There is no globally agreed definition of obstetric violence (OV), although some countries have passed legislation on the concept and provided a definition.1 In Catalonia (Spain), OV has recently been introduced into legislation as a type of violence against women and defined as preventing or hindering access to truthful information necessary for autonomous and informed decision-making. It can affect different areas of physical and mental health, including sexual and reproductive health, and can prevent or hinder women from making decisions about their sexual practices and preferences, and about their reproduction and the circumstances in which it is carried out.2 A recent literature review highlights the typologies of OV identified in the scientific literature, which include: verbal violence, physical violence, psychological violence, sexual violence, social discrimination, neglect of care, and inappropriate use of procedures and technologies.3 Prior studies highlight that more than 38% of women in Spain felt that they had experienced OV during childbirth and more than 54% felt insecure, vulnerable, guilty, incapable, or indifferent during childbirth, showing that Spain has a serious public health problem concerning OV.4,5 As structural, systemic and institutional violence, it can be recognised in all health-related systems,6 including home-based obstetric care.7 It is necessary to highlight that obstetric violence is a type of gender-based violence that is so normalised, invisibilised and denied at the professional and social level that it is still not considered violence against women.8

The Spanish health system is characterised by the fact that it is a public health system, which means that everyone who needs it can receive health care as a constitutional right. However, the Spanish healthcare management model allows for the coexistence of public and private healthcare centres. On the other hand, in 2003, the Law on Cohesion and Quality of the National Health System allowed for the political decentralisation of healthcare in the 17 Autonomous Communities into which the country is divided.9 It is worth noting that a national survey in Spain reported that 47.3% of respondents would choose private insurance for their own or a relative’s birth.10 Other studies have highlighted that the Spanish private health system tends to medicalise and intervene more during childbirth, and women perceive greater OV in private care.11

SARS-CoV-2 reached some health systems already affected by austerity.12 SARS-CoV-2 involved major changes and constant adaptations of care protocols during the different waves.13 A number of sources have reported on the possibility of increased OV during the SARS-CoV-2 pandemic.14,15 25.48% of births in Spain in 2020 were by caesarean section.16 These data seem to show a high level of unnecessary interventionism about which governments and professionals have previously expressed their concern.17 There have also been daily reports, particularly during the early months of the pandemic, of pregnant women being offered planned induction of labour for no apparent medical reason, as well as childbirth by caesarean section, being denied companionship during labour, being separated from their newborn, and having restrictions on breastfeeding.14,18 Sadler et al. have expressed growing concern that some of the restrictions and interventions that have been implemented in childbirth because of the SARS-CoV-2 outbreak are not necessary, are not based on scientific evidence, are disrespectful of human dignity, and are not proportionate to the need to curb the spread of the virus.14 Therefore, the aim of this study was to describe women’s perceptions of OV, medicalisation, and interventionism in childbirth in Spain during the SARS-CoV-2 pandemic.

A total of 6270 responses were obtained. Two hundred and ten (3.34%) questionnaires were eliminated for not including the childbirth date correctly or for stating a childbirth date outside of the pandemic. The final sample consisted of 6060 questionnaires.

SARS-CoV-2 and interventions during pregnancy, childbirth and postpartum

During pregnancy, 8.3% (n=500) of the sample reported feeling rejected or discriminated against for pandemic situation; 56.0% (n=3394) had insufficient face-to-face consultations with their midwife or gynaecologist; 85.2% (n=5165) could not go accompanied to ultrasounds or consultations, and 44.3% (n=2683) reported a lack of online antenatal education classes. 42.3% (n=2561) of the women were neither informed of the procedures they were undergoing nor explicitly asked for informed consent, or this was done only occasionally. 10.5% (n=635) said they were blamed for complications that arose during pregnancy or childbirth; 24.4% (n=1480) received ironic or disparaging remarks, and 25.5% (n=1544) were addressed using infantilising nicknames or diminutives. A total of 49.2% (n=2982) of the women stated that it was impossible for them to ask questions and express fears or concerns. The following variables displayed statistically significant differences depending on the maternal SARS-CoV-2 diagnosis: feeling rejected for suspected positive SARS-CoV-2 status (p<0.001), lack of online antenatal classes (p=0.007), information about the birth plan (p=0.041), provision of the birth plan (p=0.057), being accompanied during admission (p=0.007), and being encouraged to breastfeed (p=0.048) (Table 3 and Fig. 1).

