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Women and Birth xxx (xxxx) xxx–xxx

Contents lists available at ScienceDirect

Women and Birth

journal homepage: www.elsevier.com/locate/wombi

The magnitude of the problem of obstetric violence and its associated

factors: A cross-sectional study
Juan Miguel Martínez-Galianoa,b,* , Sergio Martinez-Vazqueza ,
Julián Rodríguez-Almagroc , Antonio Hernández-Martinezc
a
Department of Nursing of University of Jaen, Jaén, Spain
b
CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
c
Department of Nursing, Faculty of Nursing of Ciudad Real, University of Castilla-La Mancha, Ciudad Real, Spain

A R T I C L E I N F O A B S T R A C T

Article history: Background: In recent years, the concept of obstetric violence has become visible among women and
Received 4 July 2020 professionals, but its prevalence and the factors with which it is related in our healthcare environment
Received in revised form 22 September 2020 are unknown.
Accepted 1 October 2020
Aim: To determine the prevalence of obstetric violence in the Spanish healthcare system and identify the
Available online xxx
associated factors.
Methods: A cross-sectional observational study was conducted during 2019 and included 899 women
Keywords:
who had given birth in the last 12 months. An online questionnaire was distributed through midwives
Obstetric violence
Birth
and women associations in Spain. The questionnaire included sociodemographic, clinical, and assistance
Woman practices variables. The primary outcome variable was obstetric violence and its verbal, physical, and
Pregnancy psycho-affective types. Crude odds ratios (OR) and adjusted OR (ORa) were estimated using binary
Human rights logistic regression.
Results: Obstetric violence was reported by 67.4% (606) of the women; 25.1% (226) verbal, 54.5% (490)
physical, and 36.7% (330) psycho-affective. Overall obstetric violence was observed more frequently in
women who attended maternal education programme (ORa 1.56, 95% CI 1.05–2.32), those who presented
a birth plan but it was not respected (ORa 2.82, 95% CI 1.27–6.29), those who received regional analgesia
(ORa 1.61, 95% CI 1.13–2.30), those who required an urgent caesarean section (ORa 3.46, 95% CI 1.79–6.69),
underwent an episiotomy (ORa 3.34, 95% CI 2.21–5.38), and whose newborn was admitted to an intensive
care unit (ORa 2.73, 95% CI: 1.21–6.15). The presentation of a birth plan was observed as protective
factors, and the possibility of skin-to-skin (ORa 0.34, 95% CI 0.18–0.62) and felt respected (ORa 0.61, 95% CI
0.43–0.85).
Conclusions: Two out of three women perceive having suffered obstetric violence during childbirth.
Practices such as skin-to-skin contact, and the use of respected birth plans, were protective factors
against obstetric violence.
© 2020 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

What this paper adds

Statement of significance The high prevalence of the problem and certain factors that
predispose women to experience a situation of obstetric
Problem or issue violence are made visible
High number of women experience disrespectful and
offensive treatment during the care received for childbirth
What is already known
Obstetric violence has consequences for the health of
women and the newborn but also violates human rights 1. Introduction

The World Health Organization (WHO) calls for respectful

* Corresponding author at: Department of Nursing, University of Jaén, Campus de
Las Lagunillas s/n, Building B3 Office 266, 23071 Jaén, Spain.
E-mail address: jgaliano@ujaen.es (J.M. Martínez-Galiano).
childbirth care, promoting humanisation of care and empower-
ment of women so they can experience childbirth positively,
fulfilling their expectations and beliefs [1]. Despite these

http://dx.doi.org/10.1016/j.wombi.2020.10.002
1871-5192/© 2020 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: J.M. Martínez-Galiano, S. Martinez-Vazquez, J. Rodríguez-Almagro et al., The magnitude of the problem of obstetric
violence and its associated factors: A cross-sectional study, Women Birth, https://doi.org/10.1016/j.wombi.2020.10.002
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J.M. Martínez-Galiano, S. Martinez-Vazquez, J. Rodríguez-Almagro et al.
recommendations, the WHO, in its 2014 Declaration on Prevention
and Eradication of Disrespect and Abuse During Childbirth Care in
Health Centers, warns of the high number of women who
experience disrespectful and offensive treatment during the care
received for childbirth [2].
Hence, the term obstetric violence is becoming increasingly
visible. However, there is no clear and standardised concept of
obstetric violence, and, in a broad sense, obstetric violence could
be understood as any action, conduct or omission of the
pregnant woman's right where she perceives a hierarchical,
dehumanising treatment, in which she is medicalised, and that
pathologises a physiological process such as childbirth with the
consequent loss of autonomy and deprivation of the woman's
ability to decide freely and which affects her quality of life [3,4].
This includes a wide series of actions, such as carrying out
procedures without consent, lack of respect, conducting non-
recommended clinical practices during childbirth, physical
abuse, insults, discrimination, violation of the right to privacy,
the infantilisation of women, and the provision of little
attention and care, among others [5,6].
The prevalence of obstetric violence ranges between 15–91%
depending on the country, the instrument and method used, the
definition, and type of obstetric violence, as well as the type of
childbirth facility, among others factors [5–12]. The presence of
obstetric violence has been associated with factors and deter-
minants such as marital status, age, educational level, socioeco-
nomic level, employment status, race, parity, history of
miscarriage, as well as the gender and professional category of
the person attending the birth, the type of delivery, and the public
or private nature of the childbirth centre [10,13–20] Also,
different clinical practices, such as giving birth on the delivery
table in the lithotomy position, performing an episiotomy
without the woman's consent, pressure on the uterine fundus,
or carrying out vaginal examinations without the woman's
permission, are associated with a higher perception of obstetric
violence by women [8].
The association between obstetric violence and health
problems in women and their offspring has been little studied
and has only been investigated on a psychological level [21–23].
In a study carried out in Brazil with 3065 women, experiencing
obstetric violence increased the chances of having postpartum
depression at three months postpartum and for it to be at least a
moderate level [21]. The incidence of post-traumatic stress
disorder one year after childbirth in a study in Spain with 1531
postpartum women, was negatively associated with good clinical
practices carried out during childbirth based on the guidelines
established by the WHO regarding respect and humanisation of
childbirth care [23].
Obstetric violence is not only a prevalent public health
problem that has consequences for the health of women and
the newborn but also violates human rights. [24]. Research on
this topic is scarce, and especially so in developed countries
with more research encouraged [25]. Furthermore, results
regarding aspects such as, for example, predisposing factors
show inconsistent results [10,13–20]. Moreover, the preva-
lence in developed countries is not well known. Obstetric
violence is a topic that involves stigmatisation and needs to
surface, with sensitisation, staff reflection, and adequate
training [26]. Strategies and policies should be implemented,
along these lines, to eradicate obstetric violence from health
centres, guaranteeing women evidence-based care with the
greatest respect for their rights [27]; especially as a penalty
strategy has not worked where it has been implemented
[28,29]. For all these reasons, the objective was to determine
the prevalence of obstetric violence and the associated factors
that predispose its occurrence.
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2. Methods
2.1. Design and study subjects
A cross-sectional study was carried out during 2019, with a
reference population of women who had given birth in Spain,
either in public or private hospitals or at home. Inclusion criteria
were childbirth within the last 12 months and that the mother had
a sufficient level of instruction to read and understand Spanish. The
only exclusion criteria were women under 18 years of age.
The maximum modelling criterion was used for the calculation
of the sample size, where 10 events (women at risk of obstetric
violence) were included for each independent variable to be
entered in the multivariate model [30]. Taking into account that
the prevalence of obstetric violence risk in previous studies was at
least 15% [5], 100 women at risk of obstetric violence were required
to include 10 variables, and a minimum of 667 women needed to
be included. Despite this, the research team decided to include all
women who participated in the study and who met the inclusion
and exclusion criteria.
2.2. Information source
To collect the study information, we constructed and used an
online questionnaire that contained 49 items (4 open questions, 45
closed questions), which was given to the women. Information was
collected on sociodemographic variables, clinical characteristics,
obstetric results, and clinical practices that had been performed,
data on the newborn and any problems or discomfort, and the
opinion of women. The questionnaire had been previously piloted
and was distributed to women through the main women's
associations and the Federation of Midwifery Associations of
Spain (FAME), as well as its member associations, with the
involvement of midwives in the dissemination of the project and
the recruitment of participants. Once the participants were
selected and agreed to participate, they were provided with the
instructions to complete the questionnaire, which the woman then
filled out in their own time. A phone number and online chat were
provided to answer any questions raised by these women in
completing the questionnaire.
2.3. Study variables
The primary dependent variable was global obstetric violence
and its three components: physical, verbal, and psycho-affective
violence. Physical violence was defined as the use of some of the
following practices without consent and without reporting:
shaving, enema, artificial amniorrhexis or drug acceleration of
labour, repeated vaginal touches and by different professionals,
abdominal compression during pushing, episiotomy, caesarean
section, curettage, an indication of lying down or supine without
justification, or manual removal of the placenta without anaes-
thesia. Verbal invalidation, inappropriate verbal treatment, criti-
cism of the expression of emotions, and the inability to
communicate or question were considered verbal violence.
Psycho-affective violence was considered: preventing companion-
ship, preventing contact with the newborn before being trans-
ferred, feeling of not collaborating, vulnerability, guilt, and
insecurity transmitted to the woman. We define global obstetric
violence as any violation of some of the physical, verbal, or psycho-
affective components. However, the sum of all types of violence
does not coincide with global violence, as each woman can suffer
one or more types of violence.
The independent variables were sociodemographic character-
istics such as age, academic level, current work situation,
nationality, family income, desired pregnancy, maternal education
programme (it was considered adequate participation to attend a
minimum of 5 sessions), preparation of a birth plan; and clinical
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variables such as twin pregnancy, live birth, parity, induction of Table 1

