996443

article-commentary2021
VAWXXX10.1177/1077801221996443Violence Against WomenSalter et al.

Commentary
Violence Against Women

Naming Silence and

2021, Vol. 27(8) 1019­–1027
© The Author(s) 2021
Article reuse guidelines:
Inadequate Obstetric Care sagepub.com/journals-permissions
DOI: 10.1177/1077801221996443
https://doi.org/10.1177/1077801221996443
as Obstetric Violence is a journals.sagepub.com/home/vaw

Necessary Step for Change

Cynthia L. Salter1, Abisola Olaniyan1,

Dara D. Mendez1, and Judy C. Chang1

Abstract
This response article addresses the questions raised in “How Gentle Must Violence
Against Women be in Order to not be Violent? Rethinking the Word ‘Violence;
in Obstetric Settings” and concludes that naming violence is critical for describing
people’s experiences of such violence and for addressing the structures and contexts
that create and fuel such violence, not for judgment but for accountability and
change. Impact, outcome, and, at times, processes—rather than intention—should
underpin applications of the term violence; naming violence does not disempower
women, but rather naming structural, systemic, and institutional violence demands
acknowledgment, accountability, and responsibility for its effects on both patients
and clinicians; and, finally, while the unintended consequences of using such a term
may present challenges, they do not outweigh the importance of naming structural
violence in health-related systems to identify practices and processes that discriminate,
disempower, harm, and oppress.

Keywords
violence, obstetric violence, maternity care, intersectionality, reproductive justice,
systems thinking

We commend the authors for taking the uncommon and courageous step to re-
examine their prior research and revisit the conclusions they reached in their 2019
paper in which they describe “silent ward milieu” in a South African maternity ward

1
University of Pittsburgh, PA, USA

Corresponding Author:
Judy C. Chang, School of Medicine, University of Pittsburgh, 3240 Craft Place, Suite 229, Pittsburgh,
PA 15213, USA.
Email: chanjc@upmc.edu
1020 Violence Against Women 27(8)

as “gentle violence” and a form of “neglect” (Lappeman & Swartz, 2019). With this
re-examination, the authors explore more deeply the application of the term
“violence” to health care settings, health care delivery systems, and institutional
practices, specifically within the context of obstetrical and maternal health care. This
re-examination is useful for both the maternal health research community and the
violence research community—as knowledge and practice can stagnate and silo with-
out interdisciplinary, reflective questioning. Furthermore, what might appear to be an
examination of semantics offers a more weighted opportunity to explore power and
privilege in maternity care, drawing upon the research literature from both fields of
maternal health and intimate partner violence (IPV) as well as the literature on repro-
ductive justice and public health critical race praxis.
In this article, the authors consider “the utility of broadening the word ‘violence’
beyond its foundational definition,” and they pose two focused questions: (a) “Does
use of the term violence inadvertently disempower the women it is meant to empower?”
and (b) “. . . might there also be unintended, unhelpful consequences to characterizing
less than adequate obstetric care as a form of violence?” While the authors’ explora-
tion of these questions leads them to conclude that the term “violence” should not be
applied to obstetric care, our own consideration of these questions reaches exactly
opposite conclusions. We submit that impact, outcome, and, at times, processes—
rather than intention—should underpin applications of the term violence; that naming
violence does not disempower women, but rather naming structural, systemic, and
institutional violence demands acknowledgment, accountability, and responsibility for
its effects on both patients and clinicians; and, finally, that while the unintended con-
sequences of using such a term may present challenges, they do not outweigh the
importance of naming structural violence in our health-related systems to identify
practices and processes that discriminate, disempower, harm, and oppress (Crenshaw,
1991). This is particularly important within the context of the intimacy of maternity
care and the intersectional power dynamics related to gender, language, race, ethnicity,
class, and ability status. We maintain that when problems remain un-named, they too
often remain unaddressed.
We expand upon these conclusions below, offering our perspective in three sec-
tions: (a) exploring definitions of violence that include impact and accountability
while also broadening the discussion to address oppression, including underlying sys-
tems of racism and sexism, as well as researcher positionality; (b) expanding upon the
concept of disempowerment to explore agency and intersectionality; and (c) expand-
ing upon the authors’ application of the feminist ethics of care paradigm to examine
unintended consequences from a systems thinking perspective and to apply a repro-
ductive justice framework, which has conceptual building blocks of intersectionality,
reproductive oppression, and human rights (Ross & Solinger, 2017).

