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Abstract

The aim of this study was to give a voice to Arab and Jewish women in Israel who had suffered obstetric violence during various stages of fertility treatments, pregnancy, and childbirth and also to learn from the women about their experiences of obstetric violence subject to the barriers of the Israeli health system, and their recommendations of possible solutions. The study underlines the unique gender, social, and cultural context in Israel concerning pregnancy and childbirth, and was based on the feminist approach that strives to promote human rights, and eradicate phenomena of gender-related, patriarchal, and social structures. The study used a qualitative-constructivist methodology. Twenty semi-structured interviews with ten Arab women and ten Jewish women were thematically analyzed, and five main themes emerged: first, the women’s experience of becoming pregnant and pregnancy overshadowed by physical and emotional barriers from caregivers and the close environment; second, the women’s awareness of their bodies and needs during pregnancy dominated by the challenges of the health services; third, the women’s awareness of their bodies and needs during childbirth alongside incompatible expectations and nonattentive medical staff; fourth, the women’s descriptions of experiences and types of obstetric violence; and fifth, the women’s recommendations to eradicate obstetric violence.

Keywords

obstetric violence Jewish and Arab women in Israel health system barriers women’s awareness of their bodies gender-related perspective

Introduction

Women’s periods of reproduction and childbirth are characterized by major changes in their bodies and lives. Alongside the need to receive advice and support that focus on minimizing risks for the woman and her offspring, there is also the need to understand how this time is experienced by her (Larson et al., 2017). For many women, childbirth is a key event in their lives, and they develop strong expectations toward this experience. Their perception of the degree of their control over designing the experience affects their satisfaction. The greater the gap between the childbirth plan the woman had envisioned and the actual childbirth experience, the lower her satisfaction is (Preis et al., 2019).

The need to understand how women perceive the reproduction and childbirth experience is critical, especially in view of the increasing discourse during the last two decades about abusive behaviors toward women by no other than health professionals. These behaviors were named “obstetric violence,” which was found to be directly correlated with a traumatic delivery and possible post-trauma (Fernández, 2013). Notably, the phenomenon of obstetric violence is caused by health professionals both knowingly and unknowingly. Research has shown that it is rooted in gender and social perceptions that affect all those involved (Brandäo et al., 2018; Shabot, 2016).

Obstetric Violence from a Gender Perspective

Venezuela was the first country that in 2007 defined obstetric violence by law as actions classified as physical and mental violence aimed at women during pregnancy and childbirth (Shabot & Korem, 2018). But this definition does not fully reflect the entirety of the problems that derive from obstetric violence. The literature reveals that there is no global consensus on what constitutes respectful obstetric treatment and what constitutes mistreatment (Vogel et al., 2016). One finds various definitions for obstetric violence such as “dehumanized care,” “disrespect,” “abuse,” and “mistreatment of women.” These experiences could be manifested by intentional physical violence, passive unintentional violence (such as neglect due to staff shortages or overload), violence by individuals including verbal violence, or health system conditions, which is due to insufficient conditions that could damage privacy and confidentiality (Bohren et al., 2015).

The theoretical basis of the present research emphasizes that understanding the experience of pregnancy and childbirth overshadowed by obstetric violence is grounded in the perception that the relationship between pregnant women and health professionals is perceived as asymmetrical, hierarchical, based on power relations and gender hierarchy (Chadwick, 2021; Oliveira et al., 2020; Oliveira & Penna, 2017). Oliveira and Penna (2017) found that both nurses and women giving birth voiced similar narratives in the perception of obstetric violence: the nurses had seen the violence and kept quiet, and the women mentioned consensual violence. That is to say, they saw the aggressive behavior toward them as an inevitable part of the childbearing process. This aspect is different than the medical staff’s narratives, which deny obstetric violence because, in their opinion, it is specific and not as widespread as presented in the media.

This theoretical framework is supported by the World Health Organization’s (2014) report, which states that obstetric violence as a phenomenon is attributed to gender violence against women during pregnancy and childbirth. Other studies described the violence against women in the wider context of fertility, childbirth, post-delivery, or when an abortion was required (Garcia, 2020; Jardim & Modena, 2018). Notably, some indicate that this violence is different than other forms of medical violence because it is specifically aimed at women, so it is clearly gender violence. This is confirmed by studies in which women use rape metaphors (“birth rape”) to describe the violence, which includes experiences of oppression and violation of rights (Shabot, 2016).

