B Explanatory memorandum
by Ms Maryvonne Blondin, rapporteur
1. In recent years, thousands
of women worldwide have spoken out, on social networks and in the
media, against sexist acts and violence experienced during gynaecological
consultations or while giving birth. Their stories show once again
that gender inequality can lead to violence, even in the health
care sector. This issue, which has remained taboo for too long,
is at long last being discussed but in most countries, it remains
a sensitive and difficult topic to address.
2. Gynaecological violence is violence that women may suffer
during gynaecological consultations. They find themselves in a relatively
vulnerable position and can be the victims of sexism, humiliation
and physical violence during examinations.
Obstetrical violence, on the other hand, is violence that
women may suffer during childbirth. They may sometimes be treated
like children, forced to give birth in a certain position, given
excessive medication or made to feel guilty for not wanting to give
birth in a standardised way. They may be submitted to certain medical procedures
such as induced labour, fundal pressure,Note
sections or episiotomies,Note
sometimes without their consent
or without having been given information on the long-term risks
and consequences. Obstetrical violence is punishable by law in Argentina
and Venezuela but is still not widely recognised outside South America.
In France in recent years there has been a greater willingness
to talk about this subject via Twitter and using the #PayeTonUtérus
and #balancetongyneco hashtags. The media have picked up on this
very intimate subjectNote
and there has been a call for the
authorities to take appropriate action. In response to these accounts, Marlène
Schiappa, State Secretary for Gender Equality and Combating Discrimination
asked the High Council for Gender Equality to carry out a study
on this issue. The results of the study, which was published on
29 June 2018,Note
confirmed what had
been stated in the accounts and call for official recognition of
the problem, and for preventive measures and penalties. The subject
is now being talked openly about in Croatia, where the campaign
#prekinimošutnju (“#BreakTheSilence”), launched by the NGO Roda,
has encouraged many women to share their experiences.Note
Any form of violence against women is a human rights violation.
There are many international instruments to combat violence against
women. Few of them specifically mention obstetrical or gynaecological violence.
The Council of Europe Convention on Preventing and Combating Violence
against Women and Domestic Violence (“Istanbul Convention”, CETS
No. 210), which is the most comprehensive legal instrument to date
in this area, deals specifically with forced abortion and forced
sterilisation in Article 39.NoteNoteNoteNote
Back in 2014, the World Health Organisation (WHO)Note
denounced the disrespectful and abusive treatment
that women may suffer while giving birth in hospital in a statement
endorsed by 90 organisations. This abusive treatment is a threat
to their bodily integrity.
7. Gynaecological and obstetrical violence is not new. It is
the result of the continued existence of a patriarchal culture within
the medical sector, particularly in the training given to health
care staff, and of persistent gender stereotypes in society. In
addition, the budgetary restrictions of health facilities, which
have become a management objective, hinder the practice of care
respectful of the physiology of delivery. Finally, a number of professionals
do not comply with the recommended good practices (long-banned fundal
pressure or episiotomies) and as such, cause violence in care. This
issue of non-compliance with the physiology of delivery and good
practices is not on the agenda of any institution: colleges, vocational
colleges, institutions. We must address this issue at European level
and call for women to be treated with respect throughout their lives
by everybody, and in particular by health care staff and non-medical
staff in charge of their care.
2 Scope of the report
8. The motion for a resolution
on which this report is based states that the Assembly should take
stock of the situation and make recommendations to member States
on the measures which are necessary to change practices and ensure
medical care for women, while respecting their rights, their bodies
and their health.
9. I do not wish to point the finger at an entire profession,
as that would be unwarranted and disproportionate, but rather I
would like to help lift the taboos concerning the way women are
taken care of and the support they receive in terms of reproductive
and sexual health care. Practices which can be perceived as humiliating
are still taught and medical staff can, unintentionally, be abusive.
The training received by health care staff can be a key factor in
preventing obstetrical and gynaecological violence. Without specific
training, the way the medical profession thinks and therefore acts
will remain unchanged.
10. I have tried to address the structural problems which may
lead to the ill-treatment of patients, in particular staff shortages
resulting in longer working hours and the need to attend to several
patients at the same time during childbirth. This report does not
deal with access to contraception which will be the subject of a
future report by Ms Petra Bayr (Austria, SOC). Nor does it specifically
address access to abortion. I will also not be looking at the question
of access to care for women with disabilities, the particular difficulties
they may face when giving birth and the discrimination they suffer.
11. I began my work by researching
the available literature, and I wanted to do this in co-operation
with health care professionals, patients and victim support organisations.