Exploring Definitions of Violence

The authors present the 2019 World Health Organization definition of violence, noting
intentionality as a core factor. Their emphasis on intentionality can be contrasted with
Salter et al. 1021

Shapiro’s (2018) interpretation of WHO guidance that focuses on the impact of chosen
behaviors and actions rather than intent. Furthermore, it is useful to inform this defini-
tion of violence with additional elements described in the WHO definition of IPV,
which is primarily experienced by women and which includes emotional and psycho-
logical abuse, such as intimidation, belittling, and insults, as well as controlling behav-
iors, such as isolating women and controlling their access to information, services, or
resources (World Health Organization, 2012). This conceptualization of violence does
not dwell on intentionality.
In addition, as the authors note, a broad literature describes the harmful impact
obstetrical care can have on patients in a wide variety of care settings, and the
WHO devotes particular attention to mistreatment and abuse in maternity care.
Indeed “poor rapport between women and providers,” including ineffective com-
munication and lack of supportive care, is one of seven categories of mistreatment
of women in maternity care facilities described in a 2015 systematic review of 65
studies from 34 counties (Bohren et al., 2015). This and other research describes
inequities in maternity care treatment that patients experience related to racism,
low socioeconomic status, and education level—in both high-resource and low-
resource settings around the world. Recent research in the United States and
Canada, for example, found that women of color and of low socioeconomic status
report receiving substandard care (Davis, 2019; McLemore et al., 2018; Salm Ward
et al., 2013; Vedam et al., 2019). In addition, inequities in treatment and care provi-
sion affect not only the patient’s reported experiences of maternity care but also the
physical and mental health outcomes for both mother and infant (Bohren et al.,
2015; Chadwick et al., 2014; Jewkes & Penn-Kekana, 2015; Kruger & Schoombee,
2010; Wabiri et al., 2013).
Despite this evidence, Lappeman and Swartz, while noting differences in language
and ethnicity between clinicians and patients in their examination of “silent ward
milieu,” remain silent on the potential role these differences—and the historical racial
inequities related to them—might play in care and in the “silent ward milieu” itself
(Ford & Airhihenbuwa, 2010b). Furthermore, they fail to interrogate their own posi-
tionality within the health care system (Charmaz, 2014) or in relation to these inequi-
ties (Ford & Airhihenbuwa, 2010b). Given the engrained racism common through
history in many countries such as the United States and South Africa, and prior studies
demonstrating use of physical aggression and other controlling behaviors in South
African maternity settings, this seems a glaring omission (Bohren et al., 2015;
Chadwick et al., 2014; Jewkes et al., 1998; Kruger & Schoombee, 2010).

Expanding on Concepts of Disempowerment to Explore

Agency and Intersectionality
In discussing violence and agency, the authors express concern that naming the silent
ward milieu as violence will cast patients as victims and take away their agency. They
present the fact that women do not choose to have birth companions as evidence of
women’s agency to contradict medical advice, which while accurate, fails to take into
1022 Violence Against Women 27(8)

consideration the fluidity and situational nature of agency and the intersectional axes
along which power (necessary for agency) operates (Ford & Airhihenbuwa, 2010a).
For example, in the United States studies have shown that the prolonged exposure of
black women to racism and their heightened sensitivity to discriminatory practices and
bias have negatively impacted their health care-seeking behavior, and their expecta-
tions of and attitudes toward health care services and workers. (Aronson et al., 2013;
Benkert et al., 2006; Byrd & Clayton, 2001; Dovidio et al., 2008; Penner et al., 2013;
Prather et al., 2016). In South Africa, Chadwick (2017), in her interviews with 35
marginalized South African women giving birth at public hospitals, uses a decentered
view of agency, which she describes as “ambiguous” and “never total or separate from
wider relations of power” (p. 494).
Assumptions that naming violence takes away agency, however, are not unprece-
dented and have been explored in the literature on IPV as well. Crenshaw (1991)
described how U.S. women of color experiencing IPV also often experienced poverty,
class oppression, and lack of economic possibilities, and emphasized that experiences
of violence must be considered within the context of women’s lives. As described by
Mahoney (2009):