Chadwick (2021) underlined the importance of feminist researchers’ work to emphasize obstetric violence toward women in a structural systemic context grounded in aggressive social relations of patriarchy, racism, and colonialism. Thus, the root of the problem in obstetric violence is not the individual but the unjust social-gender structure.

Awareness of the various shades of violence against women has led to policy aimed at eliminating it and providing assistance. However, it seems that the structural and social obstacles in the health system prevent the provision of solutions for women in these situations (Daoud et al., 2020).

Obstetric Violence in Israel

Women in Israel also suffer from obstetric violence. Whereas the main source of the information is social media, to the best of our knowledge, there has been no academic research on obstetric violence among Jewish and Arab women with reference to the structural barriers of the Israeli health system. This lacuna has prompted us to perform the current study. A search for literature on the subject has come up with a single report submitted by the Women Call for Birth (WCB) non-profit advocacy group, which serves as an umbrella organization for various initiatives advocating reproductive health rights relating to birth (Lienhart, 2019). The report states that so far there has been no formal statement that relates directly to the phenomenon of obstetric violence in Israel, and it seems that when a formal complaint is lodged, it is dismissed by the ombudsman as a “subjective experience” of a rights violation, isolated from the organizational culture (Lienhart, 2019).

Pregnancy and Childbirth Experiences and Difficulties

Pregnancy is a unique health situation that involves physical, psychological, and social changes that challenge the woman’s adjustment to its emotional aspects (Soltani et al., 2017). Whereas many women remember the experience as positive and empowering, others endured a negative experience (Henriksen et al., 2017). The delivery experience largely depends on the congruence between the woman’s expectations and what actually happens, her communication with the health professionals, perception of pain, and sense of control (Preis et al., 2019). Women must know who is caring for them, and that the staff will not perform any procedure without their consent (Rodríguez-Almagro et al., 2019). Also, previous childbirth experiences, and perception of the support required from her spouse, affect the present experience (Karlström et al., 2015). Research has found that the woman’s culture of origin affects how she conceptualizes childbirth, and her degree of fear and expectation (Preis et al., 2018).

Women’s Awareness of Their Body and Needs During Pregnancy and Childbirth

The issue of women’s awareness of their bodies was mentioned in studies which focused on women’s control of the delivery process: particularly studies that examined the choice to give birth in their natural surroundings, away from conventional medical frameworks. Choosing home birth has a number of reasons: to avoid unnecessary medical treatments common in hospitals; a negative previous childbirth experience in a hospital; a desire for more control of the process; and being in a comfortable, familiar home environment that provides intimacy and security (Boucher et al., 2009; Galera-Barbero & Aguilera-Manrique, 2022).

Another central theme was their belief in their body’s inherent ability to give birth. When the woman believes that the process is natural, she perceives it as safe, and the pain as an integral part of childbirth, and that she should avoid external actions that might interfere except if necessary (Preis & Benyamini, 2017).

Perceptions of Abuse by Medical Staff

Women have described a wide variety of emotions caused by abusive behaviors by health personnel, including the sense that they were forced to have tests without being informed about them (Martínez-Galiano et al., 2021; Shabot, 2016), and discomfort, pain, and embarrassment during physical examinations (Aktaş & Aydın, 2017). Obstetric violence was also reported as incongruence between the woman’s birth plan and what actually happened. This caused them to feel invisible and unheard, which in turn generated feelings of frustration and helplessness vis-à-vis the system (Henriksen et al., 2017). Women also expressed a sense of having their rights abused by repeated vaginal examinations performed by numerous people (Martínez-Galiano et al., 2021). These examinations were perceived as too frequent, painful, usually without their consent, and often in an environment that did not afford privacy (Bohren et al., 2015). Other factors that were mentioned included inappropriate communication with the medical staff, a sense of being judged by midwives, embarrassment, and even impaired self-esteem (Aktaş & Aydın, 2017). The most common form of verbal abuse by medical staff was shouting, mockery, and harsh words (Alzyoud et al., 2018).