Sociodemographic and current pregnancy data of the study sample.
labour, use of natural methods of analgesia, use of epidural
analgesia, general anaesthesia, type of labour, skin-to-skin contact, Variable N (%) Mean (SD)
breastfeeding in the first hour, admission of the newborn, place of Maternal age 35.2 (4.25)
birth, and degree of support of the partner during the pregnancy, Maternal age
childbirth, and puerperium process 35 years 463 (51.5)
>35 years 436 (48.5)
Weight before pregnancy (Kg) 65.8 (13.24)
2.4. Statistical analysis Weight after childbirth (Kg) 77.3 (12.96)
First, a descriptive analysis was performed using absolute and Months after childbirth 5.4 (3.42)
relative frequencies, as well as means and standard deviation (SD) Pre-gestational BMI 24.4 (4.85)
for the quantitative variables. Next, bivariate and multivariate Education level
Primary school 15 (1.7)
analysis were performed between the potential associated factors
Secondary school 61 (6.8)
and obstetric violence: the odds ratio (OR) and adjusted Odds High school 199 (22.1)
ratios (ORa) were estimated with their 95% confidence intervals University 624 (69.4)
(95% CI). For multivariate analysis, binary logistic regression was Current working status
Full-time work 277 (30.8)
used, using the SPSS (Backward Stepwise) stepwise regression
Part-time work 131 (14.6)
method. Sick leave 189 (21.0)
This analysis was performed for physical, verbal, psycho- Unpaid leave 103 (11.5)
affective, and global obstetric violence. A p < 0.05 was considered Unemployed 199 (22.1)
significant. All analyses were performed with the SPSS v24.0 Nationality
Spanish 868 (96.6)
statistical package.
Other 31 (3.4)
Family monthly wage
2.5. Ethical considerations Less than 1000 euros 46 (5.1)
This study was approved by the Research Ethics Committee of Between 1000–2000 euros 319 (35.5)
the province of Jaen (Spain) with reference number TD-VCDEPP- Between 2000–3000 euros 282 (31.4)
Between 3000–4000 euros 78 (8.7)
2019/1417-N-19. Before starting the questionnaire, the women had Wanted pregnancy
to read an information sheet about the study and its objectives and No 64 (7.1)
check a box in which they showed their consent to participate in it, Yes 835 (92.9)
i.e., they signed an ad hoc digital informed consent. Parity
Primiparous 572 (63.7)
Multiparous 326 (36.7)
3. Results Type of birth
Normal vaginal delivery 539 (60.0)
A total of 899 women were recruited consecutively and Instrumental 170 (18.9)
participated in the study. The mean age was 35.2 years (SD 4.25 Elective C/S 60 (6.7)
Emergency C/S 130 (14.5)
years), 63.7% (572) were primiparous, and 60.0% (539) had a Place of birth
normal vaginal delivery. Childbirth care was provided in a public Public hospital 736 (81.9)
hospital for 81.9% (736), 16.9% (152) in private hospitals, 0.3% (3) in Private hospital 152 (16.9)
birthing centres, and 0.9% (8) at home. Further details on variables Midwife-led centre 3 (0.3)
Home 8 (0.9)
that characterise the study sample can be found in Table 1. The
prevalence of global obstetric violence, as reported by the women, BMI, body mass index; C/S, caesarean section; SD, standard deviation.
was 67.4% (606). Regarding the types of violence, 25.1% (226)
reported verbal violence, 54.5% (490) physical violence, and 36.7%
(330) psycho-affective violence. 0.22–0.78), those who started breastfeeding in the first hour (ORa
In terms of the coexistence of different types of violence, we 0.48, 95% CI 0.30–0.76), were able to do skin-to-skin (ORa 0.48, 95%
found that in 26.1% (239) of the sample women reported both CI 0.28–0.82), and those who felt strongly supported by the partner
physical and psycho-affective violence, in 20.1% (181) physical and in decision-making (ORa 0.24, 95% CI 0.08–0.71). Table 3.
verbal violence were reported, in 17.8% (158) verbal and psycho- Physical obstetric violence was observed more frequently in
affective violence coincided, while in 15.3% (138) all three types of women who presented a birth plan that was not respected (ORa
violence occurred. The items with the highest degree of violation 3.62, 95% CI 1.97–6.64), those who received regional analgesia (ORa
were repeated vaginal touches and by different professionals, as 1.62, 95% CI 1.14–2.29), who underwent an episiotomy (ORa 3.49,
well as the feeling of vulnerability, guilt and insecurity coinciding 95% CI 2.42–5.02), and her newborn was admitted to an intensive
in both cases in 22.2% (200) of the women, followed by the care unit (ORa 1.93, 95% CI 1.02–3.64). The following protective
acceleration of medication in labour in 21.8% (196), and abdominal factors were found, the presentation of a respected birth plan (ORa
pressure in 18.8% (169) women. Information regarding obstetric 0.71, 95% CI 0.52–0.97), being multiparous (ORa 0.71, 95% CI 0.51–
violence in its various forms is presented in detail in Table 2. 1.00) and initiating lactation in the first hour (ORa 0.62, 95% CI
The multivariate analysis showed that verbal obstetric violence 0.42–0.91).
occurred more frequently in women who attended maternal Psycho-affective obstetric violence was observed more fre-
education programme (ORa 2.04, 95% CI 1.26–3.32), those who quently in women who presented a birth plan that was not
presented a birth plan that was not respected (ORa 3.44, 95% CI respected (ORa 4.38, 95% CI 2.43–7.88), those whose delivery
2.08–5.67), those who received induction of labour (ORa 1.42, 95% ended in an instrumental delivery (ORa 2.33, 95% CI 1.47–3.69),
CI 1.00–2.02), and those whose newborn was admitted to an scheduled caesarean section (ORa 4.08, 95% CI 2.07–8.06) or urgent
intensive care unit (ORa 1.78, 95% CI 1.00–3.28). The lowest caesarean section (ORa 5.74, 95% CI 3.32–9.93), those who had an
frequency of verbal violence was observed in women who episiotomy (ORa 1.53, 95 % CI 1.00–2.36), and those whose
presented a respected birth plan (ORa 0.57, 95% CI 0.39–0.85), newborn was admitted to an intensive care unit (ORa 2.18, 95% CI
those whose delivery ended in a scheduled caesarean section 1.12–4.23). As protective factors, we observed the presence of a
(ORa 0.32, 95% CI 0.14–0.73) or urgent caesarean (ORa 0.42, 95% CI respected birth plan (ORa 0.53, 95% CI 0.36–0.78), the possibility of

