Social representations of nursing students about obstetric violence: study with a structural approachABSTRACT
Objective: To learn about the structure of nursing students’ social representations about obstetric violence.
Method: Qualitative study conducted with 117 nursing students from a state university in Brazil, between July and October 2022. Data were collected in person using the free Word evocation technique and processed using the Evoc software to create a four-box chart, through prototypical analysis.
Results: The representational structure was organized on the central elements of disrespect, suffering and violation, which attribute to the representation negative meanings related to the group’s position on the grievance and its repercussions. The similarity analysis showed that the elements with the greatest connection were disrespect and suffering.
Final considerations: Social representations of nursing students were organized around an attitudinal dimension through the terms disrespect and violation, and the affective dimension defined by suffering. It is noteworthy that, for students, obstetric violence is centered on disrespectful professional practices that cause suffering to women.
Descriptors:
Violence; Gender-based violence; Nursing students; Women’s health; Universities
RESUMO
Objetivo: Apreender a estrutura das representações sociais de estudantes de enfermagem sobre violência obstétrica.
Método: Estudo qualitativo realizado com 117 estudantes de enfermagem de uma universidade estadual do Brasil, entre julho/outubro de 2022. Os dados foram coletados de forma presencial por meio da técnica de evocações livres de palavras e processados no software Evoc para elaboração de quadro de quatro casas, mediante análise prototípica.
Resultados: A estrutura representacional se organizou a partir dos elementos centrais desrespeito, sofrimento e violação, que atribuem à representação sentidos negativos relativos ao posicionamento do grupo diante do agravo e suas repercussões. A análise de similitude retratou que os elementos com maior conexão foram desrespeito e sofrimento.
Considerações finais: Apreende-se que as representações sociais dos estudantes de enfermagem se organizaram em torno de uma dimensão atitudinal através dos termos desrespeito e violação e da dimensão afetiva definida pelo sofrimento. Ressalta-se que para os estudantes, a violência obstétrica está centrada em práticas profissionais desrespeitosas que causam sofrimento às mulheres.
Descritores:
Violência obstétrica; Violência contra a mulher; Estudantes de enfermagem; Saúde da mulher; Universidades
RESUMEN
Objetivo: Aprehender la estructura de las representaciones sociales de estudiantes de enfermería sobre la violencia obstétrica.
Método: Estudio cualitativo realizado con 117 estudiantes de enfermería de una universidad estatal de Brasil, entre julio/octubre de 2022. Los datos fueron recolectados presencialmente mediante la técnica de evocaciones libres de palabras y procesados en el software Evoc para crear un gráfico de las cuatro casas, mediante análisis prototípico.
Resultados: La estructura representacional se organizó a partir de los elementos centrales falta de respeto, sufrimiento y violación, que atribuyen a la representación significados negativos relacionados con la posición del grupo sobre el agravio y sus repercusiones. El análisis de similitud retrató que la falta de respeto y sufrimiento tenían más conexiones.
Consideraciones finales: Se aprehende que las representaciones sociales de los estudiantes de enfermería se organizaron en torno a una dimensión actitudinal a través de los términos falta de respeto y violación y la dimensión afectiva definida por el sufrimiento. Se destaca que, para los estudiantes, la violencia obstétrica se centra en prácticas profesionales irrespetuosas que causan sufrimiento a las mujeres.
Descriptores:
Violencia obstétrica; Violencia contra la mujer; Estudiantes de Enfermería; Salud de la mujer; Universidades
INTRODUCTION
Obstetric violence has gained national prominence by unveiling a gender-based violence, which requires debates to cope with it. As for its conceptualization, obstetric violence consists of neglect, disrespect, and violated rights that occur not only during labor, but also during pregnancy, prenatal care, postpartum care, and in cases of abortion1-2.
The institutionalization of childbirth has opened opportunities for frequent interventions to be performed on the body of the birthing person, changing the image of natural childbirth into something pathological and requiring medicalization. With the removal of family support and the replacement of the midwife by the figure of the physician, women started to follow norms imposed by hospitals, which resulted in a reduction in autonomy and decision-making power over childbirth events2-3.