Some women attributed their sense of injury to non-cooperation between them and the medical staff, for instance, when their birth plan was ignored (Martínez-Galiano et al., 2021). Other aspects included a sense of abandonment due to lack of support from their spouse or midwife (Henriksen, et al., 2017), a sense of neglect by the medical staff when the physician was unavailable, lack of psychological and emotional support, fear, and insufficient analgesics (Alzyoud et al., 2018). Various women also believed that their care was conditional on being quiet during the delivery and obeying the caregivers (Bohren et al., 2015).

In light of the above, this study aimed to give a voice to Arab and Jewish women in Israel who had suffered obstetric violence during various stages of fertility treatments, pregnancy, and childbirth, and planned to learn from the women about their experiences of obstetric violence subject to the barriers of the Israeli health system, and their recommendations of possible solutions. The premise of this study is the feminist approach that strives to eradicate phenomena related to cultural, gender, and patriarchal structures (Sharma, 2019). Gender structures consist of gender inequality that discriminates against women’s activities, experiences, choices, and values (Mayra, 2021).

Methodology

This study employed a qualitative-constructivist methodology based on Strauss and Corbin’s (1990) grounded theory design in an attempt to understand the meanings that women affected by obstetric violence attributed to the processes they had experienced, and their perceptions and definitions of this violence. This approach clarifies the interviewees’ reference framework, and how they experience it through understanding their world from their perspective (Taylor & Bogdan, 1998). Grounded theory allows researchers to focus on the significance that the interviewees attribute to their experiences, and to present a consolidated interpretive analysis that is as close as possible to these experiences (Charmaz, 2006). This approach is compatible with the topic and aims of the current study.

Participants

Twenty semi-structured in-depth interviews were conducted with ten Arab women and ten Jewish women in Israel, who had given birth during the previous seven years. Semi-structured in-depth interviews are characterized by flexibility and dynamism (Taylor & Bogdan, 1998), aimed at learning about situations that cannot be observed directly (Creswell, 1998).

The purposeful sampling method (Bryman, 1988) that was used is characterized by a focused effort to achieve variance among the interviewees; consequently, the ages of the participants (25–50; M = 35.5), education (at least a bachelor’s degree), religion (10 Jewish, 5 Muslim, 5 Christian), employment, residence area, and number of children (1–3) (see Appendix 1 for full demographic details).

Procedure

Data Collection

The participants were recruited through a message posted on various social media in both languages. Thirty women responded, expressed their willingness to participate, and commented that it was important to them to share their experiences. Initial contact was made by telephone including a detailed explanation about the study, and by sending an explanatory page about the research and its goals. The final 20 participants were chosen based on their willingness to participate in the research, after direct inquiry that they agreed to be interviewed and tell their story, and were sampled through convenience sampling. An informed consent form was signed by all the respondents.

The interviews were conducted in the participants’ native language: Arab women in Arabic and Jewish women in Hebrew, by a research assistant who is a social worker and speaks both languages. The interviews were held between August and October 2020, and were recorded and transcribed. Because of COVID-19 restrictions, 17 interviews were held on Zoom. Each interview lasted between one and two hours, and the respondents were assured anonymity and full confidentiality, by not specifying identifying details and using pseudonyms.

The research was approved by the college’s ethics committee on July 16, 2020, research number: 2020-60, L/SW.

Data Analysis and Trustworthiness

The data were coded after the interviews had been completed. In the process of data analysis, content and meaning of patterns were constructed based on the data from the interviews. Content similarities and differences were identified, as well as patterns, themes, and continuity, following the six analysis stages specified by Braun and Clarke (2006).

The women interviewed for this study differed demographically (age, residency, etc.), but after analyzing the first ten interviews, we extracted repeated themes. At this stage, we had identified five themes, some of which included sub-themes that described the main theme. After analyzing fifteen interviews, it was obvious that the women’s descriptions, experiences, and interpretations reinforced the five themes. At the twentieth interview, we stopped the analysis in view of the repetition of the content and interpretations—which signified saturation of the research topic.

In the present research, the authors adhered to the standards suggested by Franklin and Balan (2005)—credibility, transferability, dependability, and conformability.