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Table 2 Table 2 (Continued)

Components of obstetric violence: item variables.
Variable N (%)
Variable N (%)
No 293 (32.6)
Verbal Obstetric violence Yes 606 (67.4)
Verbal invalidation
No 763 (84.9)
Yes 136 (15.1)
Inappropriate verbal treatment
No 841 (93.5)
Yes 58 (6.5) skin-to-skin (ORa 0.23, 95% CI 0.14–0.37),), and feeling very
Criticism for expressing emotion supported by the partner in decision-making (ORa 0.10, 95% CI
No 799 (88.9) 0.02–0.43). Table 4.
Yes 100 (11.1)
Global obstetric violence was observed more frequently in
Ban expression or questions
No 775 (86.2) women who attended maternal education programme (ORa 1.56,
Yes 124 (13.8) 95% CI 1.05–2.32), those who presented a birth plan that was not
Verbal violence respected (ORa 2.82, 95% CI 1.27–6.29), those who received
No 673 (74.9) regional analgesia (ORa 1.61, 95% CI 1.13–2.30), those whose
Yes 226 (25.1)
Physical Obstetric violence
delivery ended in an urgent caesarean section (ORa 3.46, 95% CI
Shaving 1.79–6.69), underwent an episiotomy (ORa 3.34, 95% CI 2.21–5.38),
No 867 (96.4) and whose newborn was admitted to an intensive care unit (ORa
Yes 32 (3.6) 2.73, 95% CI 1.21–6.15). As protective factors, we observed the
Enema
presentation of a respected birth plan (ORa 0.61, 95% CI 0.43–0.85),
No 883 (98.2)
Yes 16 (1.8) and the possibility of skin-to-skin (ORa 0.34, 95% CI 0.18–0.62).
Indication to lie down Table 4.
No 740 (82.3)
Yes 159 (17.7) 4. Discussion
Artificial rupture of membranes
No 732 (81.4)
Yes 167 (18.6) 4.1. Main findings
Augmentation of labour
No 703 (78.2) Our results show that more than two-thirds of women have
Yes 196 (21.8)
experienced a situation of obstetric violence of some kind, and
Repetitive vaginal examinations by different practitioners
No 699 (77.8) more than half of them have been victims of this violence in a
Yes 200 (22.2) physical form. Among the factors, presenting a birth plan that was
Abdominal pressure when pushing not respected, and the admission of the newborn to NICU were
No 730 (81.2) associated with experiencing obstetric violence in all its possible
Yes 169 (18.8)
Uninformed episiotomy
forms. In addition, obstetric violence was more frequent in women
No 735 (81.8) who attended an antenatal education programme for labour and
Yes 164 (18.2) birth preparation and who underwent an episiotomy in childbirth,
Uninformed caesarean section especially highlighting its association with verbal and psycho-
No 813 (90.4)
affective violence. The administration of regional analgesia during
Yes 86 (9.6)
Manual removal of the placenta (w/o analgesia) childbirth was associated with women reporting having experi-
No 819 (91.1) enced a situation of obstetric violence in their physical form. An
Yes 80 (8.9) instrumental delivery or caesarean section, both urgent and
Uninformed curettage scheduled, were identified as risk factors for suffering psycho-
No 881 (98.0)
Yes 18 (2.0)
affective violence; however, in terms of verbal violence, caesarean
Forced to keep supine position delivery was a protective factor whereas induced labour was found
No 776 (86.3) to be a risk factor for this type of violence. The initiation of early
Yes 123 (13.7) breastfeeding, the early establishment of skin-to-skin between the
Forced to be in bed
mother and the newborn and respecting the birth plan that she
No 767 (85.3)
Yes 132 (14.7) presents are found to be factors that protect women from obstetric
Physical violence violence in its various forms. The behaviours that women
No 409 (45.5) perceived as a greater violation of their rights and therefore
Yes 490 (54.5) experienced as obstetric violence were repeated vaginal exami-
Psych-affective Obstetric violence
nations and by different professionals, making them feel vulnera-
Block birthing partner
No 820 (91.2) ble, insecure and guilty, the use of drugs to accelerate labour and
Yes 79 (8.8) childbirth, and the use of the uterus fundus pressure manoeuvre
Avoid skin-to-skin contact (Kristeller).
No 737 (82.0)
Yes 162 (18.0)
Feeling of not collaborating 4.2. Strengths and limitations
No 739 (82.2)
Yes 160 (17.8) The study sample is representative of the reference population.
Vulnerability, blame, insecurity As it is a questionnaire, a selection bias associated with non-
No 699 (77.8)
response is possible; however, the sample is large and representa-
Yes 200 (22.2)
Psych-affective violence tive, therefore, we do not believe that the responses of the women
No 569 (63.3) who did not participate may differ considerably from those that
Yes 330 (36.7) did. Moreover, the number of women who refused to participate
Global Obstetric violence (dichotomous)
was low, only 53 women. The existence of information bias is