. . . the abuse of women and its consequences must be explained “without defining the
woman herself by the experience of abuse” [emphasis added]; second the woman’s
perceptions and the context of her life must be explained . . . in a way that locates her
experience within patterns of system power and oppression. (p. 59)

Describing structural “violence” against patients in the maternity care system does
not take away patient agency but rather has the potential to illuminate and interrogate
the power dynamics inherent, implicit, and in some cases, explicit, within the health
care system. In particular, naming structural violence throws into relief the whole sys-
tem, and moves away from blaming individual perpetrators to building accountability
for the violence embedded within systems, hierarchies, and institutionalized practices
(Scott et al., 2019).

Applying a Reproductive Justice Framework and Using a

Systems Thinking Perspective to Examine Unintended
Consequences
Finally, the authors express concern that naming the “silent ward milieu” as “vio-
lence,” even “gentle violence,” will produce unintended consequences, specifically
low morale among clinicians who might resist efforts to change violent behavior, as
well as a community-level perception of the maternity hospital as a place of violence.
We advocate a systems thinking perspective that assumes and prepares for unintended
consequences as well as a reproductive justice framework that considers reproductive
health care a human right that must be available to all people. The ward silence itself
is an unintended consequence of the current maternal care structure and the power
dynamics of institutionalized racism and sexism.
Salter et al. 1023

The authors remind readers that clinicians are overworked and untrained for cul-
tural engagement, which is consistent with the emerging literature on obstetric vio-
lence. For example, a review of 25 publications describing obstetric violence around
the world noted:

Another explanation commonly given by professionals in the attempt to justify the

violent scenario of obstetric care is based on elements such as work overload, scarce
human resources, physical and mental exhaustion of professionals, precariousness of the
conditions for care provision, and lack of adequate infrastructure in institutions. (Barbosa
Jardim & Modena, 2018)

These stressful conditions in inadequate care environments result in providers them-

selves feeling violated by working conditions (Barbosa Jardim & Modena, 2018;
Sadler et al., 2016).
The authors apply the feminist ethics of care paradigm, which focuses on the rela-
tional context of actions rather than right/wrong binaries, moving away from concep-
tualizations of “perpetrators” and “victims” and resisting the tendency to label actors
as “good” or “bad”—or to blame patients. From our perspective, applying this para-
digm argues in favor of naming the structural violence, as does black feminist theory,
because both patients and clinicians are potentially harmed by the silent yet harried
environment on the ward (Crenshaw, 1991; Scott et al., 2019). Thus, clinicians also
experience the negative effects of structural violence within maternity care systems,
and they too can benefit from adequate naming and examination of that violence.
Chadwick (2017), for example, describes South African nurses in her research: “Rather
than problematic individual perpetrators responsible for ‘causing’ violence, nurses are
themselves intersectional subjects positioned in multiple ways in the birth assem-
blage” (p. 505). Helping practitioners to see both their behavior toward patients as
well as their own unsatisfactory and overwhelmed experiences of the health care sys-
tem within the context of structural violence clears a path forward for change.
It is true; some clinicians will feel attacked. But prioritizing clinicians’ comfort in the
current system over the need for addressing violence against women inherent in the
system is itself oppressive, and in the long run, unproductive. Naming obstetric violence
fits within the reproductive justice framework, which has conceptual building blocks of
intersectionality, reproductive oppression, and human rights (Ross & Solinger, 2017).
The jarring nature of the word “violence” can serve as a leverage point for driving
change. As Shapiro (2018) describes it:

One reason for calling unintended harms a kind of “violence” is to overcome the relative
ease with which such events are ignored, dismissed or trivialized. Employing the word
violence is a conscious way of highlighting a continuum of violence that we could prefer
to ignore. (p. 2)