Table 3.

Variables related to treatment and care received during pregnancy, childbirth and postpartum by maternal SARS-CoV-2 positive diagnosis.

	SARS-CoV-2 positive diagnosis								χ2	dfb	p-Value
	Total		No		During pregnancy		During childbirth
	n	%	n	%	n	%	n	%
Felt rejected or discriminated against due to suspected positive COVID-19 status
No	5560	91.7	5408	93.3	127	63.5	25	39.7	454.618	2	<0.001
Yes	500	8.3	389	6.7	73	36.5	38	60.3
Had insufficient face-to-face consultations with midwife or gynaecologist
No	2666	44.0	2544	43.9	95	47.5	27	42.9	1.059	2	0.589
Yes	3394	56.0	3253	56.1	105	52.5	36	57.1
Was accompanied to ultrasound scans or consultations
Yes	895	14.8	853	14.7	30	15.0	12	19.0	0.938	2	0.626
No	5165	85.2	4944	85.3	170	85.0	51	81.0
Lack of online antenatal classes
Yes	2683	44.3	2583	44.6	68	34.0	32	50.8	9.831	2	0.007
No	3377	55.7	3214	55.4	123	66.0	31	49.2
Received information about the procedures and was asked for informed consent in an explicit manner
Occasionally	1053	17.4	1015	17.5	31	15.5	7	11.1	3.450	4	0.486
No	1508	24.9	1435	24.8	57	28.5	16	25.4
Yes	3499	57.7	3347	57.7	112	56.0	40	63.5
Was blamed for complications
No	5313	87.7	5090	87.8	174	87.0	49	77.8	7.118	4	0.130
I do not know	112	1.8	107	1.8	4	2.0	1	1.6
Yes	635	10.5	600	10.4	22	11.0	13	20.6
Received ironic or disparaging remarks
No	4505	74.3	4319	74.5	145	72.5	41	65.1	3.462	4	0.484
I do not know	75	1.2	72	1.2	2	1.0	1	1.6
Yes	1480	24.4	1406	24.3	53	26.5	21	33.3
Was addressed with infantilising nicknames or diminutives
No	4042	66.7	3861	66.6	142	71.0	39	61.9	7.974	4	0.093
I do not know	474	7.8	453	7.8	11	5.5	10	15.9
Yes	1544	25.5	1483	25.6	47	23.5	14	22.2
Had difficulty in asking questions or expressing fears or concerns
No	2942	48.5	2821	48.7	97	48.5	24	38.1	6.396	4	0.171
I do not know	136	2.2	129	2.2	7	3.5	–	–
Yes	2982	49.2	2847	49.1	96	48.0	39	61.9
Received information about the birth plan and had her questions answered
No	2865	49.5	2737	49.5	96	50.3	32	50.8	9.995	4	0.041
NR/DKa	163	2.8	148	2.7	11	5.8	4	6.3
Yes	2759	47.7	2648	47.9	84	44.0	27	42.9
Handed in the birth plan
No	3912	67.6	3726	67.3	141	73.8	48	76.2	5.746	2	0.057
Yes	1875	32.4	1810	32.7	50	26.2	15	23.8
Was your birth plan respected? (n=1875)
No	890	47.5	862	47.6	21	42.0	7	46.7	0.621	2	0.733
Yes	985	52.5	948	52.4	29	58.0	8	53.3
24-h access to neonates
No	439	11.0	413	10.8	15	11.3	11	23.4	8.093	4	0.088
I do not know	3022	75.4	2889	75.5	101	75.9	32	68.1
Yes	546	13.6	525	13.7	17	12.8	4	8.5
Was allowed to be accompanied during admission
No	567	9.8	528	9.5	25	13.1	14	22.2	13.996	4	0.007
I do not know	29	0.5	28	0.5	1	0.5	–	–
Yes	5191	89.7	4977	90.0	165	86.4	49	77.8
Received support during postpartum
No	1590	27.5	1520	27.5	45	23.6	25	39.7	7.131	4	0.129
I do not know	246	4.3	238	4.3	7	3.7	1	1.6
Yes	3951	68.3	3775	68.2	139	72.8	37	58.7
Was encouraged to breastfeed
No	1819	32.5	1733	32.4	57	30.6	29	46.8	6.093	2	0.048
Yes	3783	67.5	3621	67.6	129	69.4	33	53.2

a

NR/DK: I do not know what a birth plan is.

b

Degrees of freedom.