In Brazil, a study conducted with 287 postpartum women indicated that 12.5% of the women recognized having suffered disrespect and abuse during childbirth. However, the analysis of the cases revealed that the women did not understand that these acts were considered obstetric violence. Being unaware with the term and the interfaces of obstetric violence makes women vulnerable and exposes them to this problem, as women naturalize this type of violence4-5.
Obstetric violence is a significant public health issue in the country, which requires training for health professionals to prevent new cases of this phenomenon in order to achieve favorable outcomes. Another strategy for dealing with this problem would be to raise awareness about this content during the initial training period for health science students, as a mechanism for reducing this problem in future professional practice6.
Professional training that perpetuates procedures not based on scientific evidence continues to strengthen the current model of childbirth care, which is centered on violent and technical professional practices. The behavior of health students can be directly influenced when this is associated with the lack of educational activities on obstetric violence during their training. Consequently, the trivialization of inadequate procedures, the lack of assistance to women and the centralization of decision-making by professionals at childbirth favor the reproduction and normalization of obsolete practices7-8.
The university has represented a way of emphasizing during initial training what are the human rights related to women’s sexual and reproductive health, so that students have knowledge of the physiological processes and obstetric care routines, as well as the rights provided by law within the scope of the Unified Health System (Sistema Único de Saúde - SUS)9.
Regarding nursing students, they understand the violence that occurs during childbirth as psychological and physical aggression and violent professional practices. During their experiences in obstetric units, 59.2% of nursing students reported having witnessed some violent behavior by healthcare professionals, with episiotomies, Kristeller maneuvers, verbal violence and non-compliance with Law No. 11,108/05, also known as the Companion Law, being the most frequently observed10.
Raising awareness among students during their initial training about this type of violence against women allows for the prevention of new cases when future professionals work in obstetric care. To promote changes in care paradigms and practices, it is important to implement curricula that address the issue through active methodologies, with classroom discussions to properly raise awareness and conceptualize obstetric violence and its interfaces6-10.
Regarding the extent to which this issue is recognized as a public health problem, it is essential that future nursing professionals recognize the different forms of obstetric violence and become familiar with the phenomenon, given that they will be able to work in obstetric care at different levels of care, from prenatal to postpartum, and must therefore provide comprehensive and humanized care. From this perspective, the following research question emerged: How do nursing students perceive obstetric violence?
To answer the guiding question, the theoretical framework of the Social Representations Theory (SRT) was chosen to guide this study as a way to contribute, from the students’ perspective, to learn about their familiarity with the object studied, in addition to providing an opportunity to analyze their thoughts about their experiences, beliefs, values and perceptions about obstetric violence.
Social representations encompass concepts, explanations, beliefs and ideas that arise from daily life through personal or group experiences and are naturally apprehended. For a society to be characterized beyond the individuals that compose it, it is necessary for the subjects to be guided by representations or values that give meaning and unite their common interests11.
In the environment where the subject lives, social representations are present11. In this context, it is understood that the topic of obstetric violence permeates the academic environment and encompasses the students’ thoughts arising from common sense, articulating with scientific knowledge. In this sense, the study aimed to understand the structure of nursing students’ social representations about obstetric violence.
METHOD
The report on the methodological design of this study followed the recommendations of the Criteria for Reporting Qualitative Research (COREQ).
Domain 1 - Research team
The main author, a nurse with experience in scientific research, studying a master’s degree in health sciences, with a focus on Nursing during the data collection period, was responsible for applying the research instrument containing the free word evocation technique and sociodemographic data. The other researchers, responsible for the analysis, discussion and conclusion, are nurses, doctors and a doctoral student in the field of nursing.
The researcher responsible for data collection did not know the participants beforehand and was introduced to them according to the students’ expression of interest in participating in the research, after an invitation, through contact in the classroom for presentation and explanation of the study’s objectives and interest in the topic.
Domain 2 - Study design
This is a descriptive, exploratory and psychosocial study of a qualitative nature, based on SRT, with a focus on its structural approach. This approach proposes that every social representation is structured around a central core and a peripheral system. The central core consists of elements that define, organize and denote the meaning of the representation. Peripheral elements, on the other hand, have a more flexible and practical nature and are essential to protect the central meaning of the representation12.
