Mothers have voice and they produce data on obstetric violence in Italy
Elena Skoko and Alessandra Battisti
Osservatorio sulla Violenza Ostetrica Italia (OVOItalia), Rome, 2017
Elena Skoko and Alessandra Battisti. “Mothers have voice and they produce data on obstetric violence in Italy”. Rome: Osservatorio sulla Violenza Ostetrica Italia (OVOItalia), 2017. Available from: https://ovoitalia.wordpress.com/english-info/.
FIRST NATIONAL SURVEY ON OBSTETRIC VIOLENCE IN ITALY DOXA-OVOIT
IN THE LAST 14 YEARS, AT LEAST ONE MILLION MOTHERS IN ITALY HAVE EXPERIENCED OBSTETRIC VIOLENCE DURING LABOUR AND BIRTH
20.000 NEWBORNS MISSING EVERY YEAR BECAUSE OF THE POOR ASSISTANCE WOMEN RECEIVED DURING THEIR FIRST EXPERIENCE OF CHILDBIRTH
According to the first national survey conducted by Doxa Institute, and commissioned by the Obstetric Violence Observatory in Italy, La Goccia Magica and CiaoLapo, 21% of mothers with children from 0 to 14 years, declared that they have experienced obstetric violence during the birth of their first child.
While childbirth is expected to be the most exciting event in a woman’s life, 4 mothers out of 10 affirm that they have been subjected to practices that undermined their personal dignity and integrity.
Episiotomy “by deceit” (without informed consent) for 1,6 million women, a practice that the WHO considers unnecessary, except on rare occasions.
The continuation of the social media campaign #bastatacere (“break the silence”) that last year gave voice to mothers against abuse in childbirth, and in favour of the law proposal that introduces obstetric violence as a criminal offence.
One million mothers in Italy (21% of the total) have suffered various degrees of obstetric violence in their first experience of motherhood – reveals the Doxa survey. For 6% of women in the last 14 years the trauma was so harsh so to make them renounce having more children, a choice that translates roughly in 20.000 children not being born every year.
Staggering and alarming data emerged for the first time from the national opinion survey “Women and Childbirth”, on the yet unexplored phenomenon of “obstetric violence”: the appropriation of the body and reproductive processes of women by health personnel during pregnancy, childbirth and post-partum.
The survey, commissioned by the Obstetric Violence Observatory in Italy (OVOItalia, founded in 2016 by Elena Skoko and Alessandra Battisti), was conducted by Doxa – the first Italian market research company, founded in 1946. The survey was financed by national civil associations La Goccia Magica e CiaoLapo. The results of the survey were presented at the press conference in September 20th, 2017, in Rome, Palazzo delle Esposizioni, with the attendance of the member of the Parliament Adriano Zaccagnini and senator Maurizio Romani. The initiative is the extension of the social media campaign “#Bastatacere: mothers have voice” that in 2016 put for the first time under the national spotlight the hidden phenomenon of abuse and disrespect in childbirth in hospital facilities, as framed by the WHO, advocating for a respectful maternity care on a national level.
The Doxa survey “Women and Childbirth” was conducted on a sample (424) representative of nearly 5 million women in Italy, aged 18-54, with at least one child 0-14 years, and it analysed – from the users’ perspective – several aspects and moments of maternity assistance during labour and birth: from the relationship with the health care providers to the type of interventions, from the communication by caregivers to informed consent, from the role of childbearing women in the process of decision making to the respect of personal dignity.
The survey revealed that for 4 women out of 10 (41%) the assistance provided at birth was in some ways violating their dignity and psychophysical integrity. The most negative experience during birth was the practice of episiotomy, suffered by over half (54%) of the interviewees. Once considered as helpful for facilitating the expulsion of the newborn, today, the World Health Organization (WHO) describes it as unnecessary, except on rare occasions. The episiotomy is a surgical intervention in the muscular area between the vagina and the anus made just before delivery to enlarge a vaginal opening. Comparing to the spontaneous tearing that may occur during childbirth, this operation requires a longer recovery time and it carries the risks of infection and haemorrhage.
“From the stories that many women shared with us – explains Elena Skoko, the founder and spokesperson of the Obstetric Violence Observatory Italy (OVOItalia) – we were aware of the fact that for many of them the maternity assistance at birth was a traumatic experience. For this reason, last year we launched the social media campaign #bastatacere. In order to understand the extent of the phenomenon: there were so many women who responded in such a short time frame that the campaign went viral. We decided to launch the Obstetric Violence Observatory in our country in order to define the extent of a phenomenon that is still submerged, yet those who experienced it wear the scars for the rest of their lives, renouncing even to have more children. Now, with the data, we know that the phenomenon is much wider than we though.”