On 10 October 2018, I met Ms Marie-Amélie Schmelck, a midwife in
Strasbourg. She spoke to me about midwives’ working conditions and
about an environment that has become less patient-friendly in recent
years. She told me that medical staff were taught the “mechanics”
but not “empathy” and she feels that “violence towards patients
is a daily occurrence in many maternity wards for structural, cultural
and sociological reasons”.
12. The committee held a hearing on 3 December 2018 with Dr Amina
Yamgnane, Obstetrician-Gynaecologist and Head of the Maternity Department
at the American Hospital in Paris, and Ms Anne-Mette Schroll, consultant,
midwife, representing the Danish Association of Midwives.
13. The committee held another hearing on 24 January 2019 with
Dr Ӧzge Tunçalp from the World Health Organisation. I was also able
to talk about the issue with Ms Liliane Maury Pasquier, the President
of our Assembly and a midwife by profession.
14. On 9 April 2019, the committee held a joint hearing with the
Parliamentary Network Women Free from Violence on the specific issue
of forced sterilisation of Roma women, with Ms Elena Gorolová, spokesperson for
the Group of Women Harmed by Forced Sterilisation (Czech Republic),
Ms Gwendolyn Albert, a human rights advocate (Czech Republic), Mr Adam
Weiss, Director of the European Roma Rights Centre (Budapest), and
Mr Stefan Ivanco, programme co-ordinator and researcher, Poradňa,
Centre for Civil and Human Rights (Slovak Republic).
15. On 3 and 4 July 2019, I carried out a fact-finding visit to
Croatia, during which I met Dr Željko Plazonić, State Secretary
at the Ministry of Health, Ms Tena Šimonović, Deputy Ombudsperson,
members of parliament and representatives of non-governmental organisations.
I had discussions with Ms Ninčević Lesandrić, MP, who had given
an account of her own experience before the Croatian Parliament;
this launched the #Breaking the silence campaign
on social networks. I also had the opportunity to visit a large
maternity hospital and meet health care staff, gynaecologists and
obstetricians, midwives and nurses. I was able to talk to women
who had given birth in this maternity hospital.
Ms Dubravka Šimonović, UN Special Rapporteur on Violence against
Women, its causes and consequences, prepared this summer a report
on “A human rights-based approach to mistreatment and violence against
women in reproductive health services with a focus on childbirth
and obstetric violence”. We discussed our recommendations during
a meeting at the Croatian Parliament. Her report was submitted to
the 74th session of the United Nations General Assembly in August
17. I would like to thank the Croatian Parliament for its support
in the preparation and conduct of my fact-finding visit, during
which I met a variety of people from different backgrounds to discuss
this issue, and the medical staff for their availability. I chose
to make a fact-finding visit to Croatia because of the testimony
given by a member of parliament and the impact this had had on social
networks. Gynaecological and obstetrical violence is a widespread
phenomenon and women are victims in many countries. I am not able
to assess the extent of this violence throughout Europe, but by
cross-checking testimonies and talking to health professionals,
I can say that there are practices that can lead to such violence
and that the lack of resources allocated to health care facilities
has an impact on patient care and can also lead to so-called institutional violence
as a result of insufficient time, equipment or staff.
of gynaecological and obstetrical violence
or inexperienced vaginal palpation, episiotomies carried out without
consent, fundal pressure, membrane stripping, condescending remarks
and refusal to allow women to give birth the way they want to; there
are numerous accounts confirming how frequent gynaecological and
obstetrical violence is. The term itself has angered specialists
who perhaps forget that it is not the practitioner’s deliberate
actions or words that justify using such a term, but the feelings
and after-effects experienced by those subjected to them.” Camille
18. First of all, I would like
to point out, as did Dr Yamgnane during our hearing, that in France
there is a medical risk in 20 to 30% of births. In such cases, it
is necessary to use forceps or suction cups, carry out a caesarean
section, an examination of the uterine cavity, stop bleeding or
have recourse to neonatal resuscitation services. According to her,
some professionals do not wish to frighten patients and therefore
can choose to understate the potential risks during their pregnancy
or childbirth. Sometimes they may also have to take swift decisions,
without asking the patient, in an emergency or if the patient’s
or baby’s life is at risk. Complications during childbirth are not
always predictable, and this can have an impact on the way women
in labour are dealt with. Childbirth can be a painful and traumatic
experience, far from the perfect delivery that had first been imagined.
Gynaecological and obstetrical violence can take many forms
and it is difficult to have an overall idea of the number of victims.
It is not easy to obtain precise information. Anne-Mette Schroll,
a Danish midwife, shared her experience at our hearing and debunked
a common misconception about the treatment of women patients in
was under the impression that Danish women were well treated in
our maternity wards. We conducted a survey that showed that 25%
of the women interviewed had some experience of violence in our facilities.”
