Obstetric Violence: A Conceptual Analysis in the Nursing Context

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Theme: Epistemology
Contribution to the subject: A conceptual analysis of phenomena found in the professional practice that contributes to advancing Nursing as a science and profession. Analyzing the concept of "Obstetric violence" assists in clarifying the phenomenon, as it treats it in detail, identifying its essential attributes, antecedents, and consequents in the Nursing context. Discussion of the theme is relevant so that Nursing professionals have subsidies to identify the cases, ensure better bonds with the patients, promote humanized, standardized, and good quality assistance, and guarantee women a dignified and safe service. In addition, it provides information and solves doubts about the theme and their rights because there is an evident need for changes in these professionals' training and qualification in terms of the absence of procedures based on scientific evidence.

Introduction
The obstetric violence (OV) phenomenon has several titles, such as violence during labor, cruel treatment during delivery, disrespect and abuse, institutional violence, and violence in cases of abortion and post-abortion, among others (1). The concept's framework is not only found in the medical area but also in human rights and in other health professions. Such significant complexity generates semantic and conceptual discussions (2).
Although a complex phenomenon, it is understood OV relates to the acts of violence committed during prenatal care, at delivery, in postpartum, and during the puerperium, in which there is disrespect for women's physical integrity and mental health, as well as loss of autonomy in terms of choices, feelings, or both (3). Since 2014, the World Health Organization (WHO) has considered OV a public health problem directly affecting women and newborns (4).
Corroborating the WHO statement, a study carried out with 409 puerperal women at a specialized comprehensive hospital in the Amhara region, northwestern Ethiopia, evidenced that three out of four (75.1 %) women reported having suffered at least one type of OV during labor and delivery. The OV types were as follows: non-consensual care -260 women (63.6 %); undignified care -226 women (55.3 %); physical abuse -192 women (46.9 %); non-confidential care -132 women (32.3 %); neglected care -52 women (12.7 %), and discriminated care -38 women (9.3 %) (5). It is noted that these numbers can be significantly higher due to women's lack of understanding to identify the acts of violence, which leads to the underreporting of cases.
The need for changes in care during pre-delivery, delivery, and birth, as well as professional training regarding the phenomenon, are essential to combat, minimize, or eradicate OV, an increasingly growing action (3).
As essential players in a woman's prenatal, delivery, and puerperium care, nurses should guarantee comprehensive care, emotional support, commitment to health, and exchange of knowledge and experiences, in addition to having scientific knowledge focused on the needs of each pregnant woman and evidence-based practices. To promote qualified, humanized, welcoming, and systematized assistance, it is indispensable to understand the OV phenomenon (6).
Knowledge about the concept of OV needs to be expanded and improved, considering that there is no precise definition in the scientific field (7), only complementary definitions, which makes it difficult to advance the knowledge of this phenomenon and its application.
Despite the high recurrence of the phenomenon, no studies indicate its antecedents, attributes, and consequents, which hinders the professionals' understanding, with the possibility of triggering consequences in the clinical practice (7). Thus, it becomes indispensable to clarify the concept.
That said, the study presents the following guiding question: What are the essential attributes, antecedents, and consequents to determine the concept of OV in the Nursing context? In search of answers to the question, the study aims at identifying the essential attributes, antecedents, and consequents to determine the concept of OV in the Nursing context.

Materials and Methods
This conceptual analysis followed the method proposed by the Walker and Avant model (8), which consists of eight sequential or simultaneous stages. Six stages were used in this study, as they specifically contemplated the study object, with no need to build a model case or additional cases. Each stage is described below. l First stage: Selection of the concept -A concept that is important and useful to deepen the theoretical developments in the area of interest should be chosen.
l Second stage: Delimitation of the analysis objectives -In this stage, the researchers should define the analysis scope (8).
l Third stage: Identification of different uses of the concept in the literature -A broad literature review is done using dictionaries, thesaurus, available literature, and even friends and colleagues, identifying as many uses of the concept as possible. In this initial phase, the analysis is not restricted to a single concept aspect. There is the possibility of considering all uses of the term in question. The authors indicate that it is necessary not to limit the research merely to the medical or nursing literature, as this can influence their understanding of the true nature of the concept (8).
l Forth stage: Determination of the essential attributes -In this phase, the researchers must determine the attributes, which are words or expressions that characterize the phenomenon. In other words, they are the defining characteristics that express the phenomenon's essence (8).
l Fifth stage: Identification of the concept's antecedents and consequents -They are useful to further refine the attributes. The authors define 'antecedents' as events or incidents that must occur or be present before the occurrence of the concept and 'consequents' as events or incidents resulting from the occurrence of the concept. In other words, the results of the concept (8). this concept or determine its existence in the real world. They are categories or classes of observable phenomena that show the occurrence of the concept using an operational definition (8).