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Table 3
Bivariate and multivariate analysis of association between sociodemographic and obstetric characteristics and verbal and physical obstetric violence.

Variable Verbal violence Physical violence

No Yes OR (95% CI) aOR (95% CI) No Yes OR (95% CI) aOR (95% CI)
Maternal age
35 years 339 (73.2) 124 (26.8) 1 (ref.) 202 (43.6) 261 (56.4) 1 (ref.)
> 35 years 334 (76.6) 102 (23.4) 0.84 (0.62–1.13) 207 (47.5) 229 (52.5) 0.86 (0.66–1.11)
Education level
Primary school 12 (80.0) 3 (20.0) 1 (ref.) 7 (46.7) 8 (53.3) 1 (ref.)
Secondary school 41 (68.3) 19 (31.7) 1.85 (0.47–7.35) 30 (50.0) 30 (50.0) 0.88 (0.28–2.72)
High school 151 (65.9) 48 (24.1) 1.28 (0.34–4.69) 84 (42.2) 115 (57.8) 1.20 (0.42–3.43)
University 469 (75.0) 156 (25.0) 1.33 (0.38–4.78) 288 (46.1) 337 (53.9) 1.02 (0.37–2.86)
Current working status
Full-time work 202 (72.9) 75 (27.1) 1 (ref.) 125 (45.1) 152 (54.9) 1 (ref.)
Part-time work 98 (74.8) 33 (25.2) 0.91 (0.56–1.46) 65 (49.6) 66 (50.4) 0.84 (0.55–1.27)
Sick leave 150 (79.4) 39 (20.6) 0.70 (0.45–1.09) 81 (42.9) 108 (57.1) 1.10 (0.76–1.59)
Unpaid leave 69 (67.0) 34 (33.0) 1.33 (0.81–2.16) 46 (44.7) 57 (55.3) 1.02 (0.65–1.61)
Unemployed 154 (77.4) 45 (22.6) 0.79 (0.52–1.20) 92 (46.2) 107 (53.8) 0.96 (0.66–1.38)
Nationality
Spanish 654 (75.3) 214 (24.7) 1 (ref.) 397 (45.7) 471 (54.3) 1 (ref.)
Other 19 (61.3) 12 (38.7) 1.93 (0.92–4.04) 12 (38.7) 19 (61.3) 1.34 (0.64–2.78)
Family monthly wage
Less than 1000 euros 36 (78.3) 10 (21.7) 1 (ref.) 22 (47.8) 24 (52.2) 1 (ref.)
Between 1000–2000 euros 229 (71.8) 90 (28.2) 1.42 (0.67–2.97) 148 (46.4) 171 (43.6) 1.06 (0.57–1.97)
Between 2000–3000 euros 215 (76.2) 67 (23.8) 1.12 (0.53–2.38) 122 (43.3) 160 (56.7) 1.20 (0.64–2.25)
Between 3000–4000 euros 130 (74.7) 44 (25.3) 1.22 (0.56–2.66) 77 (44.3) 97 (55.7) 1.16 (0.60–2.22)
More than 4000 euros 63 (80.8) 15 (19.2) 0.86 (0.35–2.10) 40 (41.3) 38 (48.7) 0.87 (0.42–1.81)
Wanted pregnancy
No 47 (73.4) 17 (26.6) 1 (ref.) 31 (48.4) 33 (51.6) 1 (ref.)
Yes 626 (75.0) 209 (25.0) 0.92 (0.52–1.64) 378 (45.3) 457 (54.7) 1.14 (0.68–1.89)
Maternal antenatal
classes
No 152 (84.0) 29 (16.0) 1 (ref.) 1 (ref.) 101 (55.8) 80 (44.2) 1 (ref.)
Yes, and less than 5 classes 99 (75.0) 33 (25.0) 1.75 (1.00–3.06) 1.77 (0.95–3.30) 57 (43.2) 75 (56.8) 1.66 (1.06–2.61)
Yes, and more than 5 422 (72.0) 164 (28.0) 2.04 (1.32–3.15) 2.04 (1.26–3.32) 251 (42.8) 335 (57.2) 1.69 (1.20–2.36)
classes
Birth plan
No 364 (74.9) 122 (25.1) 1 (ref.) 1 (ref.) 214 (44.0) 272 (56.0) 1 (ref.) 1 (ref.)
Yes, but not respected 41 (42.3) 56 (57.7) 4.08 (2.59–6.40) 3.44 (2.08–5.67) 15 (15.5) 82 (84.5) 4.30 (2.41–7.67) 3.62 (1.97–6.64)
Yes, and was respected 268 (84.8) 48 (15.2) 0.53 (0.37–0.77) 0.57 (0.39–0.85) 180 (57.0) 136 (43.0) 0.59 (0.45–4.79) 0.71 (0.52–0.97)
Twin pregnancy
No 659 (74.8) 222 (25.2) 1 (ref.) 406 (46.1) 475 (53.9) 1 (ref.)
Yes 14 (77.8) 4 (22.2) 0.85 (0.28–2.60) 3 (16.7) 15 (83.3) 4.27 (1.23–14.87)
Live newborn
No 3 (50.0) 3 (50.0) 1 (ref.) 1 (16.7) 5 (83.3) 1 (ref.)
Yes 670 (75.0) 223 (25.0) 0.33 (0.07–1.66) 408 (45.7) 485 (54.3) 0.24 (0.03–2.04)
Parity
Primiparous 408 (71.3) 164 (28.7) 1 (ref.) 213 (37.2) 359 (62.8) 1 (ref.) 1 (ref.)
Multiparous 264 (81.0) 62 (19.0) 0.58 (0.42–0.81) 196 (60.1) 130 (39.9) 0.39 (0.30–0.52) 0.71 (0.51–1.00)
Induction of labour
No 426 (77.9) 121 (22.1) 1 (ref.) 1 (ref.) 268 (49.0) 279 (51.0) 1 (ref.)
Yes 247 (70.2) 105 (29.8) 1.50 (1.10–2.03) 1.42 (1.00–2.02) 141 (40.1) 211 (59.9) 1.44 (1.10–1.89)
Natural analgesia
No 539 (74.0) 189 (26.0) 1 (ref.) 318 (43.7) 410 (56.3) 1 (ref.)
Yes 134 (78.4) 37 (21.6) 0.79 (0.53–1.18) 91 (53.2) 80 (46.8) 0.68 (0.49–0.95)
Regional analgesia
No 199 (78.0) 56 (22.0) 1 (ref.) 159 (62.4) 96 (36.7) 1 (ref.) 1 (ref.)
Yes 474 (73.6) 170 (26.4) 1.27 (0.90–1.80) 250 (38.8) 394 (61.2) 2.61 (1.94–3.52) 1.62 (1.14–2.29)
General anaesthesia
No 650 (74.8) 219 (25.2) 1 (ref.) 396 (45.6) 473 (54.4) 1 (ref.)
Yes 23 (76.7) 7 (23.3) 0.90 (0.38–2.13) 13 (43.3) 17 (56.7) 1.10 (0.53–2.28)
Type of birth
Normal vaginal delivery 425 (78.8) 114 (21.2) 1 (ref.) 1 (ref.) 285 (52.9) 254 (47.1) 1 (ref.)
Instrumental 123 (72.4) 47 (27.6) 1.43 (0.96–2.11) 0.68 (0.43–1.07) 48 (28.2) 122 (71.8) 2.85 (1.96–4.15)
Elective C/S 42 (70.0) 18 (30.0) 1.60 (0.89–2.88) 0.32 (0.14–0.73) 31 (51.7) 29 (48.3) 1.05 (0.62–1.79)
Emergency C/S 83 (63.8) 47 (36.2) 2.11 (1.40–3.19) 0.42 (0.22–0.78) 45 (34.6) 85 (65.4) 2.12 (1.42–3.16)
Episiotomy
No 500 (76.0) 158 (24.0) 1 (ref.) 356 (54.1) 302 (45.9) 1 (ref.) 1 (ref.)
Yes 173 (71.8) 68 (28.2) 1.24 (0.89–1.73) 53 (22.0) 188 (78.0) 4.18 (2.97–5.88) 3.49 (2.42–5.02)
Skin-to-skin
No 104 (55.0) 85 (45.0) 1 (ref.) 1 (ref.) 59 (31.2) 130 (68.8) 1 (ref.)
Yes 569 (80.1) 141 (19.9) 0.30 (0.22–0.43) 0.48 (0.28–0.82) 350 (49.3) 360 (50.7) 0.47 (0.33–0.66)
Breastfeeding within first
hour after childbirth
No 126 (57.5) 93 (42.5) 1 (ref.) 1 (ref.) 70 (32.0) 149 (68.0) 1 (ref.) 1 (ref.)
Yes 547 (80.4) 133 (19.6) 0.33 (0.24–0.46) 0.48 (0.30–0.76) 339 (49.9) 341 (50.1) 0.47 (0.34–0.65) 0.62 (0.42–0.91)
Admission of the newborn
to care unit