According to the French National Academy of Medicine, which
published a report entitled “A caring approach in obstetrics. The
reality of maternity wards”, “the term ‘obstetric violence’ covers
any medical act, posture, or intervention that is inappropriate
or to which no consent has been given. It therefore covers not only acts
that do not comply with clinical practice guidelines (CPG) but also
medically justified acts carried out without prior information and/or
without the patient’s consent or with clear brutality. In addition,
attitudes, behaviours or comments that fail to respect women’s dignity,
modesty and privacy are also included in this term and are related
to the failure to take into account the pain experienced during
and after childbirth.”Note
Medical acts and invasive procedures
are sometimes performed in the absence of consent during gynaecological examinations.
Medical students in several countries have practised vaginal
palpation on patients under anaesthesia who are still unconscious.Note
revelations in the press have shown us that certain practices perceived as
part of a curriculum could be considered as invasive practices against
patients. During our hearing, Dr Yamgnane shared her own experience:
“In the 1990s, during my medical studies in Brussels, I learned
to make vaginal palpations on women under general anaesthesia. It
never occurred to me during my studies to question this type of
practice.” She told us that she subsequently realised that this
practice was unacceptable.
It may be necessary, in order to save lives, to perform invasive
operations or manipulations without the patient’s consent, for example,
when emergency Caesarean sections must be performed where there
is a risk to the mother or the child. But in some clinics, the number
of Caesarean sections performed is greater than the number medically
necessary (between 10 and 15%), which raises the question of whether
Caesarean sections are imposed or whether women request them.Note
are some practitioners who, for personal reasons due to scheduling
or other constraints, may impose a delivery date on their patient
by promoting the merits of a scheduled Caesarean section delivery,
which is less dangerous and traumatic than an emergency Caesarean section.
There are also women who wish to deliver by Caesarean section and
find practitioners who are willing to schedule Caesarean sections
that may not be necessary. The number of Caesarean section deliveries varies
greatly from one country to another.
Episiotomies are another practice that may be perceived as
violence and that warrant analysis. An episiotomy is an incision
in the perineum to allow the new-born child to pass through more
easily and prevent serious tears. Although it was a relatively common
practice for first-time mothers giving birth vaginally in certain health
care facilities in France (20% on average, 34.9% among first-time
is virtually no longer used in some maternity hospitals which dispute
its usefulness. With only 1% of episiotomies, the Besançon maternity
hospital in France serves as an example and its patients have no
more complications than those of other maternity hospitals. This
incision is not always necessary and is sometimes made merely to
speed up delivery. It can have serious consequences, not only physically
but also psychologically. It can be performed without asking or
waiting for the patient’s consent, or without informing her of any
possible consequences. There is a real lack of communication between
practitioners and patients on this subject. The World Health Organisation
recommends that the percentage of episiotomies should not exceed
20%. Dr Yamgnane stated that she had never met a patient who had
consented to having an episiotomy. Once the mother is in labour,
it may be difficult to obtain informed consent.
An episiotomy can cause complications for patients who sometimes
discover only after the birth that it has been carried out.Note
of stitches can be painful and a woman may have difficulty sitting
down due to a poorly performed episiotomy. Stitches may break and
abscesses may form. The psychological effects can be even more significant.
I believe that an episiotomy performed unnecessarily and without
consent is a violation of a woman’s physical integrity.Note
must ask why this practice is still used in some hospitals when it
is not a medical necessity. We can also wonder why some women having
given birth seem not to be informed about the fact that an episiotomy
has been performed or why some doctors downplay the potential consequences
of this practice, making future mothers who do not want one feel
guilty. The quality of life of the patient, once out of the delivery
room, is not necessarily a priority.Note
25. Denial of access to pain relief or an epidural may also be
considered a form of violence. There are some (albeit few and far
between) practitioners who believe that patients should give birth
in pain. Access to epidurals is not yet widely provided across Europe,
nor is it well-regarded.
26. In the documentary “Tu enfanteras dans la douleur”, (You shall give birth in pain),
broadcasted on the ARTE channel on 16 July 2019, Ovidie, the film
director, presents the testimonies of women who have been victims
of gynaecological and obstetrical violence. I was particularly moved
by the testimony of a woman who said she had been killed from the
27. During my visit to Croatia, I had the opportunity to have
a long discussion with Ms Ivana Ninčević Lesandrić, MP, who had
shared her experience of curettage without anaesthesia following
a miscarriage in a hospital in Split. “This brutality creates physical
and psychological trauma and is a form of violence. I was left there
with no information, no choice, tied to a bed for curettage without
any pain relief. I felt every second of this medical procedure”.