Results

The thematic analysis extracted the following five main themes:

1. The Experience of Conception and Pregnancy Complications Overshadowed by Physical and Emotional Barriers, by Health Professionals and the Close Environment

Most women reported physical, emotional, and mental difficulties they had experienced during pregnancy. They described their need for support and help, which was often not forthcoming. In some reports, the experience of pregnancy was affected by whether or not it had been planned or was wanted.

A number of difficulties were mentioned including previous pregnancy and childbirth experiences—pregnancies that did not progress well, challenges of fertility treatments at advanced maternal age, waiting for test results and related anxieties, and financial issues. The women added that the medical system’s conduct (i.e., access to physicians or follow-up appointments) exacerbated the emotional and physical difficulty. Another barrier was lack of support from the environment and health system for problems not necessarily directly concerned with the pregnancy.

Ilana had given birth at a late age. She described the complexity of her emotional and physical journey:

It’s a sensitive place, all about fantasies, hope, disappointment… For the first few times, you’re optimistic, but then… alongside all that, you invest, financially, emotionally… and you encounter systems that have protocols and a certain way of doing things. …. It made me very exposed and sensitive …

Rose shared her emotional, mental, and physical difficulties, her sense of being alone, alongside limited access to health services:

… I was hospitalized several times because of dehydration. We called for an ambulance… The ambulance was delayed, I couldn’t breathe, my husband took me in his car…

2. Women’s Awareness of Their Bodies and Needs During Pregnancy Dominated by the Challenges of the Healthcare Services

Most women reported awareness of their bodies and needs during pregnancy. They emphasized that their awareness was not always consistent with medical instructions such as early hospitalization or various tests. Women after two pregnancies noted that they were more aware during the second pregnancy, which allowed them to listen to their inner voice, to know what their body was capable of, and make the right decisions, alongside the sense that the medical professionals were not attentive to them or their needs.

Mira described her first pregnancy as traumatic, but that she was aware and attentive to her body despite the physicians’ interference:

… I believe that if the fetus isn’t ready, it doesn’t come out, not that it should be dragged out to 43 weeks, the fetus was fine, and there was really no reason to induce labor. I found that to be very unpleasant….

3. Women’s Awareness of Their Bodies and Needs During Labor in Conjunction with Incompatible Expectations and Nonattentive Medical Staff

The women’s negative experiences were mostly due to lack of communication between them and the medical staff concerning how they felt about the treatment and how it fitted their needs. They sensed a gap between the instructions they were given and what their body felt was right. Women with previous childbirth experience mentioned that because they were more aware of their needs and body during childbirth, they were not reluctant to speak their mind. However, many preferred to have a companion (mother, partner, or doula) for support.

Sarit explained that she had suffered a lot of pain because she was told to push before her body was ready:

She asked me to push before my baby was in the birth canal… the body has to be given time, and the baby must pass the sapines… I was in such great pain…

Mira shared that she was not aware of the meaning of the contraction pains, and although she experienced severe pains, she waited patiently and held the pain inside even during an invasive examination. In retrospect, she realized the importance of giving voice to her pain rather than remaining restrained as was expected of her.

At some stage I told her it was very painful, but she said she had to examine me. Looking back, I know it was a painful unnecessary painful procedure… she didn’t care…

4. Women’s Descriptions of Experiences and Types of Obstetric Violence During Pregnancy and Childbirth

Women described their experiences of obstetric violence in different ways. Most women reported that when they first arrived at the hospital, care was taken with examinations according to protocol, and trust was formed, but then the attitude worsened and tainted the experience. They were treated without informed consent; the experience was perceived as arrogant and disrespectful, and they felt they had lost control of the situation.

4.1 Experiences of Obstetric Violence During Pregnancy

Most women reported that the damage was ongoing, and had started at the pregnancy planning stage. Shani described incorrect evaluations and inappropriate explanations that left her extremely anxious. She eventually had more tests done, which indicated a sound pregnancy.

…Everything went well until the second ultrasonography. The first was fine… at the second one, he kept quiet, then said ‘I see something worrying in the ventricular system that needs follow-up… you can Google it…’ I was stressed, felt I was wrong not to have done an amniocentesis, and it was the seventh month… For my last examination, we met a lovely doctor who reassured me, and said there was no problem, just the angle of the sonogram… but the anxiety remained!