Understanding social representations according to the structural approach aims to investigate how social factors influence thought processes, through the recognition and ordering of the structure of relationships between individuals. Moreover, it makes effective the role and meaning that a particular social object has for a group13.
Thus, describing the structure of students’ social thinking about obstetric violence allows us to understand where their representations, experiences, values and images are anchored in relation to this phenomenon and how their perceptions can indicate mechanisms to address different health issues faced by pregnant women and women in labor.
Social representations are organized into dimensions, namely: conceptual, imagistic and attitudinal. Analyzing the elements of the maximum tree and their connections allows these dimensions to be established. The central core of a representation presents normative and functional elements, thus having an evaluative and pragmatic role12.
The study was conducted at the Universidade Estadual do Sudoeste da Bahia (UESB), Jequié Campus. The participants in the study were students in the initial nursing program, organized over nine semesters. Participants were selected by convenience and in person in the classrooms.
The students selected to participate in the study were properly enrolled in the first and final three semesters of the course. This choice was made to capture social representations of students still in the early period of the course, which could come from common sense, while students in the last semesters could represent the object based on concrete knowledge, given the exposure with content that would bring them closer to the theme, such as the curricular component Nursing in Women’s Health Care, offered in the seventh semester.
Students in the last semesters have contact with the field of hospital practice in the obstetric sector from the seventh semester. However, due to the COVID-19 pandemic scenario, internships were not conducted, hindering access and assistance to birthing women and clinical training, limiting care to women only during prenatal monitoring in internships performed at Family Health Units (FHU).
During the collection period, 122 students were enrolled in the first and final three semesters of the course; however, five of them did not show interest in participating in the research. In the classrooms, from the 122 students, 117 agreed to participate in the study and initially completed the sociodemographic questionnaire, which included participant characterization, followed by the instrument containing the free word evocation technique, which consisted of asking participants to write down up to five words or expressions that immediately come to mind when faced with an inducing term, in this case, “obstetric violence”. All answered the questionnaire only once, no pilot test was conducted, and no form of audio or video recording was used.
Data collection took place in person in the classrooms, between July and October 2022. The researcher introduced herself at the first moment of contact with the students, explained the research objectives, and stated that participation would be voluntary, with confidentiality and anonymity guaranteed. All participants signed the Informed Consent Form and received a copy of the document.
Among the criteria for selecting participants, as previously mentioned, were students duly enrolled in the three initial and three final semesters, aged 18 years or older. Exclusion criteria included students who were absent from the university due to home assignments, maternity leave, illness, or other reasons that prevented their access to the university.
Domain 3 - Data analysis
Regarding the data from the free word evocation technique, the Ensemble de Programmes Permettant I’analyse dês Evocations (EVOC) - version 2005 software was used to assist in processing. This technique consists of two stages: initially, the prototypical analysis is performed by calculating the frequencies and mean order of word evocations, and then it focuses on creating a table that encompasses the evocations with their respective frequencies. Data processing in the software presents a four-box chart, consisting of central, first and second peripheral and contrast elements. In this way, a social representation is structurally characterized through the participants’ word evocations12.
Based on the elements obtained in the four-box chart, similarity analysis by co-occurrence was performed. Initially, all participants who evoked two or more words from the representation elements were selected. Then, the researcher manually calculated the similarity indexes (SI), dividing the number of co-occurrences of word pairs by the number of previously selected participants12.
With the values obtained in the SI, the maximum tree of social representation was constructed, starting with the strongest connections 12. Based on the co-occurrences of the words, of the 117 students, 82 evoked two or more words present in the four-box chart.
To contextualize the words or terms that consists the four-box chart, excerpts from the students’ justifications were used, followed by the participant’s pseudonym, with their participation order and corresponding semester (Ex: Participant 23, 2nd semester). To support the students’ social representations, the structural approach or Central Core Theory, proposed by Jean Claude Abric, as well as the theoretical frameworks of CCT were used as a way to explore the sociocognitive sets that structure and organize the participants’ thinking14.
This study complies with Resolutions 466/2012 and 510/2016 of the National Health Council, respecting all the proposed ethical precepts and approved by the Research Ethics Committee (REC) of UESB according to CAAE 57360822,0,0000,0055 and substantiated opinion 5,481,002/2022.