She remembers the look on the face of the gynaecologist who performed
this procedure. She said nothing, but Ms Ninčević Lesandrić felt
that she was sorry for the conditions of the treatment she was being
given. Following her testimony, she was accused of lying about her
experience. But she received hundreds of emails from women sharing
their experiences and thanking her for speaking out in public. The
testimonies of Croatian women on social networks reveal harshness
of the medical staff towards them and the utter disregard for pain.
The so-called “husband stitch” remains a taboo subject. Some
doctors add a few extra stitches when they sew up the perineum after
an episiotomy or tear.Note
additional stitches are believed to increase the pleasure of the
husband or partner during sexual intercourse. This is said to restore
a vagina typical of a young girl, which supposedly is more appealing
to men. However, the “husband stitch” can make sexual intercourse very
painful for women, although this does not seem to be a major concern
of those who perpetuate this practice.
29. Fundal pressure is another widely criticised practice. There
are no quantitative data on its application. It can be a difficult
experience since women are no longer in control of their childbirth.
This practice has been prohibited in France since 2007. It may be
difficult for a woman who gives birth, exhausted by hours of labour, to
object to a practice that the obstetrician/gynaecologist considers
necessary in order to speed up delivery. The woman is in a vulnerable
position and caregivers have a degree of authority over their patients
who defer to their judgment and recommendations.
Labour may be induced if the pregnancy goes beyond term or
if there is a risk to the unborn child or mother. It can be very
painful for the patient, triggering and accelerating contractions
faster than what would happen naturally. Induction may not work
or else entail extremely lengthy and particularly painful labour,
as every patient reacts differently. Artificial hormones are also
frequently used to speed up labour. Oxytocin perfusions may be given
without the patients’ consent. The objective is not systematically
to prevent certain risks in the event of delayed delivery, but also
to reduce the duration of labour and to free up labour and maternity
wards so that new patients can be admitted, for the sake of cost-effectiveness.
These practices can be regarded as forms of violence if they are
used by professionals for reasons other than the health of women and
the unborn child. According to the French National Academy of Medicine,
“the very frequent failure to provide information on the reasons,
the expected benefit, the procedure, the duration and the risk that
these forms of induction may not work, has given rise to widespread
31. During our hearing, Dr Ӧzge Tunçalp stated that abuse during
childbirth may take a variety of forms, such as physical assault,
sexual abuse, insults, prejudice and discrimination, poor relationships
between women and care providers (no informed consent, no pain relief)
and failure to meet professional standards of care. She further
stressed that not suffering abuse did not necessarily mean being
treated with respect. As a parliamentarian, I believe that we should
work tirelessly to promote respectful and non-discriminatory attitudes towards
women in general, including in health care systems.
Obstetrical and gynaecological violence can have serious consequences
for patients’ short-term and long-term health, which can have repercussions
for their babies. These consequences are still under-estimated.
Post-partum depression and post-traumatic stress syndrome may be
linked to obstetrical or gynaecological violence,Note
and lead to a deterioration of mother-child
relationship in the months following birth.
33. In addition, obstetrical and gynaecological violence affects
patients’ confidence in the medical profession and may make patients
reluctant to attend consultations. This can have serious repercussions
for their reproductive health.
34. Gynaecological and obstetrical violence is traumatic for both
emotional and sexual life years after the incident. In her book
“Le livre noir de la gynécologie”, Mélanie Déchalotte says that
many women use the term rape when talking about gynaecological violence.
The use of instruments such as a speculum or scissors, and instances
of fingering without consent, can be considered a violent intrusion
in a person’s body.
relationships between the medical profession and women patients
20 years ago, I walked into the room where I performed terminations
of pregnancies, closed the door and lay on the examination table,
with my legs in the stirrups. It changed the way I see and exercise. I’ve
done it regularly, over the years...”, Martin Winckler, doctor.Note
35. This report prompts us to reflect
on the unequal relationships between the medical profession and women
patients. A relationship of superiority, built on a perceived superiority
of one gender over another or of the profession of doctor in relation
to patients, can lead to treatment that is felt to be degrading
or clearly violent. The opposite is also possible, with patients
who can be aggressive towards medical staff or question their actions.
I was shocked to learn that at the Congress of Gynaecologists/Obstetricians,
which took place in Strasbourg on 7 December 2018, a slide was projected
comparing women to mares: “Women are like mares, those with large
hips are not the most pleasant to ride, but they are the ones who
give birth the most easily”.Note
women feel that it is the professionals who “deliver” the baby and
they are thought not to be capable of taking a full part in the
delivery. When women are not treated as children, they are dehumanised.