Ilana shared that she had been sexually abused by her IVF physician. He had touched her intimately and left her feeling uncomfortable to continue with him:

It was an unpleasant experience. I did the egg retrieval without anesthetic. He has a gift… but after that I had doubts whether to swallow hook, line and sinker… or to move to someone else with not such ‘good’ hands.

4.2 Experiences of Inappropriate Communication and Inhumanity During Childbirth

Some of the women described a variety of mistreatments by the attending physician during childbirth, for example, no eye contact, insufficient response to needs, limited information, delegitimization of special difficulties or pain, and more. The women want their bodies not to be treated mechanically. The women felt that the medical staff was burned out and impatient with the women in their care.

Amal described the humiliating attitude when she was giving birth: “I was a little shocked by his attitude, there was no eye contact, as if he was not talking to a human being at all. I was concerned …asked medical questions ...he ignored me…”

Hani described her fourth childbirth as a difficult, degrading, and insensitive experience:

The doctor gave me minimal information… I remember asking him a question, and he told me to Google it…

Rose described the insensitive attitude to her just because she demanded answers from the doctor and midwife.

I could never understand the saying that “women are cruel to women” but when I was hospitalized, I understood… nurses treated us as if we were spoiled and that everyone gets pregnant, and you have to be stronger. I didn’t know if I was over-sensitive because of hormones or it was really like that, until I talked to other women, and they told me they felt the same…

4.3 Experiences of Disrespect, Anger, and Having One’s Personal Choices Ignored During Childbirth

The women’s experiences of disrespect during childbirth included the perception that they were lied to, and that their preferences about how they wanted to give birth were ignored. Sarit felt that the midwife lied as a technique to move the process forward.

She said, ‘…we can see the head’, and then she looked at my mother and winked… She made me feel that I wasn’t there, and then she demanded that I push harder, instead of saying, ‘Wait, push gently until she [the fetus] passes the sapines’…

Doua described how the midwife had scolded her for speaking her mind and refusing to give in to the midwife’s pressure:

The midwife was mad at me, ‘Who are you to say no! All of us said yes and you said no’, but I had read and I knew what I wanted… I told her I was in a lot of pain, and wanted an epidural… She said, ‘There’s no need, by the time the anesthetic gets here you will have given birth already’. She decided, who told you to decide for me? Now I am in shock, and I don’t want to get pregnant or give birth…

4.4 A Sense of Unprofessionalism and Insensitivity During Childbirth, and the Need for Support

The women shared that in certain situations, which to them seemed critical and when they needed close attention from the staff, the medical staff was unavailable and insensitive to their needs. However, if the mother or another close person intervened, the attention was forthcoming. Liora, a single mother, shared and said:

No one was there… if my mother hadn’t been there, I would have been alone. The oxytocin had run out, and no one came to check it… My mother was there to ‘raise the dead’… No one noticed we were both in a stress situation. If my mother hadn’t raised her voice, nothing would have changed. Finally, they used vacuum…

4.5 Verbal Violence, Objectification, and Treating the Woman as Invisible

Most women described offensive words and behaviors directed at them by the staff. A physically disabled woman asked to see her baby, but was told that the staff couldn’t do everything for her. In another case, a woman’s sister arrived at the hospital, and was shouted at. Another woman reported that when she said she was hungry after giving birth, she was looked upon as a “cow.” In another case, a woman was ordered to eat, but there was not enough food, and her husband had to go out to buy food.

Many women reported lack of cooperation during childbirth, being ignored, or not being treated as “a person.” They see when the team is under pressure, or when something is going wrong, but their questions are not answered, and their bodies are treated mechanically.

