Obstetric violence and complications of childbirth in healthcare facilities in Uttar Pradesh, India: contextualizing institutional birth experiences and practices towards dignity

Maternal, newborn, and child mortality and morbidity are declining globally with persisting regional disparities in survival. India accounts for a high burden of maternal and child deaths with the highest perinatal and early child mortality rates in Uttar Pradesh (UP). Decreasing mortality rates in India have been largely attributed to increased facility-based delivery. The rapid rise of facility deliveries worldwide, however, has revealed poor quality of care and widespread mistreatment of women during childbirth, particularly among marginalized, subaltern women. Obstetric violence is significantly associated with maternal complications, suffering, and trauma. Using a critical theory lens and ethnographic approach, this study examined the structural context and dynamics of obstetric violence and complications of childbirth – postpartum haemorrhage, birth asphyxia, and anemia – in public hospitals and community health centres in two districts in UP. The study drew on datasets from a larger hospital ethnography evaluation of a maternal and newborn initiative in UP. Multistage analyses of direct patient case observations, interviews, and hospital records data were centred on birth stories of twenty-two women patients to understand experiences and interactions of institutional actors. Obstetric and epistemic violence were pervasive across the continuum of intrapartum and immediate postpartum care including: physical/verbal abuse; neglect; erasure; non-consented interventions; and substandard care. Obstetric violence and birth complications were deeply entangled in complex assemblages of birth. Social and biomedical processes underlying obstetric care within contexts of scarcity contributed to systems of dysfunction and precarity. Violence emerged as relational and structured harms, mediated by biomedicalized, gendered, classed relations of power, synergistic with caste, religion, and age. Violence functioned as reproductive governance through routine disciplining, forc