Figure 1.

Treatment and care received during pregnancy, childbirth, and postpartum and SARS-CoV-2 positive diagnosis.

50% (n=3028) of the women received no information about the birth plan or were not aware of what it was. As a result, only 32.4% (n=1875) handed in their birth plan. Of these, 47.5% (n=890) reported that their birth plan was not respected. Support during maternity admission was allowed in 89.7% (n=5191) of the cases, with 68.3% (n=3951) of the women receiving support during the postpartum period and 32.5% (n=1819) reporting that they were not encouraged to breastfeed. 23.2% (n=1345) of the sample believed that unnecessary and/or harmful procedures were performed on her or her baby and 6.5% (n=374) were unable to identify them. Of all the variables listed in Table 4, only offering bottles without consent (p<0.001), preventing being accompanied (p<0.001), separating the healthy baby from the mother at birth (p=0.009), and having vaginal examinations performed by different individuals (p=0.021) yielded statistically significant differences when compared to having a positive SARS-CoV-2 diagnosis (Fig. 2).

Table 4.

Interventions during childbirth and feelings about maternal care and SARS-CoV-2 positive diagnosis.

	SARS-CoV-2 positive diagnosis								χ2	dfa	p-Value
	Total		No		During pregnancy		During childbirth
	n	%	n	%	n	%	n	%
Unnecessary and/or harmful procedures (n=6060)
No	4068	70.3	3887	70.3	139	72.8	42	66.7	1.076	4	0.898
I do not know	374	6.5	357	6.5	12	6.3	5	7.9
Yes	1345	23.2	1289	23.3	40	20.9	16	25.4
Kristeller manoeuvre (n=1719b)
Yes	506	29.5	488	19.7	15	28.8	3	14.3	2.307	2	0.306
No	1212	70.5	1157	70.3	37	71.2	18	85.7
Unjustified Caesarean section (n=511c)
Yes	118	23.1	109	22.2	7	43.8	2	40.0	4.848	2	0.089
No	393	79.6	381	77.8	9	56.3	3	60.0
My baby was bottle-fed without my consent (n=1719)
Yes	201	11.7	190	11.5	3	5.8	8	38.1	15.980	2	<0.001
No	1518	88.3	1456	88.5	49	94.2	13	61.9
Episiotomy (n=1208d)
Yes	505	41.8	482	41.7	13	36.1	10	62.5	3.302	2	0.192
No	703	58.2	674	58.3	23	63.9	6	37.5
Lack of information (n=1719b)
Yes	688	40.0	659	40.0	21	40.4	8	38.1	0.035	2	0.982
No	1031	60.0	987	60.0	31	59.6	13	61.9
Restricted eating and drinking during childbirth (n=1719b)
Yes	591	34.4	567	34.4	15	28.8	9	42.9	1.378	2	0.502
No	1128	65.6	1079	65.6	37	71.2	12	57.1
No company allowed (n=1719b)
Yes	296	17.2	275	16.7	10	19.2	11	52.4	18.662	2	<0.001
No	1423	82.8	1371	83.3	42	80.8	10	47.6
I was not allowed to move freely (n=1719b)
Yes	623	36.8	613	37.2	12	23.1	7	33.3	4.458	2	0.108
No	1087	63.2	1033	62.8	40	76.9	14	66.7
Unjustified induced labour (n=1208d)
Yes	186	15.4	180	15.6	4	11.1	2	12.5	0.638	2	0.727
No	1022	84.6	976	84.4	32	88.9	14	87.5
Hamilton manoeuvre (n=1719b)
Yes	317	18.4	305	18.5	7	13.5	5	23.8	1.268	2	0.530
No	1402	81.6	1341	81.5	45	86.5	16	76.2
I gave birth with a mask on (n=1719b)
Yes	916	53.3	877	53.3	31	59.6	8	38.1	2.784	2	0.249
No	803	46.7	769	46.7	21	40.4	13	61.9
Early umbilical cord clamping (n=1719b)
Yes	413	24.0	394	23.9	16	30.8	3	14.3	2.394	2	0.302
No	1306	76.0	1252	76.1	36	69.2	18	85.7
I had my pubic hair shaved (n=1719b)
Yes	55	3.2	51	3.1	3	5.8	1	4.8	1.329	2	0.515