EPISIOTOMY WITHOUT CONSENT FOR 1,6 MILLION CHILDBEARING WOMEN IN ITALY
In Italy, in the last 14 years, 3 women out of 10 – the equivalent of 1,6 million women (61% of the ones that received episiotomy) – declare that they did not give their informed consent to the intervention.
According to the results of the survey, the practice of episiotomy appears to be extensive inside Italian maternity wards: one woman out of 2 was subjected to it (54%). For 15% of women that underwent the procedure, about 400.000 mothers, it was perceived as a genital mutilation, while 13% of mothers, about 350.000, felt deceived by medical personnel: if at the beginning they thought episiotomy was necessary and harmless, only later they realized it had negative consequences. More episiotomies have been reported at the South and on the islands (58%), closely followed by Centre and North-East (equally 55%), and the North-West with 49%.
When asked about the overall satisfaction regarding the care they received, 67% of interviewees considered the health care provided as adequate. However 1.350.000 women (27% of the sample) declared they felt only partially assisted by medical team, more specifically – they wished they were more involved in what was happening during childbirth. This data was further confirmed by 6% of new moms that affirm they went through labour and birth all alone and without due assistance.
Briefly, one out of 3 women felt excluded from the decision-making process and from fundamental choices related to her childbirth.
OBSTETRIC VIOLENCE: WHEN BIRTH ENDS UP IN A TRAUMA
In order to leave little to interpretation, the interviewees were offered a very last question: “The definition of obstetric violence is the following: appropriation of women’s body and reproductive processes by health personnel; to force a woman to undergo unnecessary C—section; to force an unnecessary episiotomy on a woman; to force a woman to give birth lying on her back with her feet on stirrups; to expose a woman naked in front of many subjects; to separate a mother from her newborn without medical reason; not including a woman in decisions concerning her body and her birth; verbal humiliations before, during and after birth. Based on the provided information, do you think you experienced obstetric violence during your birth?” While 56% responded “Absolutely not” and 23% said “I think not”, there was 21% of the total that affirmed that they were subjected to some form, verbal or physical, of obstetric violence at their first experience of birth: 17% of them responded “Partially yes”, and 4% stated “Absolutely yes”.
“In front of this objective picture of the phenomenon – declared Alessandra Battisti, lawyer and co-founder of Obstetric Violence Observatory Italy – we expect a collaboration with doctors and the institutions in the direction of including women in decision-making processes, on personal and political level, in order to make a real change in maternity health care provision, in the direction of respect of the human dignity. As stated by the WHO and by the United Nations High Commissioner for Human Rights (UNHCHR), the abuse, the negligence and the lack of respect during childbirth can lead to the violation of basic human rights of a woman and a child, putting their lives and their security at risk. The campaign that we launched last year was addressed to women in the first place, inviting them to claim their rights and to not suffer any form of mistreatment, including the violence at birth. Our intention was also to support the law proposal presented by the member of the Parliament Adriano Zaccagnini that promotes the recognition of obstetric violence as a criminal offence, since without judicial recognition it is very difficult for women to seek legal redress.”
BIRTH BY CESAREAN: A CUSTOMARY PRACTICE, NOT ALWAYS AN EMERGENCY
The Doxa survey indicates that, in Italy, 32% of women gave birth by caesarean. However, not all caesareans are done for the same reason: if 15% of women stated it was an emergency C-section, there were 14% declaring they had a scheduled C-section, indicated by their health care providers. For the remaining 3% of women, the C-section was their own decision.
THE 4% OF NEGLECT THAT PUT THE LIFE OF NEWBORNS AND MOTHERS IN DANGER
According to the survey, 84% of women gave birth to their first/unique child inside a public hospital. 12% have chosen a private facility that is funded by the national health care system, 3% opted for private clinics and only 1% gave birth at home or inside birth centers.
Inappropriate practices denounced through the survey were numerous. 27% of mothers said they did not receive adequate support and information on breastfeeding and 19% denounced the lack of privacy during various stages of their permanence inside the hospital. Furthermore, 12% of women complained that they were not allowed to have a person of choice with them during labour, while 13% were not given an adequate pain relief.
Finally, it is quite alarming to find out, in regard to safety and risk at birth, that 4% (about 14.000 women per year) affirmed being neglected, which resulted in suffering life-threatening, avoidable complications. The Italian National Health Institute estimates that there are 1259 cases of “near miss” every year in Italy, while the maternal mortality rate is underestimated by 60%.