RESULTS
A total of 117 students from the first three and last three semesters of the nursing course, of both genders, participated in the free word evocations, with the number of women being more representative (97). Most of the interviewees were between 21 and 25 years old (59) and self-identified as brown (49).
The corpus formed by the participants’ evocations on the inducing term “obstetric violence” totaled 540 words, of which 102 were different. The mean order of evocations (MOE), calculated with the aid of the EVOC software, was 2.70, the minimum frequency was 13 and the average frequency was 23. The data analysis resulted in the four-box chart illustrated in Chart 1. In total, 11 terms comprised the structure of the social representations of nursing students about obstetric violence.
The most relevant and significant words for the group of belonging are grouped in the upper left quadrant, in Chart 1, which includes the most likely cognitions to constitute the potential central core of the representation with the terms disrespect, suffering and violation that were more frequent and were evoked more promptly by the students. These elements, according to the students’ justifications, point out to obstetric violence as actions based on disrespect, which violate women’s rights and are responsible for the suffering of women, as shown in the following statements:
[Obstetric violence] It is a disrespect for the rights that women have during their gestation period, from the first day they find out until the day of delivery. (Participant 21, 9th semester)
Disrespect, because [the professional] does not respect the woman's body, the individuality of the woman and can say these aggressive things, right? Act aggressively. (Participant 23, 2nd semester)
Suffering due to the whole situation, because given all this violence that some women go through, it is not a situation that will leave women satisfied, so that whole context causes them suffering. (Participant 21, 9th semester)
Violation at the moment when the woman is there giving birth and at that moment she is violated, all her dignity thrown away. (Participant 25, 8th semester)
A violation of her rights as a woman as a pregnant woman, so she loses her rights to autonomy. (Participant 21, 9th semester)
In the upper and lower right quadrants are located the first and second peripheral elements respectively. The first periphery is composed of the neglect element, which, despite having a high frequency, was evoked later. Thus, this condition indicates that it is an important peripheral element that may later present itself in a central form.
Neglecting care for women strengthens students’ thinking towards the functional and normative issue of actions and feelings related to obstetric violence and was described as practices that should not be carried out by professionals.
Attitudes of professionals who are neglecting care or carrying out some act as practices that should not be performed with this woman and are exposing her, exposing her to violence. (Participant 7, 8th semester)
The second periphery presents less frequent elements that were evoked late with a high rate of M.O.E. The elements woman, childbirth and vulnerability, allow a more immediate representation of the students and express how obstetric violence is attributed to the moment when the woman is vulnerable.
It's like a hierarchy, as I see it, so the patient is there, kind of vulnerable at a vulnerable time and he is there abusing her vulnerability to do what he wants. (Participant 9, 3rd semester)
Since the woman is in a state of vulnerability at that moment, I believe that’s it, [the professional] thinking that he is above everything and that he can do everything as if he were the owner of that moment. (Participant 5, 1st semester)
The lower left quadrant has the elements of the contrast zone, these are terms that have low frequencies, but they were promptly evoked and are directly related to behaviors, actions and repercussions of obstetric violence for those who experience it. The elements abuse, aggression, inhumane and traumas can reinforce the ideas of the first periphery and complement the central core, making it possible to identify the students’ thoughts regarding the profile and attitudes of the healthcare professionals who practice this violence.
The students’ justifications for these elements reflect the dehumanization of care, aggressive practices and an understanding that the professional can abuse the parturient in different ways, including the abuse of power due to their privileged position.
Inhumane, because as a professional I shouldn't say that, these comments because she's going through a difficult time there, feeling pain and hearing these comments is complicated. (Participant 12, 2nd semester)
Obstetric violence reminds me of aggression, it's like violence, as the name suggests, against the rights of this pregnant woman during childbirth and during pregnancy as well, basically this would be both the physical issue and the psychological issue. (Participant 18, 9th semester)
Abuse in the sense of going beyond what is appropriate in their job [professional], so making some unnecessary contact, the issue I mentioned about contact with intimate parts in a more sexual manner. (Participant 22, 2nd semester)
Abuse by professionals towards pregnant women would be that, an abuse of power. (Participant 9, 3rd semester)
The traumas were described as having short- and long-term repercussions on women’s lives, including the desire to experience a new pregnancy.