With this report, I wish to promote better treatment and more egalitarian
relations between the medical profession and women patients. We
also find a determination to control delivery: the position, the
place and the follow-up. Birth plans are still too often ignored
and patients’ views disregarded.
37. The taboo around women’s bodies is an opportunity for domination.
Patients will not dare to confront a doctor because they are embarrassed
to talk about intimate matters. They will also not complain if there
is violence, which can have devastating consequences. Nor will they
necessarily object to practices they consider to be humiliating
or invasive, not wishing to go against the health care staff.
Deciding not to have children may be a choice and is described
by some as emancipation.Note
young women who have not had children face many difficulties, or
even refusals, if they wish to be sterilised. Doctors send them
to psychologists and tell them that they may subsequently regret
this choice. Sterilisation is rarely practised in Europe, whereas
it is common in North America and India, for example. The decision
not to have children is not considered final and for many women
is met with platitudes such as maternal instinct, the biological
clock or the desire for a child at a later stage. Women having made
this choice are misunderstood and stigmatised in our societies.
Despite years of progress in the gender equality field, women, whatever
positions they hold, continue to be regarded in terms of their potential
future role as mothers. It seems that the medical establishment,
like society in general, finds it hard to accept that a woman may choose
to live her life without children, whatever the reason.
39. In the same vein, women are urged to have children once they
have turned thirty; they are told not to wait too long, and pregnancies
of women who are 35 or over are known in some medical circles as
“geriatric pregnancies” or potentially high-risk. Women are judged,
criticised and expected to conform throughout their sexual lives.
No heed is paid to what they actually want.
40. Gynaecological consultations and childbirth are intimate moments
in the life of women, during which they are particularly vulnerable.
At our meeting in the Croatian Parliament, a male doctor and member
of parliament said that he too felt particularly vulnerable and
a victim of violence during medical examinations while he was being
against lesbian women
41. Medical examinations can be
carried out roughly by some practitioners. In testimonies posted
on social networks, many women have reported comments made by gynaecologists,
criticising their lifestyle, sexual orientation or appearance. Lesbian
women may be stigmatised by some doctors or even humiliated during consultations,
which may lead them to stop having regular medical check-ups.
According to the European Union lesbian, gay, bisexual and
transgender survey conducted by the European Union Agency for Fundamental
one in ten of the respondents who
had accessed health care services in the year preceding the survey
reported that they had felt personally discriminated against by
health care personnel. LGBTI people encounter two main obstacles
to medical care: access and the attitude of health care professionals
towards LGBTI people. It would seem, for example, that lesbians
are not routinely offered cervical cancer screening, being considered
a low-risk group.
When LGBTI people use a health service, the care providers
often presume heterosexuality and may use inappropriate language,
thereby contributing to the invisibility and exclusion of lesbians
and bisexuals. As some surveys have shown,Note
denial of care based
on discrimination is ill-treatment and encourages patients to relinquish
their right to care. The case of gynaecological care for lesbians
is very telling: the rate of sexually transmitted infections is
higher for this population group than for heterosexual women since
the former have stopped going for gynaecological examinations following
denial of care.Note
France, some 12% of women who have sex with women have contracted
an STI in recent years,Note
against 3% for heterosexual women.Note
Gynaecological health care
ought to be an ideal opportunity for prevention and screening. Yet
lesbians are often denied such care or given poor advice.
I will not give details on the situation of intersex people
in this report but invite you to consult the report by Mr Piet De
Bruyn, former member of the Assembly, on the situation of intersex
people in Europe and the discrimination to which they are subjected.Note
45. Forced sterilisation is one
of the most serious forms of violence, as it takes away a woman’s
ability to decide whether or not she wishes to have a child. It
is never needed in order to save lives: there are other, non-irreversible,
methods of contraception that can be offered to a woman for whom
a pregnancy would constitute a serious health risk.
46. The Istanbul Convention calls on States Parties to criminalise
forced sterilisation. GREVIO’s first evaluation reports show that
these States Parties take different approaches to forced sterilisation.
Some States, such as Monaco and Albania, have not criminalised this
practice. GREVIO is encouraging the Albanian authorities to introduce
the offence of forced sterilisation into criminal law and has found
shortcomings in this field.
However, GREVIO notes that forced sterilisation has been criminalised
by the majority of States covered by evaluation reports. This is
the case for Turkey, which has made forced sterilisation a criminal
offence under Article 101 of the Turkish Criminal Code. In Denmark,
forced sterilisation is a criminal offence. GREVIO calls on the
Danish authorities to widen the provision of telephone counselling
currently available to include forced sterilisation. In their report
submitted to GREVIO,Note
the Austrian authorities stated
that Austrian law makes forced sterilisation a criminal offence,
regarding it as “bodily harm”, and making it punishable by a sentence
of one to 15 years.