Rawan’s description is a very harsh example of this attitude:

… They called me ‘the patient with bile salts.’ This was very unkind. I remember when I gave birth, I slept for a while to get some rest …. and I was dreaming about the midwife’s hand while she was doing the circular movement to expand it for me so the boy could come out… I was by myself, the placenta didn’t come out, so the doctor had to take it out with her hands… I was still with an epidural, but she didn’t tell me she was taking it out with her hands or how painful it would be … when she inserted her hand, I started screaming…

4.6 A Sense of Helplessness vs. a Medical Staff That Works with Limited Physical and Human Resources

Women described their sense of helplessness and vulnerability; all the more so when there were complications during childbirth. For instance, they felt that the staff’s instructions could harm the fetus, or that they were often forgotten due to lack of manpower. Sarit expressed her mental distress and fear in the delivery room, when no one bothered to explain the treatment plan to her, although she was alert:

It was stressful. A caesarean is not a simple process. People are bustling around you… you feel like you are in a beehive. … Then they cut your stomach, and you’re conscious… I was afraid…

One of the women shared that she needed emergency surgery, and was asked to sign a form when she was not fully conscious. Women also reported lack of medical equipment during crisis, reduced staff (which creates more problems), and inappropriate conduct of the medical staff due to ongoing pressure. Some women related that examinations were performed disrespectfully and without prior warning—a “rape experience” to some. Nabila said:

I lost consciousness… the experience was very traumatic and emotionally difficult… I lost the ability to move, but I could hear what was going on… I heard them say my blood pressure was dropping, and that they didn’t know why… And no one explained anything to me.

4.7 Uncertain Conduct by the Medical Staff, and Performing Invasive Examinations Without Informed Consent

The women described many experiences of confusing behavior by the medical team and no explanations about procedures that were done to their bodies. Nur told us:

… She was being unkind to me, and my hormones were off, so I started crying and left… If something like this happened to me now, I would react, but back then I didn’t have the capacity to answer because my emotional state was shaky…

One of the women explained that she did not ask questions after her caesarean, because she was not in a state of mind to do so, but was busy being a mother. Another woman’s experience was that no one explained to her what happens after delivery—all she wanted was to see her baby, but the midwife was more interested in weighing her.

5. Women’s Suggestions on How to Eradicate Obstetric Violence

The women who had experienced obstetric violence presented two main suggestions for eradicating obstetric violence:

a. Adopting a Gender-Sensitive Treatment Approach to Women in the Context of Fertility, Pregnancy, and Childbirth

Women spoke about the importance of gender sensitivity from the medical staff. One woman shared that she wanted to be treated by an empathetic and attentive doctor, for which she had to travel far from home. Some women found that female staff were more understanding and empathetic, while others described female staff as inflexible and callous. Mira recounted:

There were male doctors, but mostly female doctors, who were more empathetic… There was one woman, probably an intern, who said she was sorry, and explained what she was doing… It hurt, but she explained… Until the delivery, she was the only one…

Some women reported that male doctors were more sensitive to their difficulties than female doctors were. They emphasized that the medical team’s approach and their gender awareness were important, not just the staff’s gender. Nur said: “Honestly, male doctors were way better than females… They were empathetic, although men don’t give birth…”

Almost all the Arab women who were interviewed referred to the sensitivity of intimate examinations by male obstetricians. They preferred doctors from a different culture (the “outgroup”) because with them they felt less exposed physically and emotionally. Ilham told us:

When I was in the emergency room, I felt shy when an Arab doctor examined my vulva and vagina… Apparently, it’s more complex with an Arab doctor …

b. Highlighting the Importance of Humane and Professional Values, and a Respectful and Equal Attitude

The women emphasized the humane and attentive attitude that respects the woman and her knowledge of her body, and the professional attitude that manages the situation while providing information and sharing the decision-making process with the woman, as significant factors in the perception of their experience. Sarit imparted:

…He should have a professional attitude, give the epidural on time, .. give me confidence… give me the opportunity to concentrate on myself, and let my mother and the baby’s father take care of me and help me… Roles should be clear, everyone should know how to do their job…

Discussion

The perspective of this study is that medical personnel do not deliberately harm women, but perpetuate a patriarchal culture (Chadwick, 2021; Oliveira et al., 2020). Raising the issue of obstetric violence in a social-gender context should remind healthcare personnel of their obligation to provide humane and respectful treatment, and their responsibility to eradicate the phenomenon (Briceño Morales et al., 2018).

