric violence. This is consistent with previous findings that obstetric violence leads to trauma [45–47]. The participants’ statements about the pain, suffering and helplessness they experienced during childbirth indicate that traumatic birth experiences are associated with negative psychological outcomes, such as PTSD, postpartum depression and difficulties in maternal attachment [46, 48]. This suggests that negative experiences encountered in health services may also negatively affect women’s future birth plans and their relationships with the health system.

The subcategory of anger and frustration included the expression of feelings like distrust, perceptions of injustice and blaming of the healthcare personnel and the medical system. If the participants’ expectations were not met during the labor process and they received inadequate information or support, then they expressed greater anger and frustration. According to Taghizadeh et al. (2021), obstetric violence undermines trust in the health services generally, which negatively affects women’s future access to and choice of health services [49]. This finding once again demonstrates the importance of ensuring a systematic approach and training of health personnel.

Obstetric violence in Turkey must be examined within the unique sociocultural and institutional dynamics that shape the childbirth experience. Despite a 98% institutional birth rate [50], the Turkish healthcare system predominantly follows a biomedical, physician-led model, which often limits women’s participation in their own birth process and encourages routine, interventionist practices. Studies have reported high rates of non-consensual episiotomy (up to 60%), routine fundal pressure (over 40%), and restricted mobility during labor (more than 35%), particularly in large urban state hospitals [51–53].

Such practices are not only institutional but also cultural. In Turkish society, childbirth is often viewed as a clinical act where medical authority dominates, and women are expected to comply rather than lead. The hierarchical nature of healthcare teams, especially in academic or training hospitals, reinforces this dynamic, as decisions are rarely shared and informed consent is often verbal, rushed, or omitted entirely [54]. Furthermore, many women lack awareness of their reproductive rights or fear retaliation if they question authority figures, which leads to normalization of obstetric violence and discourages formal reporting [55].

Finally, our finding that some women experienced happiness and gratitude despite obstetric violence shows that some women were able to reframe the labor process positively despite traumatic experiences. The feelings of maternal joy and gratitude brought about by meeting their babies for the first time can be explained from the perspective of posttraumatic growth [56]. This finding reveals that obstetric violence does not have an identical impact on all women and that individual and cultural differences may modulate their emotional responses. However, only a few women reported these positive emotions, which highlights the predominance of traumatic experiences and the inadequacy of the support mechanisms offered by the health system.

Limitations and strengths of the research

Unlike many other studies, this qualitative study examined the problems and experiences of women who have personally experienced obstetric violence during the labor process. The study aimed to provide valuable information for developing interventions that can address the problems faced by these women. It draws attention to obstetric violence and includes the most important examples of the effects of obstetric violence on women, especially during the labor process.

Conducting interviews on such a deeply personal and potentially distressing topic presented both ethical and methodological challenges. Some women expressed hesitation in discussing specific incidents due to fear of being judged or retraumatized. The research team took extensive precautions to ensure emotional safety, including the use of trained interviewers, informed consent, and the availability of psychosocial support referrals when needed.

İmportant limitation stems from the nature of qualitative research itself. Our findings are context-specific and cannot be generalized to the entire population. The sample was limited to women who had recently given birth in a single institution in Turkey, and who were willing to speak openly about potentially traumatic experiences. Despite reaching data saturation, the emotional sensitivity of the topic might have constrained participants'willingness to fully disclose certain experiences.

The lack of a universally accepted definition of obstetric violence complicates efforts to effectively study and address it, including the development of policies and interventions to reduce obstetric violence. The expression and perception of obstetric violence may vary across cultures and health care providers, making it difficult to generalize findings globally. Factors such as socioeconomic status, ethnicity and health system characteristics can influence the prevalence and types of obstetric violence experienced.

Obstetric violence may also go unreported due to its normalization in some healthcare settings and power dynamics between patients and providers. This may lead to insufficient data for comprehensive analysis.

Despite these limitations, the study has notable strengths. It provides a rare in-depth exploration of obstetric violence directly from the voices of affected women, a perspective that remains underrepresented in the literature. The use of purposive sampling, thematic saturation, and a rigorous content analysis process helped to ensure the credibility and richness of the data. Furthermore, by documenting physical, emotional, structural, and cultural dimensions of violence, the study sheds light on both individual experiences and systemic failures in maternal care.

We believe these findings offer important insights for healthcare professionals, policy makers, and researchers seeking to promote respectful, rights-based maternity care. Future studies may benefit from mixed-methods approaches, multicenter designs, and culturally validated tools for measuring obstetric violence in diverse populations.

Recommendations

Addressing the problem of obstetric violence requires systemic changes in health practices, including routine screening for violence, improving the quality of care, ensuring respectful and consensual interventions for women during childbirth, births in single rooms with an attendant of the woman’s choice, and the provision of one midwife for every pregnant woman. In addition, unnecessary interventions should be avoided by allowing women freedom of position during labor process. Combating obstetric violence requires a multifaceted systemic approach, including improved communication, training on recognizing and addressing obstetric violence, policy changes and gender-sensitive interventions. Ensuring dignified and respectful maternity care for women requires collaboration between health care providers, policy makers and researchers. Supportive regulatory practices to increase and maintain confidentiality can lead to dignified birth care and improve health outcomes for mothers and newborns. Educational programs that focus on respectful and patient-centered care can significantly reduce the incidence of obstetric violence. Implementation of specific laws and policies that define and penalize obstetric violence can provide a legal framework for prevention. Finally, regarding future research, standardized definitions, different methodologies and studies with larger samples are needed to better understand and combat obstetric violence globally.

Abbreviations

WHO

World Health Organization

NST

Non-Stress Test

SRQR

Standards for Qualitative Research Reporting

PTSD

Post-Traumatic Stress Disorder

Authors’ contributions

E.Ö.: Conceptualization, Methodology, Investigation, Formal Analysis, Visualization, Writing – Original Draft. E.Ö.: Conceptualization, Methodology, Investigation, Formal Analysis, Writing – Original Draft, Writing – Review & Editing, Supervision. E.Ö., D.S.G. Aunto: Methodology, Visualization, Writing – Original Draft, Writing – Review & Editing. E.Ö., D.S.G.: Methodology, Visualization, Writing – Original Draft, Writing – Review & Editing. E.Ö.,D.S.G.: Conceptualization, Methodology, Writing – Review & Editing, Supervision.

Funding

This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors of this study provide the cost of data collection.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.