The combination of factors drives 14% of maternity service users to declare that they would definitely choose another facility for a second pregnancy, while 72% would come back to the same hospital, nonetheless. Another 14% remain uncertain.
FIRST BIRTH: AN INDUCED TRAUMA THAT DRIVES 6% OF MOTHERS TO GIVE UP THE DESIRE FOR MORE CHILDREN
For the majority of interviewees (63%), the experience at the first birth did not influence the choice of having other children or it was not the factor that influenced the choice of not having other children (15%). Yet, 11% of mothers in Italy confirm that they experienced trauma in relation to the maternity health care; because of that they delayed further pregnancies for many years, a choice that may have significant unnoticed impact on the fertility at the national level. Finally, for the 6% of mothers the trauma was so strong as to make them decide to completely renounce having any more children, which translates in 20.000 of children not being born every year – a consequence on the national birth rate that has not been taken into the account.
#BASTATACERE: THE CAMPAIGN GIVING VOICE TO MOTHERS AGAINST OBSTETRIC VIOLENCE
The social media campaign “#Bastatacere: mothers have voice”, launched in April 2016, was an initiative curated by Elena Skoko and Alessandra Battisti with the purpose of drawing the public and institutional attention to the phenomenon of obstetric violence, through individual stories of women shared on the dedicated Facebook page. Ten national associations of mothers coordinated the on-going initiative, with dissemination support of 20 more associations. In 15 days the official Facebook page https://www.facebook.com/bastatacere reached 21.000 likes, about 700.000 daily visits, 70.000 daily interactions, and, most importantly, more then 1.100 stories of obstetric violence in the format of a banner-photo. The #bastatacere campaign was directly connected to the law proposal “Norms for the Protection of the Rights of Women and Newborns in Childbirth and Regulation for the Promotion of Physiological Birth”, deposited at the Parliament in March 2016, prior to the social media campaign, by Adriano Zaccagnini (Democratic Progressive Movement). The law proposal promotes the recognition of obstetric violence as a criminal offense. At the end of the campaign the Obstetric Violence Observatory in Italy (OVOItalia) was born, with the aim of collecting data and testimonies of violence against women and babies at different stages of labour and birth. OVOItalia’s Ethical Committee members are Alessandra Battisti, Elena Skoko, Michela Cericco, Eleonora Piras, Claudia Ravaldi, Giovanna Riso, Nadia Babani, Annalisa Melis, Luana Vignoli.
HOW TO SUPPORT THE ACTIVITIES OF THE OBSTETRIC VIOLENCE OBSERVATORY
Everyone can give their contribution to the #bastatacere campaign and to the activities of OVOItalia aimed at raising awareness, providing information, producing data, and conducting researches on the issue of obstetric violence. It is possible to give a donation through the association La Goccia Magica, on the website http://www.lagocciamagica.it/ or through their bank account IBAN IT68Z0895139130000000344705, indicating #bastatacere on the memo line.
The advocacy initiatives described above have benefited from the participation of the coordinators Elena Skoko and Alessandra Battisti in the EU-funded COST Action IS1405: BIRTH: Building Intrapartum Research Through Health – an interdisciplinary whole system approach to understanding and contextualising physiological labour and birth, supported by the COST (European Cooperation in Science and Technology) Programme as part of EU Horizon 2020.
For information and interview requests, please, contact email@example.com.
 A maternal near miss (MNM) is defined as pregnant or recently delivered woman who survived a complication during pregnancy, childbirth or 42 days after termination of pregnancy.
 Donati S, Senatore S, Ronconi A; Regional Maternal Mortality Working Group, Acta Obstet Gynecol Scand. 2012 Apr;91(4):452-7. doi: 10.1111/j.1600-0412.2012.01352.x. Epub 2012 Feb 22. https://www.ncbi.nlm.nih.gov/pubmed/22229438
 La Goccia Magica (Genzano di Roma), Nanay (Roma), Centro Alma Mater (Rieti), Forum Parto Naturale (Reggio Calabria), CiaoLapo Onlus (Prato), Rinascere al Naturale Onlus (Lecce), Comitato per la Buona Nascita (Puglia-Calabria-Umbria-Toscana), Innecesareo Onlus (Mantova), Città delle Mamme Frascati (Frascati), Cerchidarcobaleno (Padova).