In the United States, for example, naming racism has allowed for the exploration of its
impact on health outcomes and investigation into the effects health care workers’ biases
can have on racial disparities in health outcomes, including maternal outcomes. Despite
1024 Violence Against Women 27(8)

some clinicians’ negative response, naming and identifying racism, including working
with providers to reflect and identify how racism and other forms of oppression show up
in their thinking and actions, was a first step to addressing the problem. This naming has
also led to the development and implementation of anti-racism frameworks in medical
training and health care institutions (Hardeman et al., 2018; Liaison Committee on
Medical Education, 2019). The potential and positive impact of these changes on improv-
ing patient–clinician communication and patient-centered care and reducing clinician
bias, emphasize the importance of naming an issue to allow for accountability and to spur
change. A 2016 review concludes that the term obstetric violence is a “useful tool for
addressing structural violence in maternity care” and for recognizing that obstetric vio-
lence is a form of violence against women (Sadler et al., 2016, p. 47).
In conclusion, naming obstetric violence is critical for describing the experiences
of those experiencing such violence, and addressing the structures and contexts that
create and fuel such violence, not for judgment but for accountability and change.
Naming allows for study, for redress, and for growth. Obstetric violence itself often
begins as a consequence of complex health care systems that in many cases are not
centered on the pregnant people entering those systems and that violence has been
institutionalized as normal. Naming and acknowledging structural violence can begin
to challenge the normalization of obstetric violence, interrogate systems to allow for
nuanced discussion of power dynamics, realistic care limitations, and recognition of
full humanity of both patients and clinicians.

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.

ORCID iD
Judy C. Chang https://orcid.org/0000-0001-6512-3798

References
Aronson, J., Burgess, D., Phelan, S., & Juarez, L. (2013). Unhealthy interactions: The role of
stereotype threat in health disparities. American Journal of Public Health, 103(1), 50–56.
https://doi.org/10.2105/AJPH.2012.300828
Barbosa Jardim, D. M., & Modena, C. M. (2018). Obstetric violence in the daily routine of care
and its characteristics. Revista Latino-Americana de Enfermagem, 26, e3069. https://doi.
org/10.1590/1518-8345.2450.3069
Benkert, R., Peters, R., Clark, R., & Keves-Foster, K. (2006). Effects of perceived racism,
cultural mistrust and trust in providers on satisfaction with care. Journal of the National
Medical Association, 98(9), 1532–1540.
Salter et al. 1025