48. GREVIO’s report on Portugal indicates that Article 144 of
the Criminal Code covers forced sterilisation and makes it a criminal
offence. It encourages Portugal to go further and address, through
research, all forms of violence against women, such as forced sterilisation.
Montenegro amended its Criminal Code in 2017 to include criminalisation
of forced sterilisation. However, GREVIO expresses regret that there
are no prevention and protection measures to accompany these legislative
changes. Generally speaking, GREVIO welcomes States’ legislation
criminalising all forms of violence against women, but encourages
States to go further by, for example, improving prevention and care
for the victims.
In its Resolution
“Putting an end to coerced sterilisations and castrations”,
the Assembly called on member States to “revise their laws and policies
as necessary to ensure that no one can be coerced into sterilisation
or castration in any way for any reason” and “ensure that adequate
redress is available to victims of recent (and future) coerced sterilisation
or castration, including the protection and rehabilitation of victims,
the prosecution of offenders and financial compensation which is
proportionate to the seriousness of the human rights violation suffered”.
I applaud Ms Maury Pasquier’s report on this very difficult subject.
She presents a detailed study of the situation of not only Roma
women, but also transgender people, persons with disabilities and
“the marginalised, stigmatised, or those considered unable to cope”,
who have been victims of forced sterilisation or castration.
50. This report gives me the opportunity to make the point that
Roma women may also find themselves in a particularly vulnerable
situation, whether during routine gynaecological examinations or
when they give birth. They may experience poor care, poor treatment,
be stigmatised, humiliated or moved to a separate section of the
maternity ward. Roma women have sometimes been the target of deliberate
obstetrical violence, such as forced sterilisation.
51. Elena Gorolová, spokesperson for the Group of Women Harmed
by Forced Sterilisation in the Czech Republic, recounted her personal
experience to the committee during a hearing held in April 2019.
She was forcibly sterilised in 1990, immediately after having given
birth to her second child by caesarean section. She had no opportunity
to give free and informed consent, being simply asked, during her
confinement, to sign a paper without anyone explaining what it was
actually about. She felt devastated upon learning that she could not
have any more children. She has been campaigning for years in the
Czech Republic to obtain compensation for the injury caused but
has been heavily criticised for what she is doing, as much by her community
as by the authorities.
According to Adam Weiss, Director of the European Roma Rights
Centre, forced sterilisation is intersectional discrimination and
has been practised in a number of Council of Europe member States.
For instance, the United Nations Human Rights Committee has asked
the Slovakian Government to establish an independent body to investigate
the full extent of forced sterilisation.Note
sexism in the medical field
We may also ask ourselves why
women’s health and the female body are still perceived as taboo. Women’s
bodies belong to them, the issue of gynaecological and obstetrical
violence raises questions about our progress in terms of gender
equality and equality in general. The words of the women who testified
about the gynaecological and obstetrical violence they have experienced
have been attacked and downplayed by some doctors.Note
It is important
to remind that, in countries where it exists, the Patient Charter
stipulates that the informing patients of medical procedures is
mandatory as well as respect for their privacy.
Martin Winckler, doctor and writer, says that health professionals
are incapable of self-questioning: “The problem of gynaecologists
is their paternalism, this way they have of thinking they know everything.
In addition, they think they are morally superior, even more so
with women because of the prevailing sexism. They need to review
I do not wish to generalise. We should
be reflecting, as Dr Yamgnane pointed out at our hearing, on how
to “do what we do better, and not stigmatise”.
The sexism of some doctors may entail a disregard for pain.