This study is unique in that it shows that obstetric violence does not occur only in the delivery room, but at all reproduction and pregnancy stages, and that experienced violence negatively affects women even years later. Also, this study gave a voice to the interviewed women and their recommendations to change the healthcare system’s conduct, while recognizing its barriers.

The first issue that came up was the experience of conception and pregnancy overshadowed by physical and emotional barriers by health professionals and the close environment. In previous studies and in this one, women reported emotional and physical difficulties during fertility treatments, pregnancy, and childbirth (Soltani et al., 2017), and indicated a number of factors that exacerbated the difficulty; for example, whether the pregnancy was wanted or not (Gourounti, 2016), previous pregnancy and childbirth experiences (Karlström et al., 2015), fertility treatments at an advanced age (Dornelles et al., 2016), anxiety while waiting for test results, and lack of support from significant others resulting in loneliness (Gourounti, 2016; Karlström et al., 2015).

Alongside these difficulties, the women presented an important finding—barriers related to the healthcare system’s conduct, which intensified their difficulties. Among the barriers the women mentioned were lack of physical access to physicians, appointments availability, support from the health services, and the environment. A systematic review by Kyei-Nimakoh et al. (2017) found that significant barriers of obstetric care were related to the cost of health services, the physical distance to services, and long waiting periods. This points to the importance of early detection of these barriers, so that appropriate services can be provided to minimize women’s difficulties.

The next issue was women’s awareness of their bodies and needs during childbirth alongside incompatible expectations and non-attentiveness from the medical staff. The woman’s awareness of her body and needs during pre-pregnancy and pregnancy is amplified during childbirth, when she wants more control over the process (Preis et al., 2019), and that nothing is done without her consent (Rodríguez-Almagro et al., 2019). The women in this study reinforced the argument that women who give birth in hospital delivery rooms find themselves in an asymmetric power relationship. The medical teams are perceived as knowledgeable, and women are expected to comply with their requests. Shabot (2021a) noted that many women who give birth in medical environments suffer from prejudice since they are perceived as irrational, and as flawed epistemic agents.

Another central theme described experiences and types of obstetric violence, and its various manifestations including inappropriate communication and inhumanity from the medical team; experiences of disrespect, anger, and having one’s personal choices ignored during childbirth; a sense of unprofessionalism and insensitivity during childbirth, and the need for support from a significant other; verbal violence; sexual abuse; objectification and being treated as invisible; ignoring the woman’s personal choices; a sense of helplessness vs. a medical staff that works with limited physical and human resources; loss of control and trust due to uncertain conduct by the medical staff; and invasive examinations without informed consent. These findings corroborate previous studies that found that women had tests performed without being informed about them (Martínez-Galiano et al., 2021; Shabot, 2016; Shabot, 2021b); felt invisible and unheard, which generated feelings of frustration and helplessness vis-à-vis the system (Henriksen et al., 2017); lack of trust in the staff’s merit (Henriksen et al., 2017); repeated vaginal examinations performed by numerous people (Martínez-Galiano et al., 2021); verbal violence that included shouting, mockery, and harsh words (Alzyoud et al., 2018); a birth experience that was described as comparable to rape (Annborn & Finnbogadóttir, 2022); lack of partnership with the medical staff (Martínez-Galiano et al., 2021); and a sense of abandonment because of lack of support from the birthing partner or midwife (Alzyoud et al., 2018; Henriksen et al., 2017).

A central experience was the sense of being treated as an object rather than a person. In their research, Ladeira and Borges (2022) studied body colonization and women’s objectification in the obstetric system, and described the medicalization culture that perceives women as fragile, a body that requires help and care to function properly. Furthermore, the perception of pregnancy and childbirth as a pathological rather than a physiological process makes the woman’s body an object that has to be “fixed” and restored to its “normal” condition.