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Table 3 (Continued)
Variable Verbal violence Physical violence

No Yes OR (95% CI) aOR (95% CI) No Yes OR (95% CI) aOR (95% CI)
No 569 (76.6) 182 (23.4) 1 (ref.) 1 (ref.) 370 (47.6) 408 (52.4) 1 (ref.) 1 (ref.)
Intermediate care 41 (69.5) 18 (30.5) 1.44 (0.81–2.56) 0.51 (0.25–1.04) 23 (39.0) 36 (61.0) 1.42 (0.83–2.44) 0.88 (0.48–1.63)
NICU 36 (58.1) 26 (41.9) 2.37 (1.39–4.02) 1.78 (1.00–3.28) 16 (25.8) 46 (74.2) 2.61 (1.45–4.69) 1.93 (1.02–3.64)
Place of birth
Public hospital 549 (74.6) 187 (25.4) 1 (ref.) 335 (45.5) 401 (54.5) 1 (ref.)
Private hospital 113 (74.3) 39 (25.7) 1.01 (0.68–1.51) 64 (42.1) 88 (57.9) 1.15 (0.81–1.64)
Midwife-led centre 3 (100.0) 0 (0.0) 1.00 (0.00–0.00) 2 (66.7) 1 (33.3) 0.42 (0.04–4.63)
Home 8 (100.0) 0 (0.0) 1.00 (0.00–0.00) 8 (100.0) 0 (0.0) 1.00 (0.00–0.00)
Partner support during
childbirth
None 8 (44.4) 10 (55.6) 1 (ref.) 1 (ref.) 7 (38.9) 11 (61.1) 1 (ref.)
Little 17 (48.6) 18 (51.4) 0.85 (0.27–2.65) 0.85 (0.23–3.13) 8 (22.9) 27 (77.1) 2.15 (0.63–7.37)
Something 33 (58.9) 23 (41.1) 0.56 (0.19–1.63) 0.63 (0.19–2.14) 19 (33.9) 37 (66.1) 1.24 (0.41–3.71)
Quite 158 (70.2) 67 (29.8) 0.34 (0.13–0.90) 0.47 (0.15–1.44) 95 (42.2) 130 (57.8) 0.87 (0.33–2.33)
A lot 457 (80.9) 108 (19.1) 0.19 (0.07–0.49) 0.24 (0.08–0.71) 280 (49.6) 285 (50.4) 0.65 (0.25–1.70)

C/S, caesarean section; NICU, neonatal intensive care unit; OR, odds ratio; 95% CI, 95% confidence interval.