No	1664	96.8	1595	96.9	49	94.2	20	95.2
I had my amniotic sac ruptured to speed up childbirth (n=1719b)
Yes	574	33.4	548	33.3	20	38.5	6	28.6	0.828	2	0.661
No	1145	66.6	1098	66.7	32	61.5	15	71.4
I was separated from my healthy baby at birth (n=1719b)
Yes	435	25.3	421	25.6	6	11.5	8	38.1	7.096	2	0.029
No	1284	74.4	1225	74.4	46	88.5	13	61.9
I had closely followed vaginal examinations performed by different individuals (n=1719b)
Yes	590	34.3	576	35.0	10	19.2	4	19.0	7.575	2	0.021
No	1129	65.7	1070	65.0	42	80.8	17	81.0
Use of synthetic oxytocin (n=1719b)
Yes	675	39.3	650	39.5	17	32.7	8	37.1	0.989	2	0.610
No	1044	60.7	996	60.5	35	67.3	13	61.9
Use of vacuum cup or forceps (n=1208d)
Yes	346	28.6	331	28.6	11	30.6	4	25.0	0.168	2	0.919
No	862	71.4	825	71.4	25	69.4	12	75.0
Other interventions that I consider unnecessary (n=1719b)
Yes	261	15.2	253	15.4	5	9.3	3	14.3	1.310	2	0.519
No	1458	84.8	1393	84.6	47	90.4	18	85.7
During pregnancy or childbirth: anxiety
No	4269	70.4	4086	70.5	139	69.5	44	69.8	0.101	2	0.951
Yes	1791	29.6	1711	29.5	61	30.5	19	30.2
During pregnancy or childbirth: insecurity
No	2672	44.1	2551	44.0	98	49.0	23	36.5	3.442	2	0.179
Yes	3388	55.9	3246	56.0	102	51.0	40	63.5
During pregnancy or childbirth: anger
No	3544	58.5	3392	58.5	117	58.5	35	55.6	0.225	2	0.894
Yes	2516	41.5	2405	41.5	83	41.5	28	44.4
During pregnancy or childbirth: lack of support
No	2158	35.6	2073	35.8	69	34.5	16	25.4	3.030	2	0.220
Yes	3902	64.4	3724	64.2	131	65.5	47	74.6
During pregnancy or childbirth: indifference
No	5235	86.4	5003	86.3	172	86.0	60	95.2	4.257	2	0.119
Yes	825	13.6	794	13.7	28	14.0	3	4.8
Generally speaking, the attention received made me feel:
Empowered	2193	36.2	2102	36.3	80	40.0	11	17.5	30.216	8	<0.001
Angry and indignant	667	11.0	622	10.7	27	13.5	18	28.6
Indifferent	768	12.7	735	12.7	26	13.0	7	11.1
Vulnerable, guilty, and incapable	1570	25.9	1506	26.0	48	24.0	16	25.4
Other	862	14.2	832	14.4	19	9.5	11	17.5

a

Degrees of freedom.

b

Sample of women who responded “yes” plus “do not know” to unnecessary and/or harmful procedures.

c

Sample of women who responded that they had had a caesarean section as a type of childbirth (n=1309) and who perceived caesarean section as an unnecessary procedure (n=511, 39.04%).

d

Sample of women who reported having had a vaginal or instrumental childbirth (n=4751) and who perceived episiotomy as an unnecessary procedure (n=1208, 25.43%).

Figure 2.

Interventions during labour and SARS-CoV-2 positive diagnosis.

Feelings related to the health care received

The health care received during pregnancy caused feelings of lack of support (64.4%, n=3902), insecurity (55.9%, n=3388), anger (41.5%, n=2516), and anxiety (26.9%, n=1791). Overall, only 36.2% (n=2193) of the women felt empowered by the health care they received. Women with a positive SARS-CoV-2 diagnosis during pregnancy vs during childbirth felt empowered (40%, n=80 vs 17.5%, n=11); angry and indignant (13.5%, n=27 vs 28.6%, n=18); indifferent (13%, n=26 vs 11.1%, n=7); vulnerable, guilty, or incapable (24.0%, n=48 vs 25.4%, n=16), respectively (χ2=30.216, df=8, p<0.001) (Table 4 and Fig. 3).