Several traumas, such as the woman being afraid of getting pregnant again, fearing that the same thing that happened before will happen, and in a way, losing confidence. (Participant 11, 2nd semester)
Postpartum depression beforehand and even a refusal to want to have another child, so she will carry the traumas forever, every time she talks about childbirth she will remember, every time she says you want to have another child, she will remember. (Participant 24, 9th semester)
From the prototypical analysis, it was possible to perform the similarity analysis by co-occurrence of the elements that compose the four-box chart, as shown in Figure 1. A maximum similarity tree is presented with the connectivity between the representational terms, identifying the structure and organization of thought of the students involved in this study.
According to the similarity tree, it is highlighted that the term disrespect situated in the central core of the four-box chart, Chart 1, presented the strongest connections with the terms suffering (0.14) and violation (0.13).
Similarity tree by co-occurrence of nursing students’ evocations of the inducing term obstetric violence. Jequié, Bahia, Brazil, 2022. (n= 82)
It was observed that the notions of disrespect, suffering, and violation structure and organize the social representations of these students, since they organize the elements around them and maintain a strong connection with them. Disrespect presented six connections, while suffering presented three. Violation has only two connections, therefore, even though it is an element of the possible central core of the four-box chart, it strengthens the element disrespect with which it maintains a strong connection (0.13). Thus, negative meanings are attributed to the representation, related to the group's positioning in the face of harm and its repercussions for women.
DISCUSSION
It is identified that the social representations of students are organized around an attitudinal dimension through the terms disrespect and violation and an affective dimension defined by suffering. It is important to emphasize that social representation is a knowledge that structures how individuals perceive and react to reality11.
A possible central element is the term disrespect, which is strongly linked to the terms violation, inhumane and neglect, which together reflect on the attitudinal dimension of social representation and express a judgment on the actions of professionals in a negative aspect of what was experienced by students in their training process. Furthermore, the link between the elements of vulnerability and disrespect represents that these behaviors are based on the vulnerable condition of the woman during childbirth.
The term obstetric violence is the one that best defines actions of disrespect and mistreatment that constitute the forms of this phenomenon, practiced interpersonally, structured on issues of social and gender inequality. Conceptualizing this recurring problem among women can contribute to regulations and policies to cope with that15.
The interfaces of the concept of obstetric violence present models of care for childbirth that relate disrespect to lack of support, which directly refers to the lack of humanization of care. During training, the technocratic model prevents students from freely working on good health practices, which disrespects and violates women’s rights. The incipient professional training to work in obstetrics reflects disrespect for women, their socioeconomic and gender conditions16.
From the above, it is understood that obstetric violence needs to be looked at in a targeted manner and debated as a priority. Actions to prevent this issue can begin during the professional training period, with the awareness of health science students about women's rights to receive respectful healthcare in accordance with their decisions and choices17.
Worldwide, rates of obstetric violence are concerning and the numbers of violence reported by women vary: 67.4% for some type of mistreatment during childbirth in Spain; in Pakistan 100%, 99.7%, 97.5% for ineffective communication, lack of supportive care and loss of autonomy, respectively; in Saudi Arabia 60% did not have the right to choose a companion and were forced to lie on their back during childbirth18-20. These data serve as a warning by identifying obstetric violence as a global public health issue, which presents worrying and significant numbers.
In Mexico, women participated in a study that associated obstetric violence with four categories, namely: discrimination, neglect, abuse and denial of autonomy. These acts committed by healthcare professionals were identified as violations of women’s human, sexual and reproductive rights, attitudes that nursing professionals should be attentive to avoid while they are in the delivery room21.
Psychological obstetric violence is another form of violence that has been frequently practiced by healthcare professionals with different academic backgrounds who make inappropriate statements and reprimand women who express their desires. Women constantly hear phrases such as “it is good to do them, but it is not good to have them” and are asked to collaborate, obey professionals, and remain silent during labor5,22.