unlikely: the data collected, as well as the way the possible
answers were posed, did not require a high educational level. The
questions were asked in a way that was basic, simple, affordable,
and understandable for any educational level. Although the
information was collected in a short period of time, a memory
bias cannot be completely ruled out, but if any influence on the
results had occurred, we believe that it would be minimal. It is also
not possible to completely discard a confounding bias, despite
having tried to minimise it both in the study design and in the data
analysis, adjusting for the variables that could influence the results.
One of the limitations of the study is the self-declaration by the
woman of the situation of violence experienced. It is a subjective
situation that she has experienced; however, it cannot be
compared with any official record or document as the variable
obstetric violence does not appear in them. The questionnaire was
presented online, this perhaps limited the participation of women
who do not have internet access, although this would be rare as
most of the population has devices (smartphones, tablets,
computers, etc.) with connection to the internet. The online
questionnaire has previously been used as an instrument for data
collection in various investigations [6,23].
4.3. Interpretation
The prevalence of obstetric violence found in this study is high.
The percentages of this violence are very disparate in the literature,
but our results are in line with that found by different authors [5–
7]. Of the different types of violence, the most frequent was
physical violence, followed by psycho-affective and verbal
violence. The percentage of women who reported to have been
in a situation of physical obstetric violence is higher than that
reported by Mirhet in a study carried out in Ethiopia with 409
women, approximately six percent [31], as well as several other
studies [5,14,32], although below that found by other authors [7].
Regarding obstetric violence in its verbal mode, our study shows a
slightly lower prevalence than that reported by other authors
[14,32]. although similar to that found by Jardim & Moden in a
literature review on the subject [33]. The percentage of women
who reported having experienced psycho-affective violence also
coincides with that reported elsewhere: 36.7%, by Madrid et al. in
the study that they carried out in Mexico with 140 women [7]. It
should be kept in mind that the assessment of obstetric violence is
not homogeneous and there is considerable variability; thus the
same behaviour can be understood by some researchers as verbal-
type violence and by others as psycho-affective type.
The most frequent behaviours that women denounced as
violent were repeated vaginal touching, and by different personnel,
coinciding with other authors. [7,10,15,34]. Also, the Kristeller
manoeuvre or pressure on the uterine fund, despite being a
practice not recommended, is used frequently and this makes
women perceive an incorrect treatment by professionals, which is
in line with results of other authors [7,12,15,33,35]. Furthermore,
controlling the normal rhythm of labour for non-clinical interests
through drug acceleration was another practice that women
experience as violent behaviour towards them, coinciding with
what other researchers report. [7,12,16,33]. Other aspects that
stand out are the feeling of vulnerability, guilt, and insecurity that
women experienced and that make them feel that they are going
through a situation of obstetric violence; failure to inform and
request permission to perform any procedure or lack of privacy
makes women feel vulnerable and insecure as Siraj et al. and other
authors also reflected [10,11,33].
No association has been identified between experiencing
obstetric violence and sociodemographic variables such as age,
marital status, or economic level, contrary to what several other
authors found [10,13–16,18,31,34,36,37]. In a literature review that
included 16 studies, Shrivastava & Sivakami found that socio-
demographic variables and a lower social level were associated
with a greater probability of suffering obstetric violence [13], Along
this same line, others have also found that younger women with a
lower education level are at greater risk of verbal violence [36].
Sheferaw et al. found that abuse was less frequent in women 35
years of age or older [37]. However, Siraj et al. reported that having
a secondary education level or higher caused women to manifest,
to a greater extent, having experienced a situation of obstetric
violence, these same authors associated not being married with a
lower incidence of child abuse in childbirth [10]. Hameed & Avan
[14] found that unemployed compared to working women was a
factor for not experiencing obstetric violence, contrary to our
results. However, in line with our results, Lansky et al. did not find
an association between maternal age, maternal educational level,
or income level with the incidence of obstetric violence, although
they did detect an association with marital status in the opposite
line found in our results [32]. Parity has been associated with a
higher incidence of obstetric violence, with multiparous being a
factor that favours abuse, as also reported by Vedam et al. in their
study carried out with 2700 women in the United States [18],
although other authors did not identify it [14]. Failing to find an
association between sociodemographic variables and the inci-
dence of obstetric violence, highlights that all women, regardless

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Table 4
Bivariate and multivariate analysis between sociodemographic and obstetric characteristics with psych-affective and global obstetric violence.