Many endometriosis sufferers have taken years to identify their
condition because their pain has been systematically downplayed
by their gynaecologists. Women may also sense an indifference to
pain during routine examinations or when an IUD is inserted.Note
In Finland, a “Me too during childbirth” information campaign
(«Minä myös synnuttäjänä») was initiated by midwives, doulas and
women who have given birth to promote the right to respect during
childbirth and the right to information. “We demand that the right
to self-determination laid down in Finnish law and international human
rights agreements be upheld in full within Finnish maternity care
and hospitals. We seek a cultural shift towards consent being taken
as the basic principle of maternity care. The birthing mother must
be assisted and cared for in the way required by the law: in full
cooperation with her.” This campaign underlines the need to acknowledge
that obstetrical violence is a reality in Finland as in other parts
of the world. This collective states that “Birth is a part of a
woman’s sexuality, and the experience and consequences of obstetric
violence are much the same as other sexual violence. Because of
this, obstetric violence must be considered as a form of sexual
violence. The difference to other sexual violence is that in maternity
care the professional’s power is institutional and medical. The
perpetrator may also defend their actions by claiming that they
were in the mother’s or baby’s best interest.”Note
57. In Croatia, inspections have been carried out in hospitals
following #breakthesilence but the results have not yet been made
public. As in other countries, hospitals are under-resourced and
understaffed. There is reported to be a lack of analgesics and anaesthetics
in some hospitals. Many health professionals have gone abroad to
work. Victims have spoken of the difficulty of reporting gynaecological
or obstetrical violence in hospitals. A female doctor told me that
she could not agree to the use of the term violence, because it
would imply that a health professional was trying deliberately to
inflict pain on patients. It is important to note differences in
facilities between large cities and more rural areas, including
islands, where health care establishments may be less well equipped
or very remote.
58. There has been a fall in the number of episiotomies in Croatia
(13,934 in 2012 and 9,035 in 2018). In 2018, 67.5% of vaginal deliveries
were without an episiotomy. During the visit to the maternity ward
of Petrova Hospital in Zagreb, I was told that all patients are
informed of all medical procedures during a consultation or delivery.
A team of gynaecologists, surgeons, urologists and anaesthetists
is addressing the issue of endometriosis treatment (ranging from
medication to surgical interventions). Gynaecologists are required
to renew their licence every six years in Croatia, which gives them
the opportunity to update their skills. The doctors I met told me
of their commitment to providing human-oriented care and their desire
that all deliveries and other procedures should go smoothly. I also
met women who seemed very satisfied with how their childbirth had
gone. Every birth, every pregnancy, every patient is unique.
59. In Italy, the #bastatacere (Enough silence) twitter movement
has collected a large number of testimonies. A study referred to
in the documentary “You shall give birth in pain”, claims that 21%
of Italian mothers have already suffered obstetrical violence and
that 64% of episiotomies were carried out without consent.
or structural violence
60. So-called institutional or
structural violence results from the way services are organised,
lack of time and of staff and the need for cost-effectiveness. The
time required to ensure that patients are cared for in the best possible
way is not the same as the time it takes to comply with economic
requirements. Similarly, professionals no longer have time to discuss
any traumatic experiences they have had in the delivery room and be
given the necessary follow-up. Health professionals often work in
difficult conditions, and many hospitals are understaffed, which
affects patient care. Young mothers are frequently encouraged to
return home as soon as possible without being given any support
after leaving hospital. Health care professionals stress the importance
of having sufficient resources in hospitals.
61. Without wishing to advocate for childbirth at home, in a maternity
facility or in a hospital, I maintain that a caring reception and
follow-up for patients and compassionate support during pregnancy
and childbirth and the postnatal period are essential. In birthing
centres, the organisation provides for one midwife per patient, while
in hospitals, a midwife may be in charge of three to five women
at the same time. This disparity of means raises questions. More
effort needs to be focused on preparation for childbirth, which
should be an opportunity for sharing information, discussions on
violence prevention and preparation for the birth project and its
Failure to take into account the past experience of the patient,
who may have been the victim of other forms of violence, can make
her relive this experience and cause her pain. Lack of time and
the requirements of efficiency and cost-effectiveness mean that
physicians spend less time with patients, and therefore do not ask
questions about their past experiences, and this can lead to complications
and a re-experiencing of trauma. In a society where time spent with
women who are about to give birth is limited, it may be difficult
to provide the compassionate care that is so important.Note
Here too, early antenatal
examination is a tool to discuss vulnerabilities and agree with
the team on an individualised care path.
practices and recommendations
63. The key issues in the report
are gender equality and respect between medical staff and patients.
I believe that obstetrical and gynaecological violence and abuse
can be prevented. It generally reflects a certain mindset and a
contempt towards women. It testifies to a desire for domination
and perpetuates a patriarchal culture that we should be seeking
to end. Promoting gender equality in every field will help combat
all forms of violence against women, including obstetrical and gynaecological
64. This subject is regarded as taboo by some people and as something
that should remain in the private sphere, like other forms of violence
against women. Obstetrical and gynaecological violence affects women when
they are particularly vulnerable: before, during and after childbirth,
during a visit to the doctor, or even when put to sleep by an anaesthetic.
This violence is pernicious and can be invisible. It is often internalised
by the women who suffer it, who are told that it is one of the hazards
of childbirth and are required to accept the pain and stop complaining.