As opposed to previous research that found that low socioeconomic or ethnic women were mistreated and experienced insults and vilification because of their background (Bohren et al., 2015), in the present study, Arab women (who belong to an ethnic minority in Israel) reported experiences that were very similar to those of Israeli-Jewish women. This finding strengthens the claim that obstetric violence is based on gender violence directed specifically at women (Shabot, 2016), and supports the interviewees’ voice that women’s needs should be addressed while taking the healthcare system’s barriers into consideration. They suggested that the healthcare system should adopt a gender-sensitive approach to women in the context of fertility, pregnancy, and childbirth, and emphasized the importance of humane and professional values, and a respectful and equal attitude. Most Arab interviewees referred to the sensitivity of examinations, particularly intimate examinations, by male obstetricians from their own ethnic group, and preferred “other group” doctors, with whom they felt less exposed. Amir et al. (2012) examined the gender preference of obstetricians and gynecologists by Arab women in Israel, and found that most religious or traditional women preferred a female doctor or midwife. Humane values and respect were parallel to gender preferences. This finding reinforces the recommendations in the present study, and in previous research, concerning the importance of the interpersonal aspect in forming a woman’s birth experience as a whole (Huschke, 2022; Marques et al., 2020; Rodrigues et al., 2021).

Limitations

The sample of this study was targeted rather than random. In this type of study, some population groups are not represented, and it is possible that hearing their testimonies could have contributed additional insights. We were unable to interview Arab and Jewish women from low socioeconomic and low education groups. We presume that the women who consented to be interviewed have high self-awareness and robust mental resources.

Contribution

This qualitative study has expanded the knowledge concerning obstetric violence as a process that takes place on a continuum from fertility treatments to childbirth experiences among Jewish and Arab women, and has examined this issue within gender contexts alongside structural barriers of the healthcare system in Israel. Also, this study not only gives a voice to women’s experiences but also brings their insights and suggestions to eradicate the problem, in belief that they have the knowledge, and—together with them—we can formulate solution and answers.

Conclusion

The current study can be a basis for expanding knowledge and research in the field of obstetric violence, and investigating other issues and populations that were not addressed in the current study. This research can offer a basis for further research using both quantitative and qualitative methods. The current findings can be a knowledge base for health professionals, caregivers, and policy makers regarding the barriers in the health system and their relationship to obstetric violence, and offer alternatives to eradicate the phenomenon based on the insights of women.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

On July 16, 2020, the authors received the approval from the ethics committee of Ruppin Academic Center. Research Number: 2020-60, L/SW.

ORCID iD

Raghda Alnabilsy

Appendix

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The Experience of Pregnancy and Childbirth Overshadowed by Obstetric Violence and Structural Barriers of the Israeli Health System from the Perspective of Arab and Jewish Women

Abstract

Keywords

Introduction

Obstetric Violence from a Gender Perspective

Obstetric Violence in Israel

Pregnancy and Childbirth Experiences and Difficulties

Women’s Awareness of Their Body and Needs During Pregnancy and Childbirth

Perceptions of Abuse by Medical Staff

Methodology

Participants

Procedure

Data Collection

Data Analysis and Trustworthiness

Results

1. The Experience of Conception and Pregnancy Complications Overshadowed by Physical and Emotional Barriers, by Health Professionals and the Close Environment

2. Women’s Awareness of Their Bodies and Needs During Pregnancy Dominated by the Challenges of the Healthcare Services

3. Women’s Awareness of Their Bodies and Needs During Labor in Conjunction with Incompatible Expectations and Nonattentive Medical Staff

4. Women’s Descriptions of Experiences and Types of Obstetric Violence During Pregnancy and Childbirth

4.1 Experiences of Obstetric Violence During Pregnancy

4.2 Experiences of Inappropriate Communication and Inhumanity During Childbirth

4.3 Experiences of Disrespect, Anger, and Having One’s Personal Choices Ignored During Childbirth

4.4 A Sense of Unprofessionalism and Insensitivity During Childbirth, and the Need for Support

4.5 Verbal Violence, Objectification, and Treating the Woman as Invisible

4.6 A Sense of Helplessness vs. a Medical Staff That Works with Limited Physical and Human Resources

4.7 Uncertain Conduct by the Medical Staff, and Performing Invasive Examinations Without Informed Consent

5. Women’s Suggestions on How to Eradicate Obstetric Violence

a. Adopting a Gender-Sensitive Treatment Approach to Women in the Context of Fertility, Pregnancy, and Childbirth

b. Highlighting the Importance of Humane and Professional Values, and a Respectful and Equal Attitude

Discussion

Limitations

Contribution

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

Ethical Approval

ORCID iD

Appendix

References