#Bastatacere, a campaign that gave voice to mothers
Elena Skoko and Alessandra Battisti partnered with 10 Italian mothers’ associations (La Goccia Magica, Nanay, Centro Alma Mater, Forum Parto Naturale, Ciao Lapo Onlus, Rinascere al Naturale, Comitato per la Buona Nascita, Innecesareo Onlus, Città delle Mamme Frascati, and Cerchidarcobaleno) in organizing and coordinating the social media campaign “#bastatacere: le madri hanno voce” addressing the phenomenon of obstetric violence (also known as abuse and disrespect in childbirth, mistreatment, birth trauma), that started on April 4th and ended on April 19th, 2016. The campaign was elaborated and led by Elena Skoko and Alessandra Battisti. Full report in Italian is available here.
#Bastatacere campaign was launched as a new Facebook Page, and in 15 days received 21.621 likes, over 1.136 photo-banners and many more stories in written format, it had 700.000 daily visitors and over 70.000 daily interactions. The campaign received over 60 articles in mainstream press and blogs on the Internet.
The campaign format included a personal story of a traumatic childbirth experience written on a paper and then photographed (photo-banner). The campaign lasted 15 days and it required anonymity regarding the names of places and persons in order to protect the women who were sharing the stories of abuse and disrespect in maternity care, since in Italy defamation is a penal offense.
Coincidentally, a campaign of the same name, Basta tacere!, was conducted 44 years ago in Italy (1972) where women inside the growing feminist movement lamented the very same issues regarding the reproductive and maternity healthcare they have been receiving at the time. The comparison of two initiatives brought forward a long-term situation that has still not been properly addressed by the institutions and the society reminding us that abuse in maternity assistance was and remains a feminist issue.
After the closing of the campaign, we formed the Obstetric Violence Observatory Italy (OVOItalia) as part of the international coordination of observatories InterOVO. OVOItalia’s aim is to continue the collection of stories on obstetric violence. OVOItalia provided a survey QuestOVO where the stories continue to be shared in a data-friendly format. #Bastatacere campaign and QuestOVO represent the first national data (identified as “gray literature“) on the phenomenon. The Italian campaign introduced the term of “obstetric violence” to the large audience and to the media that manifested spontaneous interest from its very start.
#Bastatacere initiative was openly and directly linked to two official documents:
- the law proposal “Norms for the Protection of the Rights of Women and Newborns in Childbirth and Regulation for the Promotion of Physiological Birth”
- the WHO Statement on “The prevention and elimination of disrespect and abuse during facility-based childbirth”.
In Italy, on March 11th 2016, Hon. Adriano Zaccagnini submitted to the Italian Parliament the law proposal “Norme per la tutela dei diritti della partoriente e del neonato e per la promozione del parto fisiologico” (“Rules for the Protection of the Rights of Women and Newborns in Childbirth and Regulation for the Promotion of Physiological Birth”). The law proposal was based on the draft written by Alessandra Battisti and Elena Skoko with direct collaboration with Italian mother-activists. The Bill demands the respect of fundamental human rights of mothers and newborns, since individual and public health outcomes and safety during childbirth cannot be reached without the acknowledgment and protection of fundamental human rights of the human being. In #bastatacere campaign we asked the women to tell us if what is written in this bill confirmed their experiences. The response was beyond our expectation.
The Bill introduces the offense of obstetric violence in compliance with the WHO Statement on “The prevention and elimination of disrespect and abuse during facility-based childbirth” (2014). WHO highlights that abuse, neglect or disrespect during childbirth can amount to a violation of a woman’s fundamental human rights, as described in internationally adopted human rights standards and principles. Reports of disrespectful and abusive treatment during childbirth in facilities include:
- outright physical abuse,
- profound humiliation and verbal abuse,
- coercive or unconsented medical procedures (including sterilization),
- lack of confidentiality,
- failure to get fully informed consent,
- refusal to give pain medication,
- gross violations of privacy,
- refusal of admission to health facilities,
- neglecting women during childbirth to suffer life-threatening, avoidable complications,
- and detention of women and their newborns in facilities after childbirth due to an inability to pay.
- Among others, adolescents, unmarried women, women of low socio-economic status, women from ethnic minorities, migrant women and women living with HIV are particularly likely to experience disrespectful and abusive treatment”.
In the campaign, we put this list of abuses in evidence for women to understand what experiences were considered as obstetric violence, since the phenomenon is not officially or culturally acknowledged, not even by women who experienced it. The list turned out to be very useful, as many women did not understand what happened to them and what were they supposed to tell.
#Bastatacere campaign had a shocking and profound impact on the public opinion, on the maternity care providers, on mothers, and on the institutions that finally have to find the way to acknowledge and address the phenomenon of obstetric violence.
Text by Elena Skoko and Alessandra Battisti