Bohren, M., Vogel, J., Hunter, E., Lutsiv, O., Makh, S., Souza, J., Aguiar, C., Coneglian,
F., Araújo Diniz, A., Tunçalp, O., Javadi, D., Oladapo, O., Khosla, R., Hindin, M., &
Gülmezoglu, A. (2015). The mistreatment of women during childbirth in health facilities
globally: A mixed-methods systematic review. PLOS Medicine, 12(6), e1001847. https://
doi.org/10.1371/journal.pmed.1001847
Byrd, W., & Clayton, L. (2001). Race, medicine, and health care in the United States: A histori-
cal survey. Journal of the National Medical Association, 93(3 Suppl.), 11S–34S.
Chadwick, R. (2017). Ambiguous subjects: Obstetric violence, assemblage and South African
birth narratives. Feminism & Psychology, 27(4), 489–509. https://doi.org/10.1177/095
9353517692607
Chadwick, R., Cooper, D., & Harries, J. (2014). Narratives of distress about birth in South
African public maternity settings: A qualitative study. Midwifery, 30, 862–868. https://doi.
org/10.1016/j.midw.2013.12.014
Charmaz, K. (2014). Constructing ground theory (2nd ed.). SAGE.
Crenshaw, K. (1991). Mapping the margins: Intersectionality, identity politics, and violence
against women of color. Stanford Law Review, 43(6), 1241–1299. https://doi.org/10
.2307/1229039
Davis, D.-A. (2019). Obstetric racism: The racial politics of pregnancy, labor, and birthing.
Medical Anthropology, 38(7), 560–573. https://doi.org/10.1080/01459740.2018.1549389
Dovidio, J., Penner, L., Albrecht, T., Norton, W., Gaertner, S., & Shelton, J. (2008). Disparities
and distrust: The implications of psychological processes for understanding racial dispar-
ities in health and health care. Social Science & Medicine, 67(3), 478–486. https://doi.
org/10.1016/j.socscimed.2008.03.019
Ford, C. L., & Airhihenbuwa, C. O. (2010a). Critical Race Theory, race equity, and public health:
Toward antiracism praxis. American Journal of Public Health, 100(Suppl. 1), S30–35.
https://doi.org/10.2105/AJPH.2009.171058
Ford, C. L., & Airhihenbuwa, C. O. (2010b). The public health critical race methodology:
Praxis for antiracism research. Social Science & Medicine, 71(8), 1390–1398. https://doi.
org/10.1016/j.socscimed.2010.07.030
Hardeman, R. R., Burgess, D., Murphy, K., Satin, D. J., Nielsen, J., Potter, T. M., Karbeah,
J., Zulu-Gillespie, M., Apolinario-Wilcoxon, A., Reif, C., & Cunningham, B. A. (2018).
Developing a medical school curriculum on racism: Multidisciplinary, multiracial conver-
sations informed by Public Health Critical Race Praxis (PHCRP). Ethnicity & Disease,
28(Suppl. 1), 271–278. https://doi.org/10.18865/ed.28.S1.271
Jewkes, R., Abrahams, N., & Mvo, Z. (1998). Why do nurses abuse patients? Reflections from
South African obstetric services. Social Science & Medicine, 47, 1781–1795. https://doi.
org/10.1016/s0277-9536(98)00240-8
Jewkes, R., & Penn-Kekana, L. (2015). Mistreatment of women in childbirth: Time for action
on this important dimension of violence against women. PLOS Medicine, 12(6), Article
e1001849. https://doi.org/10.1371/journal.pmed.1001849
Kruger, L., & Schoombee, C. (2010). The other side of caring: Abuse in a South African
maternity ward. Journal of Reproductive and Infant Psychology, 28, 84–101. https://doi.
org/10.1080/02646830903294979
Lappeman, M., & Swartz, L. (2019). Rethinking obstetric violence and the “neglect of neglect”:
The silence of a labour ward milieu in a South African District. BMC International Health
and Human Rights, 19(30), 1–11. https://doi.org/10.1186/s12914-019-0218-2
Liaison Committee on Medical Education. (2019). Functions and structure of a medical school.
1026 Violence Against Women 27(8)

Mahoney, M. R. (2009). Victimization or oppression? Women’s lives, violence, and agency. In