Figure 3.

Feelings linked to health care and SARS-CoV-2 positive diagnosis.

This study provides data on the care women received during childbirth in the first waves of the SARS-CoV-2 pandemic in Spain and the feelings they had about it. The women revealed that many of the measures adopted by the Spain government to control the pandemic during pregnancy and childbirth seemed arbitrary and ineffective. Women who tested positive for SARS-CoV-2 during childbirth felt rejected or discriminated against and were less encouraged to breastfeed. Being SARS-CoV-2 positive during childbirth also increased the likelihood that babies would be separated from their mothers, babies would be given bottles of formula, and women would be alone during labour. Women who tested positive for SARS-CoV-2 during childbirth felt less empowered and angrier and more indignant than the rest of the sample. In contrast, early umbilical cord clamping, closely followed vaginal examinations, and the use of vacuum cup or forceps occurred less frequently among SARS-CoV-2 positive women at the time of childbirth. One third of the sample reported OV.

The results of this study seem to be in line with the changes that have occurred in the adaptation of health services to the SARS-CoV-2 pandemic worldwide, especially with the changes occurring in Europe.19 European countries changed in the reassignment of maternity centres and in the rules of use, for example, restricting access to the companion. Other changes that occurred were the sudden change in care (by phone or online), which in Spain had more variability where some hospitals went to telephone consultations and other clinics continued with face-to-face care.19 All of these changes have raised concerns about women’s rights. In this study more than two thirds of women felt that institutions did not support their rights and that governments issued non-evidence-based protocols and arbitrary measures. A study of obstetric professionals in the Netherlands concurred with this view.20 Future studies should explore this interesting question further in Spain. The truth is that the great challenge posed by the pandemic to health systems meant that their response may have been at times marked by very palpable discrepancies both within the same organisation and internationally.21,22 In this context, discrepancies are understood as a lack of consensus on how two or more health professionals should act on the same problem. These discrepancies and constantly changing protocols for health care may have resulted in many women receiving conflicting recommendations. No previously published studies have been found to compare these results, although the results seem to represent the experience of women. This finding may constitute an important line of future research.

In the present study, women who were SARS-CoV-2 positive during childbirth felt more rejection and discrimination in health care as well as less empowered, in line with the results of other studies.23 It is important to note that women in this study reported receiving more ironic or disparaging comments; having more difficulty, fear and uneasiness to ask questions; and being blamed more for obstetric complications if they were SARS-CoV-2 positive during childbirth. The studies published on Spain to date do not consider these variables. The literature suggests that experiencing one or more episodes of discrimination in health care may be associated with higher levels of post-traumatic stress.23,24 Future studies could verify this relationship in women who have given birth during the pandemic.

In many European countries, online antenatal sessions and online clinical follow-ups seemed to be more adaptable19 than in Spain. As other studies indicate, the lack of online sessions may also be linked to feelings of desolation, anxiety, anger, and insecurity.25,26 In terms of interventions, it is well known that providing support at this stage of a woman’s reproductive life is crucial.27 We strongly agree with other authors that providing support has become even more important in this time of uncertainty and fear caused by SARS-CoV-2,26 with most of the women in the sample being denied support and twice as many women in Spain being deprived of it if the SARS-CoV-2 test result at birth was positive, according to the data in this study. Although some restraint may have been positive for mother and baby.28

Although breastfeeding is widely supported by the scientific literature in women with SARS-CoV-2,21,29 one third of the women in this study and almost half of the women who tested positive for SARS-CoV-2 at childbirth reported that they were not encouraged to breastfeed. In addition, three times as many babies of SARS-CoV-2 positive women were given bottles without the mother’s consent and were separated from their mothers at birth, practices that are not advised by scientific evidence, which compels policy makers to do some serious thinking.21,30 Interestingly, interventions that require very close contact with the woman, such as closely followed vaginal examinations, occurred less frequently in SARS-CoV-2 positive women. This may be linked to healthcare providers’ own fear of becoming infected,31,32 although further studies are need to confirm this.