In the first stage, the OV concept was selected considering the relevance in the professional practice and research of the authors of this study who investigate violence and vulnerability. The second stage is in line with the research objective.
The third, fourth, fifth, and sixth stages were developed simultaneously. In the third stage -Identification of the different uses of the concept in the literature, a systematic scoping literature review was carried out, as proposed by the recommendations outlined in the Joanna Briggs Institute Reviewer's Manual (JBI [9]) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist (PRISMA-ScR [10]). The review was registered in the Open Science Framework (OSF) platform at https://osf.io/682fr/.
The research question -What are the essential attributes, antecedents, and consequents to determine the concept of OV in the Nursing context?-was determined through the PCC mnemonic, in which 'P' refers to participants (pregnant, parturient, and postpartum women). The first 'C' refers to the concept (OV, attributes, antecedents, and consequences) and the second one to the context (Nursing), following the PRISMA-ScR recommendations (10).
As for the eligibility criteria, all types of studies related to pregnant, parturient, and puerperal women addressed the theme of OV. Its attributes, antecedents, and consequents linked to the Nursing area were included. In addition, studies of any nature, available in full without a time frame and in any language, were considered, excluding duplicates indexed in more than one database.
The search followed the recommendations proposed by the JBI (9) through three stages: the first corresponds to the initial search, developed in the Theses and Dissertations Catalog of Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), using the following health descriptors (DeCS): gestantes (pregnant women), parto (parturition), período pós-parto (postpartum period), violência (violence), and enfermagem (nursing) with crossings using the OR and AND Boolean operators.
Subsequently, in the third stage, which consists of the list of references, the bibliographic references were analyzed and selected to choose the documents to be included and excluded from the study, as well as incorporating additional information.
The selection of the relevant documents was carried out by two reviewers in a paired, thorough, and independent manner. Initially, the titles and abstracts were read, excluding those papers that were incomplete or did not answer the questions established. Subsequently, the studies selected were read in full, excluding those that did not substantially portray the concept, antecedents, attributes, and consequences of OV in the Nursing context.
Any and all divergences between the reviewers were discussed to reach a consensus, considering the study eligibility criteria and methodological rigor. The selection of the corresponding words in the databases resulted in 22 final articles according to the respective crossing strategy ( Figure 1). After selecting the studies included to comprise the sample, the extracted data were analyzed according to the stages of determining the essential attributes, identifying the antecedents and consequents of the concept, and defining the empirical references of it. The essential antecedents and consequents were critically analyzed and distributed according to what was addressed in the articles. The attributes were classified according to the OV typification.
Only in the last stage the OV concept was extracted from the manuscripts and transformed into a textual corpus for processing and analysis in the R Interface pour les Analyzes Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ) software. This program clearly structures the distribution of the vocabulary. By employing the similarity analysis, the results indicate the connection between the words, also distinguishing the common parts and the specificities, resulting in a maximum tree (11). Consequently, it was possible to observe the terms that operationally define the concept of OV. It is worth noting that, as it is a review, it was not necessary to submit this study to any research ethics committee.
The antecedents related to OV were organized (    The main OV consequences found in the literature were organized (Table 4). It was observed that the interventions performed caused significant physical and psychological sequelae for women's life and marital and maternal relationships, as well as traumas. In addition, they had consequences for the newborns, which could lead to their death. The following stand out among the consequents: 'maternal and child morbidity and mortality,' 'loss of the woman's autonomy at delivery,' 'emotional and psychological harms,' and 'physical harms.'

Discussion
The expressions or terms presented using the similarity analysis evidence that the phenomenon can occur during prenatal care, delivery, the puerperium, in case of abortion, and when there are violations of the woman's human rights and integrity, loss of autonomy and decision-making. The findings of this research point to empirical indicators that operationally define the concept of OV, which contributes to clarifying the phenomenon and providing theoretical support for nurses to timely identify the occurrence and intervene appropriately.
The category of the antecedents identifies that, for the occurrence of OV, several factors involved are related not only to the woman but to the entire pregnancy-puerperal process. The following stand out, unfavorable financial conditions, skin color, schooling level, lack of knowledge about the theme, inadequate infrastructure, precariousness in terms of materials and resources, and unqualified professionals.