Primiparous, disadvantaged women with lower purchasing power were identified in a study in Pakistan as those most deprived of respectful maternity care, with obstetric violence manifested through ineffective communication, lack of supportive care and resources in the maternity ward, loss of autonomy, physical and verbal abuse and discrimination. A relevant fact is the low number of women who did not have access to health education on essential aspects of preparing for childbirth19.
A study showed that for pregnant and postpartum women, the social representation of obstetric violence was configured through professional practices based on personal decisions and that had no scientific basis, such as the no longer recommended episiotomies, Kristeller maneuvers and repeated vaginal exams23. These practices, in addition to being outdated, demonstrate the lack of humanization in the care of the female body.
For the nursing students in this study, the healthcare professional who practices obstetric violence is considered inhumane and negligent and was characterized based on the lack of humanized conduct in care, with the perpetration of physical and psychological aggression at a time of vulnerability of the woman, depriving her of experiencing a respectful birth. These actions can negatively impact women’s perception of the care received and the experiences during childbirth24.
Obstetric violence represented by the dehumanization of care is expressed through criticism of a woman crying or moaning due to labor pain, as well as indifference from the care team and lack of privacy during the hospital environment25.
A study conducted with puerperal women in Brazil identified neglect in care in the statements of the interviewees who indicated that they did not receive adequate attention from professionals, and felt unassisted during labor, which generated concerns, mainly about the health status of their child5. Similarly, 71% of women who participated in a study in Saudi Arabia had their births assisted by nursing students and reported that they did not provide information about their rights or procedures for women. Situations like these made women uncomfortable and left them afraid of the words, phrases or behaviors of healthcare professionals20.
To talk about social representations of obstetric violence, it is necessary to understand the social nature of the fact, what behaviors of healthcare professionals result in disharmony, violations, actions or omissions and are performed by those considered socially and, by law, to be the caregivers of the physical and emotional well-being of women. For the students, the term violation, which describes the conduct, practice and action of the professional, was strongly linked to the term aggression (0.09) and expresses the ways in which women’s rights are violated and their bodies invaded when they do not receive dignified care during childbirth, involving the behaviors of healthcare professionals who harm them.
A study that aimed to determine the prevalence of obstetric violence in the Spanish healthcare system corroborates this finding by identifying that from the 899 participating women who gave birth between 2018 and 2019, 67.4% suffered obstetric violence, with physical violence being the most prevalent (54.5%), followed by psychoaffective (36.7%) and verbal (25.1%). The behaviors that women considered to be a greater violation of their rights were repeated vaginal exams performed by different professionals, the use of medications to accelerate labor and delivery, and the Kristeller maneuver. These attitudes made the parturients feel vulnerable, insecure, and guilty18.
The elements of aggression and abuse present in the contrast zone express the conceptual dimension that students have about obstetric violence, as they show the organization of thought, as well as the images constructed in reference to this type of violence. There is a greater understanding among students about the actions that characterize obstetric violence. The conceptual elements allude to violent acts or the conduct of the aggressor.
The terms abuse and aggression refer to this conceptual field in light of the students’ understanding of the actions practiced by healthcare professionals against women. Physical, sexual and psychological violence, whether through abuse of power, sexual abuse, physical and verbal aggression in all stages of pregnancy, labor, and postpartum, are present in the reports of nursing students.
In this direction, a qualitative study highlighted in the statements of puerperal women some common practices of childbirth care, which are characterized as aggressive to the woman, among them, the performance of episiotomy, amniotomy, repeated vaginal exams, directed pushing and violation of autonomy by professionals when performing these acts without the proper communication and authorization of the women. It is clear that there is resistance by professionals to change their behavior, which naturalizes these interventions and camouflages them as intrinsic to childbirth3.
Abuse, besides being referred to as a direct action on the woman's body, was also understood as a professional behavior, as the holder of knowledge and authority figure. Different forms of abuse and aggression are referred to by women as situations of physical and verbal mistreatment considered as undignified care that impose non-consensual interventions or interventions accepted based on partial or distorted information from healthcare professionals8. Often these behaviors go unnoticed by women, indicating a veiled violence.