Variable Psych-affective violence Global violence

No Yes OR (95% CI) aOR (95% CI) No Yes OR (95% CI) aOR (95% CI)
Maternal age
35 years 296 (63.9) 167 (36.1) 1 (ref.) 142 (30.7) 321 (69.3) 1 (ref.)
>35 years 273 (62.6) 163 (37.4) 1.06 (0.81–1.39) 151 (34.6) 285 (65.4) 0.84 (0.63–1.10)
Education level
Primary school 10 (66.7) 5 (33.3) 1 (ref.) 5 (33.3) 10 (66.7) 1 (ref.)
Secondary school 39 (65.0) 21 (35.0) 1.08 (0.33–3.57) 20 (33.3) 40 (66.7) 1.00 (0.30–3.32)
High school 125 (62.8) 74 (37.2) 1.18 (0.39–3.60) 57 (28.6) 142 (71.4) 1.25 (0.41–3.81)
University 396 (63.2) 230 (36.8) 1.17 (0.39–3.45) 211 (33.8) 414 (66.2) 0.98 (0.33–2.91)
Current working status
Full-time work 169 (61.0) 108 (39.0) 1 (ref.) 88 (31.8) 189 (68.2) 1 (ref.)
Part-time work 87 (66.4) 44 (33.6) 0.79 (0.51–1.22) 44 (33.6) 87 (66.4) 0.92 (0.59–1.43)
Sick leave 120 (63.5) 69 (36.5) 0.90 (0.61–1.32) 63 (33.3) 126 (66.7) 0.93 (0.63–1.38)
Unpaid leave 60 (58.3) 43 (41.7) 1.12 (0.71–1.78) 35 (34.0) 68 (66.0) 0.91 (0.56–1.46)
Unemployed 133 (66.8) 66 (33.2) 0.78 (0.53–1.58) 63 (31.7) 136 (68.3) 1.01 (0.68–1.49)
Nationality
Spanish 552 (63.6) 316 (36.4) 1 (ref.) 287 (33.1) 581 (66.9) 1 (ref.)
Other 17 (54.8) 14 (45.2) 1.44 (0.70–2.96) 6 (19.4) 25 (80.6) 2.06 (0.84–5.07)
Family monthly wage
Less than 1000 euros 26 (56.5) 20 (43.5) 1 (ref.) 14 (30.4) 32 (69.6) 1 (ref.)
Between 1000–2000 euros 200 (62.7) 119 (37.3) 0.77 (0.41–1.45) 106 (33.2) 213 (66.8) 0.88 (0.45–1.72)
Between 2000–3000 euros 181 (64.2) 101 (35.8) 0.73 (0.39–1.36) 94 (33.3) 188 (66.7) 0.88 (0.45–1.72)
Between 3000–4000 euros 117 (67.2) 57 (32.8) 0.63 (0.33–1.23) 53 (30.5) 121 (69.5) 1.00 (0.49–2.02)
More than 4000 euros 45 (57.7) 33 (42.3) 0.95 (0.46–1.99) 26 833.3) 52 (66.7) 0.88 (0.40–1.92)
Wanted pregnancy
No 39 (60.9) 25 (39.1) 1 (ref.) 22 (34.4) 42 (65.6) 1 (ref.)
Yes 530 (63.5) 305 (36.5) 0.90 (0.53–1.51) 271 (32.5) 564 (67.5) 1.09 (0.64–1.86)
Maternal antenatal
classes
No 128 (70.7) 53 (29.3) 1 (ref.) 76 (42.0) 105 (58.0) 1 (ref.) 1 (ref.)
Yes, and less than 5 classes 83 (62.9) 49 (37.1) 1.43 (0.89–2.30) 45 (34.1) 87 (65.9) 1.40 (0.88–2.23) 1.64 (0.96–2.80)
Yes, and more than 5 358 (61.1) 228 (38.9) 1.54 (1.07–2.21) 172 (29.4) 414 (70.6) 1.74 (1.23–2.46) 1.56 (1.05–2.32)
classes
Birth plan
No 298 (61.3) 188 (38.7) 1 (ref.) 1 (ref.) 141 (29.0) 345 (71.0) 1 (ref.) 1 (ref.)
Yes, but not respected 21 (21.6) 76 (78.4) 5.74 (3.42–9.62) 4.38 (2.43–7.88) 8 (8.2) 89 (91.8) 4.55 (2.15–9.62) 2.82 (1.27–6.29)
Yes, and was respected 250 (79.1) 66 (20.9) 0.42 (0.30–0.58) 0.53 (0.36–0.78) 144 (45.6) 172 (54.4) 0.49 (0.36–0.66) 0.61 (0.43–0.85)
Twin pregnancy
No 562 (63.8) 319 (36.2) 1 (ref.) 292 (33.1) 589 (66.9) 1 (ref.)
Yes 7 (38.9) 11 (61.1) 2.77 (1.06–7.21) 1 (5.6) 17 (94.4) 8.43 (1.12–63.64)
Live newborn
No 1 (16.7) 5 (83.3) 1 (ref.) 1 (16.7) 5 (83.3) 1 (ref.)
Yes 568 (63.6) 325 (36.4) 0.24 (0.03–2.04) 292 (32.7) 601 (67.3) 0.41 (0.05–3.54)
Parity
Primiparous 312 (54.5) 260 (45.5) 1 (ref.) 131 (22.9) 441 (77.1) 1 (ref.)
Multiparous 256 (78.5) 70 (21.5) 0.33 (0.24–0.45) 162 (49.7) 164 (50.3) 0.30 (0.23–0.40)
Induction of labour
No 377 (68.9) 170 (31.1) 1 (ref.) 206 (37.7) 341 (62.3) 1 (ref.)
Yes 192 (54.5) 160 (45.5) 1.85 (1.40–2.44) 87 (24.7) 265 (75.3) 1.84 (1.37–2.48)
Natural analgesia
No 439 (60.3) 289 (39.7) 1 (ref.) 216 (29.7) 512 (70.3) 1 (ref.)
Yes 130 (76.0) 41 (24.0) 0.48 (0.33–0.70) 77 (45.0) 94 (55.0) 0.52 (0.37–0.72)
Regional analgesia
No 194 (76.1) 61 (23.9) 1 (ref.) 125 (49.0) 130 (51.0) 1 (ref.) 1 (ref.)
Yes 375 (58.2) 269 (41.8) 2.28 (1.64–3.17) 168 (26.1) 476 (73.9) 2.72 (2.01–3.67) 1.61 (1.13–2.30)
General anaesthesia
No 560 (64.4) 309 (35.6) 1 (ref.) 286 (32.9) 583 (67.1) 1 (ref.)
Yes 9 (30.0) 21 (70.0) 4.23 (1.91–9.35) 7 (23.3) 23 (76.7) 1.61 (0.68–3.80)
Type of birth
Normal vaginal delivery 432 (80.1) 107 (19.9) 1 (ref.) 1 (ref.) 235 (43.6) 304 (56.4) 1 (ref.) 1 (ref.)
Instrumental 85 (50.0) 85 (50.0) 4.04 (2.80–5.83) 2.33 (1.47–3.69) 33 (19.4) 137 (80.6) 3.21 (2.12–4.87) 1.11 (0.67–1.83)
Elective C/S 20 (33.3) 40 (66.7) 8.08 (4.54–14.38) 4.08 (2.07–8.06) 11 (18.3) 49 (81.7) 3.44 (1.75–6.77) 1.91 (0.89–4.10)
Emergency C/S 32 (24.6) 98 (75.4) 12.36 (7.87–19.42) 5.74 (3.32–9.93) 14 (10.8) 116 (89.2) 6.41 (3.57–11.44) 3.46 (1.79–6.69)
Episiotomy
No 429 (65.2) 229 (34.8) 1 (ref.) 1 (ref.) 254 (38.6) 404 (61.4) 1 (ref.) 1 (ref.)
Yes 140 (58.1) 101 (41.9) 1.35 (1.00–1.83) 1.53 (0.99–2.36) 39 (16.2) 202 (83.8) 3.26 (2.23–4.75) 3.45 (2.21–5.38)
Skin-to-skin
No 40 (21.2) 149 (78.8) 1 (ref.) 1 (ref.) 18 (9.5) 171 (90.5) 1 (ref.) 1 (ref.)
Yes 529 (74.5) 181 (25.5) 0.09 (0.06–0.14) 0.23 (0.14–0.37) 275 (38.7) 435 (61.3) 0.17 (0.10–0.28) 0.34 (0.18–0.62)
Breastfeeding within first
hour after childbirth
No 81 (37.0) 138 (63.0) 1 (ref.) 35 (16.0) 184 (84.0) 1 (ref.)
Yes 488 (71.8) 192 (28.2) 0.23 (0.17–0.32) 258 (37.9) 422 (62.1) 0.31 (0.21–0.46)
Admission of the newborn
to care unit

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Table 4 (Continued)
Variable Psych-affective violence Global violence