In a study carried out with nine low-income and black-skinned women in northeastern Brazil, physical, verbal, and institutional OV instances were reported. There were practically no reports of respect | for women during delivery and minimal obstetric interventions (2). The greater a woman's vulnerability, the ruder and more derogatory the treatment she was offered (35). Secondly, adolescents (12,15,20,30), sex workers (30), drug users (30), homeless women (30), homosexuals (15,32), and inmates (15,30) are more prone to negligence and omission of care (30).
A research study conducted with Chilean women evidenced that those with low schooling levels, minors, homosexuals, and indigenous reported more OV cases, mainly those treated in the public health system (36).
Lack of knowledge about the theme (15-18, 22, 25, 26, 28, 31, 32) was a significant finding of an OV antecedent. A study conducted in India with 305 women identified that 257 suffered some disrespect and abuse; of this total, 89.1 % answered "no" when asked about any treatment they considered humiliating. This reveals that this type of violence is seen as something normal when knowledge is inadequate (37).
However, when understanding the act, the answers were notably different, as revealed by a survey carried out in Spain, in which 17,541 questionnaires were delivered, 38.3 % realized that they had suffered OV and 44.4 % perceived that they were subjected to unnecessary or painful procedures, of which 83.4 % were not asked for their due informed consent (7).
Naturalization and perpetuation of the practices (12,15,17,(24)(25)(26), an OV antecedent, such as pain related to delivery (38), is also associated with a lack of knowledge on the topic. It is believed that delivery is a painful process, naturalizing the unfavorable situations experienced by the women and not recognizing some procedures as violence but common and routine situations (39).
Knowledge about the body and the physiology of delivery favors the reduction of vulnerability, the fight against OV and women's empowerment, ensuring their rights and autonomy and counteracting abusive actions performed by professionals.
The professionals' inability to offer qualified assistance, which allows for predicting violence and intervening, reflects a society that has always naturalized violent behaviors and procedures as non-violent. In addition, the professional-user hierarchy, with unilateral authority, tends to lead professionals to verbalize and perform violent techniques or both without noticing that they are, in fact, violent (41). Therefore, it is fundamental that professionals know the OV antecedents, attributes, and consequents to provide good quality care throughout the pregnancy-puerperal process.
The attributes, which are essential characteristics of the phenomenon, were grouped according to the type of violence into physical, psychological or emotional, institutional, sexual, and structural, which allowed for a better understanding of OV.
These attributes are mentioned in several interviews with women in maternity hospitals in the Czech Republic (42). In another research study carried out in a hospital in Azuay, Ecuador, the women also reported these attributes they characterized as types of physical violence (43). These studies corroborate the results found in the current one, validating the essence of the phenomenon.
Some women point out another perception about the Kristeller maneuver and oxytocin administration. In a research study carried out with 57 puerperal women in the central area of the Huasteca region of San Luis Potosí, Mexico, it was reported that these procedures are an act of gratitude towards the mothers at delivery, as they help the infant to descend more quickly and minimize moments of prolonged suffering (44).
However, when episiotomy and episiorrhaphy were mentioned (44), the women's reports of actually feeling OV were unanimous, mainly in cases where they were not informed. This agreement is observed in several pieces of scientific evidence (16,43,44).
Physical violence is more prevalent because it is more easily identifiable among women, as shown by a research study carried out at a public hospital in North Shewa, Amhara, Ethiopia. It was pointed out that 100 % (435) of the women identified some of these attributes that characterize OV related to physical characteristics (45).
The harms caused by psychological OV go beyond the physical aspect, leaving emotional and psychological scars for a long time, undermining the emotional realm and bringing about consequences that negatively interfere with the puerperal period, a delicate moment for puerperal women (46). It should be noted that these problems can lead to postpartum depression (47).
In an analysis of the notifications of pregnant women in Brazil between 2011 and 2018, with 2,033,026 cases, the type of violence with the highest incidence was physical (61.9 %), followed by psychological (31.2 %) and lastly, sexual (27 % [48]).
The incidence of reports that mention the essential characteristics of the phenomenon, that is, the attributes, is considerably high.
A multicenter survey carried out in the United States with 2,138 women indicates that one out of six (17.3 %) mentions some type of abuse, such as yelling, disrespect, unknown or erroneous information, denial of care, embarrassment, and loss of decision-making autonomy. It is believed that more women have suffered psychological violence, although they could not identify it (49).
From the institutional category perspective, the attribute with the highest incidence was not allowing the presence of a companion (12, 14, 15, 17, 23-26, 28, 29, 32, 33). Brazilian women are supported by the Companion Law (Law 11,108) of April 7 th , 2005, which allows for the presence of a companion during delivery, childbirth, and the immediate postpartum period, either in private or public health services (50).
Although supported by law, qualitative studies (51, 52) still notice reports of Brazilian women who claimed they were not allowed to have a companion and accepted so due to lack of information, even with distress.