Yet obstetrical and gynaecological violence is not inevitable. We
must endeavour to break the taboo and call for patients to be treated
with respect, including in emergencies.
65. To have a clearer idea of the extent of this violence, it
is important to undertake data collection by calling on member States
to collect data on consultations, childbirth and acts of gynaecological
and obstetrical violence from hospitals, health care professionals
(doctors, midwives, nurses) and patients. Analyses of these data
will have to be carried out in order to identify priority areas
for action and urgent problems that need to be addressed.
66. Putting patients at the heart of health care systems again
ought to be a priority. This means allocating adequate funding to
health care facilities so that they are properly responsive to patients,
their backgrounds and their needs. The entire health care system
must put in place the conditions needed for respectful care and ensure
that sufficient funding is given to health facilities for patients
to be treated with dignity and respect.
67. My wish is obviously not to attack the profession but rather
to direct attention to force of habit in medical practice. Health
care staff training ought to include, if it does not already, specific
courses on the doctor/patient relationship, the notion of consent,
gender equality, care for LGBTI people and vulnerable persons and prevention
of sexism and violence.
In 2018, WHO published recommendations on intrapartum care
for a positive childbirth experienceNote
according to which an intervention
should not be undertaken in the absence of a clear medical indication. Routine
or liberal use of episiotomy is not recommended for women undergoing
vaginal birth. Fundal pressure to facilitate childbirth during labour
is not recommended either. WHO makes clear that all women are entitled to
a positive experience of childbirth and, in particular, respect
and dignity, support from a companion of their choice, effective
communication by maternity staff, pain relief strategies, mobility
in labour and birth position of choice.
69. Certain clinical protocols may be perceived or experienced
as violent. Strict, unbending compliance with them may mean that
doctors use practices that can be perceived as rough. A decision
to perform an emergency caesarean may be taken very swiftly in order
to save life, but the operation may be upsetting to the patient.
Keeping patients informed whenever possible, explaining the protocols
and taking a compassionate approach to care could lead to a change
70. Legal provisions penalising obstetrical and gynaecological
violence are not yet widespread. We should therefore be pressing
for the drawing up of such provisions. Medical associations should
introduce penalty systems for doctors who fail to behave respectfully
towards their patients. Similarly, sexist remarks and attitudes
among caregivers should be clearly prohibited and punished, as they
should in all professions.
71. Simplified mechanisms for filing complaints within and outside
hospitals should be accessible and ensure the protection of victims.
They may file a complaint for lack of information, lack of consent,
and wrongful practice of fundal pressure or episiotomy.
72. Many women who have suffered violence of this sort do not
realise it. Information and awareness-raising campaigns ought to
be conducted to alert public opinion to these risks and acts and
encourage victims of violence to lodge complaints. Continually making
it easier to talk about obstetrical and gynaecological violence will
help to change practices.
73. Sharing of good practice to combat and prevent obstetrical
and gynaecological violence should be encouraged. Access to information
should also be provided. Of course, financial resources are necessary
to prevent so-called structural violence, but a change in mentality
and active promotion of gender equality from an early age, as well
as during medical studies, might give people cause to think about
medical practice and help change attitudes and prevent violence.
74. Gynaecological and obstetrical
violence reveals a gender inequality that is deeply rooted in our
societies. Women’s voices are not heard and are even considered
less important. Women are no longer fully involved in their childbirth
but, it is claimed, are guided by their emotions, are vulnerable
and unable to make rational decisions. These acts of violence show
us that gender stereotypes have an impact not only on women’s place in
society but also on access to care and treatment. Danièle Bousquet,
former president of the French Supreme Council for Gender Equality,
said that such violence reveals a desire for control over women’s
bodies. It is time to intensify our efforts to promote gender equality
in all areas in order to put an end to such practices.
75. Women victims of gynaecological and obstetrical violence are
victims of both patriarchal and institutional domination. However,
such violence is not inevitable and can be prevented. Medical practices
are perceived by some patients as dehumanising. Compassionate support
for patients during consultations and monitoring post-illness and
during childbirth should be the norm. I would like to stress that
health care workers should not be stigmatised but should be guided,
trained and supported in order to ensure that patients and women
about to give birth are received and treated with dignity and compassion.
The force of habits, technical procedures carried out mechanically,
automatic reflexes and a lack of personnel and resources can all
have negative consequences for patients.
76. Taking the time to listen to women, respect their choices
and provide them with information are essential for preventing gynaecological
and obstetrical violence. We must work together to ensure that women
can have control over their bodies, be involved in their childbirth
and experience true equality, free from violence and stereotypes.
This is not a purely technical question but rather a question of
respect for human rights, for which a political commitment can make
a valuable contribution.