No Yes OR (95% CI) aOR (95% CI) No Yes OR (95% CI) aOR (95% CI)
No 520 (66.8) 258 (33.2) 1 (ref.) 1 (ref.) 274 (35.2) 504 (64.8) 1 (ref.) 1 (ref.)
Intermediate care 23 (39.0) 36 (61.0) 3.16 (1.83–5.44) 1.13 (0.56–2.30) 11 (18.6) 48 (81.4) 2.37 (1.21–4.64) 0.97 (0.45–2.11)
NICU 26 (41.9) 36 (58.1) 2.79 (1.65–4.72) 2.18 (1.12–4.23) 8 (12.9) 54 (87.1) 3.67 (1.72–7.82) 2.73 (1.21–6.15)
Place of birth
Public hospital 469 (63.7) 267 (36.3) 1 (ref.) 238 (32.3) 498 (67.7) 1 (ref.)
Private hospital 89 (58.6) 63 (41.4) 1.24 (0.87–1.78) 45 (29.6) 107 (70.4) 1.14 (0.78–1.66)
Midwife-led centre 3 (100.0) 0 (0.0) 1.00 (0.00–0.00) 2 (66.7) 1 (33.3) 0.24 (0.02–2.65)
Home 8 (100.0) 0 (0.0) 1.00 (0.00–0.00) 8 (100.0) 0 (0.0) 1.00 (0.00–0.00)
Partner support during
childbirth
None 3 (16.7) 15 (83.3) 1 (ref.) 1 (ref.) 2 (11.1) 16 (88.9) 1 (ref.)
Little 11 (31.4) 24 (68.6) 0.44 (0.10–1.82) 0.28 (0.05–1.55) 5 (14.3) 30 (85.7) 0.75 (0.13–4.31)
Something 26 (46.4) 30 (53.6) 0.23 (0.06–0.89) 0.21 (0.04–10.1) 11 (19.6) 45 (80.4) 0.51 (0.10–2.56)
Quite 138 (61.3) 87 (38.7) 0.13 (0.04–0.45) 0.13 (0.03–0.60) 60 (26.7) 165 (73.3) 0.34 (0.08–1.54)
A lot 391 (69.2) 174 (30.8) 0.09 (0.03–0.31) 0.10 (0.02–0.43) 215 (38.1) 350 (61.9) 0.20 (0.05–0.89)

C/S, caesarean section; NICU, neonatal intensive care unit; OR, odds ratio; 95% CI, 95% confidence interval.

of their social status, can experience such a situation. This may be
because most women in Spain give birth in the public health
system (universal and free access) where all women are treated
equally regardless of age, educational level, or economic status.
Women who attended most of the health education programme
during birth were more likely to experience obstetric violence; this
may be because this programme addresses the different clinical
practices, their benefits, contraindications, etc., as well as their rights
in the process of pregnancy and childbirth. Therefore, these women
are more knowledgeable on the subject, allowing them to identify
inappropriate behaviours more easily; however, other authors
identify attendance at this programme as a protective factor for
this type of abuse [14]. Induced labour has also been found to be a risk
factor, induced labour often has a longer duration, which means that
women require much more care and attention from staff, this may
explain the association between both variables. The type of delivery,
instrumental or caesarean delivery, was found to be associated with
more violence. However, for verbal obstetric violence, caesarean
delivery was identified as a protective factor. The active participation
of the woman (pushing, etc.) in times of heightened tension and
stress for the health professional such as the expulsion period may be
what explains that women who avoid this period of labour, during a
caesarean section, are less likely to suffer verbal obstetric violence as
they do not need indications to guide or correct the push, among
others. Type of labour was also identified as a risk factor by other
authors [16]. Galdos Tejada & Orcotorio Quispe identified vaginal
delivery as a risk factor for physical obstetric violence but not for
other types of obstetric violence [15], similar to the findings of other
authors [38]. In line with Hameed & Avan, and contrary to what one
might think a priori, no association has been found between giving
birth at home or in a hospital and the incidence of obstetric violence
[14]; however, Vedam et al. did find a higher prevalence of abuse in
women who gave birth in hospitals than those who did so at home
[18].
Presenting a birth plan which is not respected was also associated
with a higher incidence of abuse. Women have expectations about
childbirth that they reflect in this document when these expect-
ations are not met by different circumstances, women can
experience this as a violation of their rights, in line with the results
of Llobera et al. [39] and other authors [40]. Not allowing women to
establish early skin-to-skin contact and the early initiation of
breastfeeding also caused women to experience situations of abuse;
factors that Barbosas Jardim & Modena also identified in an
integrative literature review of 24 publications [33] as well as other
authors [6,12,39]. The admission of the newborn to the NICU also
predisposed the woman to feel a victim of obstetric violence.
Approximately 50% of the women participating in a study carried out
by Iglesias et al. considered that they had performed an episiotomy
unnecessarily, causing women to perceive this practice as obstetric
violence [12] in line with our results and those of others [41]. The
administration of regional analgesia was also associated with a
higher incidence of obstetric violence, contrary to that identified by
other authors [10]. Although it was thought that women value the
administration of analgesia to relieve labour pain, the use of this
analgesia entails having to carry out a series of practices
(administration of medications for the progression of labour,
amniorrhexis, limitation of mobility, etc.) that women can identify
as obstetric violence. Women who had a high level of support from
their partner were less likely to feel they had experienced situations
of violence obstetrical verbal and psycho-type.
Health professionals always look for the best outcomes for the
health of the mother and the newborn, although seeking this well-
being [10] practices may be carried out without sufficient
explanation to the woman, which makes her feel mistreated
during childbirth.
5. Conclusions
The prevalence of perceived obstetric violence is high, with
physical violence especially standing out. Clinical practices not
recommended by scientific evidence such as performing repetitive
vaginal examinations, the Kristeller manoeuvre, the acceleration of
labour by exogenous administration of oxytocin, the systematic
performance of episiotomy, not allowing early skin-to-skin contact
between the mother and the newborn, as well as the early start of
breastfeeding, which when performed by health professionals in
childbirth care are experienced by women as violent behaviour
towards them. Women can be victims of obstetric violence
regardless of their age, educational level, socioeconomic status;
whereas multiparous women are more likely to experience
obstetric violence. Other factors such as a woman’s birth plan
not being respected, the admission of the newborn to the NICU, the
administration of regional analgesia, or having attended the
programme for childbirth preparation were identified as risk
factors for perceiving having experienced a situation of obstetric
violence.
Author/s agreement
Juan Miguel Martínez Galiano confirm that the work contained
in this paper is the author/s original work, the article has not
received prior publication and is not under consideration for
publication elsewhere. All authors have seen and approved the
manuscript being submitted. All authors agree to abide by the

8
G Model
WOMBI-1199; No. of Pages 9
J.M. Martínez-Galiano, S. Martinez-Vazquez, J. Rodríguez-Almagro et al.
copyright terms and conditions of Elsevier and the Australian
College of Midwives.
Ethical statement
The research involved the participation of human participants.
The participants signed the informed consent.
This study was approved by the Research Ethics Committee of
the province of Jaen with reference number TD-VCDEPP-2019/
1417-N-19. The ethical approval was received on the 31st October
2019.
Funding
This research has not received external funding.
Conflicts of interest
None declared.
CRediT authorship contribution statement
Juan Miguel Martínez-Galiano: Conceptualization, Methodol-
ogy, Writing - original draft, Writing - review & editing,
Supervision. Sergio Martinez-Vazquez: Conceptualization, Writ-
ing - review & editing. Julián Rodríguez-Almagro: Conceptuali-
zation, Writing - review & editing. Antonio Hernández-Martinez:
Conceptualization, Methodology, Formal analysis, Writing - review
& editing, Supervision.
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