Repeatedly touching the vagina can cause harm, such as inciting premature birth and infection in the infant (53) and inducing pain and discomfort. In a study, Mexican women mentioned that they feel unnecessarily invaded in their privacy and exposed, with several touches practically at the same time, reporting that there seems to be no communication between the health professionals (44).
A shocking report in a research study conducted in northern Brazil reveals that the health professional performed the vaginal touch examination and asked all the students present to repeat the procedure, causing discomfort, invasion of privacy and exposure of the woman's intimacy (53). This scenario proves to be totally inhuman to the woman.
That is a reality not only in Brazil but also in other countries, such as Iran, where the prevalence of sexual OV stands out in relation to the other types. This assertion is indicated in a study conducted with 725 women, in which 14.8 % suffered sexual violence, 9.9 % were victims of psychological violence, and 6.5 % of physical violence. Domestic sexual abuse was also very evident (48).
Finally, the structural OV attributes refer to precarious assistance or omission to the detriment of the infrastructure (18), lack of human and material resources (18), lack of beds (18), imposition of institutional routines (18) and shortage of professionals (12). This is more likely to occur in public institutions before the woman's hospitalization, affecting both her and the professionals, which entails overload and undignified working conditions (18).
These attributes are proven through diverse evidence in practice. During data collection, nurse-researchers noticed a deficit in terms of equipment and a lack of necessary maintenance, especially in the public sector, in addition to communication difficulties between professionals and the absence of adequate signs in the environment (14).
In the category of the OV phenomenon consequents, resulting events or incidents were detected, such as loss of women's autonomy, emotional and psychological harms, and maternal and child morbidity and mortality.
When a woman loses her autonomy during delivery (15-17, 23-26, 29, 32), her primary role is obliterated, in addition to her decision-making power. For this gap, it is recommended that women look for a support network during prenatal care to acquire knowledge (54 The formation of groups of pregnant women in southern Brazil showed that those who regularly participated in the meetings were able to enjoy significant autonomy and were willing to argue and impose their wishes, showing greater awareness of the delivery moment (55).
These terms corroborate a research study conducted in northeastern Brazil, in which the puerperal women mentioned having suffered emotional and psychological consequences, resulting in frustration, anger, anguish, and impotence. In the interviews, it is possible to see hints of postpartum depression and trauma after the episiotomy procedure. Consequently, the same women reported that these problems affected their sex lives (52).
Procedures considered routine and standardized in health services, without indication, can cause or intensify pain (15,26,27,32), physical harm (12, 14, 26-28, 30, 32), and unnecessary suffering. In view of this, the importance of dialogue between professionals, especially nurses, and pregnant women is emphasized, in addition to providing fundamental information about the pregnancy-puerperal process and encouraging self-knowledge about their bodies, role, and decision-making power (57).
An important OV consequence is maternal and child morbidity and mortality (13-17, 19, 25, 26, 28, 30) during labor and the puerperium, mainly due to cesarean sections without indication, which intensifies the likelihood of respiratory problems for the newborn (15) and triples the mother's mortality risk, in addition to the possibility of also causing loss of the uterus (27).
OV can lead to maternal morbidity and mortality due to several factors, such as adverse events related to aggressive management of vaginal and cesarean deliveries, neglect to perceive the suffering experienced by the woman, hostility, negligence, and delay in assisting women who are having an abortion -spontaneous or desired-and not allowing the presence of a companion (51).
Finally, it is crucial that nurses are aware of the OV phenomenon and duly trained and able to identify it and intervene in a timely manner, offering humanized, comprehensive, empathetic, and qualified assistance.
It is believed that this concept analysis contributes to Nursing science, research, and clinical practice, considering that it provides scientific support with a deep discussion of the phenomenon, presenting the OV antecedents, attributes, and consequents in detail. This enables nurses to recognize the empirical indicators of the concept; thus, it is likely that they will have a greater knowledge that will lead them to more precise Nursing care in the clinical practice.
As a limitation, we cite non-elaboration of the model case and additional cases; however, there was an in-depth analysis of empirical bases and compliance with methodological rigor.

Conclusions
In this research, it was possible to analyze the OV concept, identifying 76 related attributes, 31 antecedents, and 39 consequents. The study made it possible to contribute greater clarity to the phenomenon, offering theoretical and scientific support for nurses to identify OV cases and contributing to the evolution of Nursing epistemology.
The multidimensionality of the topic studied was comprehensively observed, as it presents several typifications, each with their respective essential characteristics, in addition to their multiple antecedents and consequents in the scenario of OV during the pregnancy-puerperal period.