Finally, the figures for OV as perceived by women throughout the world have been reflected in the pre-pandemic literature. In Spain, 38% of women identified themselves as victims of prior obstetric violence.4 Similar findings for maternal perception of OV were obtained in the present study. Most women feel that this violence is not justified by the pandemic context. These results directly contradict the assumptions that SARS-CoV-2 is a risk factor for the increase in OV,14 since it seems that OV is deeply rooted in the Spanish health system, constituting a major public health problem that needs to be addressed, according to the perception of its female users.4

This study highlights the arbitrariness and ineffectiveness of government measures on delivery care during the SARS-CoV-2 pandemic, pointing to the need for evaluation and adjustment for a more effective approach. SARS-CoV-2 positive women experienced discrimination and rejection, highlighting the importance of policies that ensure equitable and compassionate treatment. The adaptation of health services raised concerns about women’s rights. In addition, the gap in online antenatal education, promotion of breastfeeding and personalised care are crucial areas to address. The persistence of OV underlines the need for concrete measures. Despite methodological limitations, these findings provide an essential basis for improving crisis childbirth care, ensuring policies focused on women’s needs and rights.

It is important to clarify that some methodological aspects of the study may limit the internal and external validity of these results. In particular, this is a cross-sectional study based on the opinion and perception of the participants, which means that information biases may be present. An information bias may have existed because people can respond freely. In addition, sampling was non-randomised and, in 2020, 341,315 births took place in Spain according to data from the National Institute of Statistics,16 so the sample may not be representative of the study population. Furthermore, there was a possibility of selection bias, as the questionnaire was distributed to groups that may be more sensitive to the subject matter of the study. On the other hand, data collection can also be considered a limitation, as it was done with a self-administered online questionnaire. This type of sampling as well as data collection may have shown a lack of racial diversity among the results, and therefore could not be analysed. It is important to note that although the incidence of SARS-CoV-2 diagnosis was not an objective of the present study, it is possible that there is a sample selection bias in considering SARS-CoV-2 positive women and neonates regardless of their medical history. For this reason, it has not been possible to analyse SARS-CoV-2 positive or negative diagnosis during pregnancy vs. during birth (in 4 arms). Another noteworthy consideration is that asking women about obstetric interventions refers to obtaining informed consent and how they felt about the interventions performed, not the appropriateness of the obstetric intervention. Despite these limitations, we believe that the results of this study are relevant for patients, professionals, managers, researchers, and policy makers, as they offer insights on the quality of childbirth care in a situation of crisis caused by an infectious disease, a situation that could happen again. In addition, hypotheses are derived from this study that will need analytical studies to confirm them. These studies may link women’s post-traumatic stress to childbirth interventions received during a pandemic or health providers’ fears caused by caring for women during childbirth to their potential consequences on the change of care. Finally, we believe that the differences in treatment and procedures identified between women with and without SARS-CoV-2 can help to improve care protocols and policies related to the protection of women.

As general conclusions of this study, the SARS-CoV-2 pandemic forced major changes in the healthcare system worldwide. Pregnant women and childbirth were not exempt from the impact of these changes. Thus, the results of this study suggest that one in three women perceived OV in their obstetric care. Furthermore, women perceived that many of the obstetric measures taken in Spain to control were arbitrary and unfair. In addition, women who tested positive for SARS-CoV-2 during childbirth felt rejected or discriminated against and were less encouraged to breastfeed. Testing positive for SARS-CoV-2 during childbirth also increased the likelihood of babies being separated from their mothers, babies being given bottles of formula, and women being left alone during the birth process. Women who tested positive for SARS-CoV-2 during childbirth felt less empowered and angrier and more indignant than the rest of the sample. In contrast, early umbilical cord clamping, closely followed vaginal examinations, and the use of vacuum cup forceps occurred less frequently when the mother tested positive for SARS-CoV-2 at the time of childbirth. One third of the sample reported experiencing OV. Understanding these experiences of pregnancy, childbirth, and postpartum care during a pandemic provides an opportunity to develop specific policies for the protection of women in future health crises.

This study received ethical approval from the Universitat Jaume I (CD/06/2021). The first question of the online survey asked women to confirm their consent to participate in the study.

Not funding.