M. Fineman & R. Mykitiuk (Eds.), The public nature of private violence: The discovery of
domestic abuse (pp. 59–93). Routledge.
McLemore, M., Altman, M., Cooper, N., Williams, S., Rand, L., & Franck, L. (2018). Health
care experiences of pregnant, birthing and postnatal women of color at risk for preterm birth.
Social Science & Medicine, 210, 127–135. https://doi.org/10.1016/j.socscimed.2018.02.013
Penner, L. A., Hagiwara, N., Eggly, S., Gaertner, S. L., Albrecht, T. L., & Dovidio, J. F. (2013).
Racial healthcare disparities: A social psychological analysis. European Review of Social
Psychology, 24(1), 70–122. https://doi.org/10.1080/10463283.2013.840973
Prather, C., Fuller, T. R., Marshall, K. J., & WLt, J. (2016). The impact of racism on the sexual
and reproductive health of African American women. Journal of Women’s Health, 25(7),
664–671. https://doi.org/10.1089/jwh.2015.5637
Ross, L., & Solinger, R. (2017). Reproductive justice: An introduction. University of California
Press.
Sadler, M., Santos, M., Ruiz-Berdún, D., Rojas, G. L., Skoko, E., Gillen, P., & Clausen, J.
A. (2016). Moving beyond disrespect and abuse: Addressing the structural dimensions of
obstetric violence. Reproductive Health Matters, 24(47), 47–55. https://doi.org/10.1016/j.
rhm.2016.04.002
Salm Ward, T., Mazul, M., Ngui, E., Bridgewater, F., & Harley, A. (2013). “You learn to
go last”: Perceptions of prenatal care experiences among African-American women with
limited incomes. Maternal and Child Health Journal, 17(10), 1753–1759. https://doi.
org/10.1007/s10995-012-1194-5
Scott, K. A., Britton, L., & McLemore, M. (2019). The ethics of perinatal care for black
women. Journal of Perinatal & Neonatal Nursing, 33(2), 108–115. https://doi.org/10.1097/
JPN.0000000000000394
Shapiro, J. (2018). “Violence” in medicine: Necessary and unnecessary, intentional and unin-
tentional. Philosophy, Ethics, and Humanities in Medicine, 13(7), 1–8. https://doi.org/10
.1186/s13010-018-0059-y
Vedam, S., Stoll, K., Taiwo, T., Rubashkin, N., Cheyney, M., Strauss, N., McLemore, M.,
Cadena, M., Nethery, E., Rushton, E., Schummers, L., & Declercq, E. (2019). The Giving
Voice to Mothers study: Inequity and mistreatment during pregnancy and childbirth in the
United States. Reproductive Health, 16(1), 77. https://doi.org/10.1186/s12978-019-0729-2
Wabiri, N., Chersich, M., Zuma, K., Blaauw, D., Goudge, J., & Dwane, N. (2013). Equity in
maternal health in South Africa: Analysis of health service access and health status in a
national household survey. PLOS ONE, 8(9), Article e73864. https://doi.org/10.1371/jour-
nal.pone.0073864
World Health Organization. (2012). Understanding and addressing violence against women:
Intimate partner violence. https://apps.who.int/iris/bitstream/handle/10665/77432/WHO_
RHR_12.36_eng.pdf;jsessionid=EEA605E396B6939EE2EE4BDEAF8A3421?seque
nce=1

Author Biographies
Cynthia L. Salter, PhD, MPH, is a Researcher and Assistant Professor in Behavioral and
Community Health Sciences at the University of Pittsburgh Graduate School of Public Health.
Her research focuses on maternity care, person-centered care, and social determinants of health
in both the U.S. and the global health setting.
Salter et al. 1027

Abisola Olaniyan is a doctoral student at the University of Pittsburgh Graduate School of

Public Health. She is also a medical doctor with an MPH with a concentration in Global Health.
Her interest lies in improving maternal and child health outcomes, and addressing racial inequi-
ties in maternal and child health through program and policy development, implementation, and
advocacy. Before the commencement of her doctoral program, she worked with Clinton Health
Access Initiative (CHAI) Nigeria on the immunization program. She has also worked with the
State Ministry of Health in Nigeria, where she was responsible for formulating and implement-
ing policies and interventions aimed at improving maternal and child health indices in the state.
Dara D. Mendez, PhD, MPH, is an Assistant Professor in the Departments of Epidemiology
and of Behavioral and Community Health Sciences at University of Pittsburgh Graduate
School of Public Health and an affiliate faculty member of the Center for Health Equity and
the Geoinformatics Laboratory at Pitt. She completed her postdoctoral training as a Kellogg
Health Scholar and earned her MPH and PhD in Maternal and Child Health with a focus in
Epidemiology at the University of North Carolina, Chapel Hill and BA in Sociology/
Anthropology premed at Spelman College. Mendez applies a variety of methods and
approaches in her work related to the complex intersections between racism, multiple forms
of oppression, stress and place in understanding black maternal and infant health as well as
racial/ethnic inequities in pregnancy, birth, and women’s health. Mendez works closely with
community-based and governmental agencies including serving on the Infant Mortality
Collaborative for Allegheny County, the BEST Allegheny Initiative, the Pennsylvania
Maternal Mortality Review Committee, as well as the ACHD/DHS COVID-19 Equity
Advisory Task Force and the Black COVID-19 Equity Coalition.
Judy C. Chang, MD, MPH is an Associate Professor of Obstetrics, Gynecology, and
Reproductives Sciences and of Internal Medicine and the Institute for Clinical Research
Education, University of Pittsburgh. She has been conducting research in the field of intimate
partner violence and violence against women for more than 20 years. Her other research focuses
on patient-provider communication regarding sensitive topics such as intimate partner violence,
prenatal substance use, and mental health concerns.