The students’ statements show that obstetric violence is interpreted in terms of the healthcare professional’s failure to recognize women as protagonists of childbirth. This demonstrates the hierarchical relationship between healthcare professionals and women during childbirth, with women considered to be the object of intervention only for the birth.
Professionals emphasize the power they believe they exert by ordering actions, and women are only responsible for obeying. In this context, the image of a vulnerable woman is represented by the way she is abused, with vulnerability and lack of instruction seen as justification for the practice of this grievance.
It is clear that the representation of women’s vulnerability in experiencing some form of violence continues to be rooted in the social model of behavior towards women in relation to men. Thus, it is evident that for students, these meanings are anchored in the imaginary of society that assumes women’s inferiority due to physical fragility.
Women are commonly unfamiliar with or have never heard of the concept of obstetric violence. Among nursing students, contact with the subject has been frequent, through social networks or at university, however, knowledge on the subject is superficial5,26. The lack of awareness about the subject among both women and students favors the continuation of obstetric violence, and it is important to familiarize the object of study to prevent new cases and reduce its consequences for those who experience it.
The element of suffering located in the central core has strong connections with the element of traumas in the second periphery and with the element of woman in the second periphery, which is connected to the element of childbirth. These bring the affective dimension of the students’ representations and are linked to the feelings that women experience at the childbirth, as well as the repercussions that these experiences and traumas bring to the lives of the parturients. It is understood that experiences of this magnitude directly influence the awareness of normal childbirth culture among women7.
In view of this fact, the understanding of the consequences of obstetric violence goes beyond the conceptual, attitudinal and imagistic dimensions. This praxis consists of not limiting oneself to visible clinical findings, caused by aggression or physical abuse, but of incorporating humanized and comprehensive practices into care.
In this context, a national survey conducted with more than 23,000 Brazilian women identified a possible association between disrespect and abuse during childbirth in hospitals or maternity wards and the onset of postpartum depression, reflecting how practices that indicate obstetric violence can have repercussions for a woman’s entire life27.
Turkish women with different sociodemographic and obstetric characteristics experienced forms of obstetric violence during childbirth, with psychological violence being the most prevalent, resulting in feelings such as stress, anxiety, worry, sadness, helplessness, anger and fear. The traumas resulting from obstetric violence were expressed physically and mentally in the short and long term revealing a negative effect on women’s health, as well as a serious problem in the healthcare system in Turkey28.
The experience of childbirth is sometimes characterized by pain, suffering and aggression. To ensure positive experiences to prevail during this moment, women need to enjoy better care conditions from prenatal stages onwards. Promoting care free from disrespect and abuse during pregnancy and childbirth, as well as improving communication between women and professionals, can increase women’s satisfaction with the care they receive3-4.
Given these findings, it can be inferred that this affective dimension, based on suffering and trauma, expresses the emotional state of women in the eyes of students, which can be triggered by unexpected situations that women experience during childbirth. It is corroborated that the object of study encompasses the students’ everyday lives, as they discuss the content, visit obstetric wards and may work in the future to assist women in the different stages of childbirth. This can help them identify situations of obstetric violence and contribute to breaking the cycle of disrespectful and violent care.
A study conducted with health science students showed that educational intervention on obstetric violence during initial training can change students' perception of the phenomenon. Moreover, completing internships in the gynecology and obstetrics sectors and having attended a birth were significantly associated with greater perceptions that students had about some forms of this violence17. Understanding the social representations of nursing students about obstetric violence can also contribute to understanding how the academic environment influences the social and scientific thinking of this group.
The university is identified as a space that promotes knowledge and is open to debates, expository and dialogic classes, lectures, and participation in research groups that can foster knowledge arising from common sense, as a way to better train and aggregate scientific knowledge and familiarize the group of nursing students, with obstetric violence.
Health science students who participated in a study that aimed to identify the perception and knowledge about obstetric violence revealed that the lack of more humanized training for those who will provide care to pregnant women, combined with unqualified professionals during initial training, are factors that contribute to women continuing to experience different forms of this violence29. These findings demonstrate the need to reformulate curricular matrices so that professionals feel qualified to act in a humanized and respectful manner in the future.
When analyzing the perception of Indian and British medical students about obstetric violence, it was identified that 66% and 74% of these students, respectively, had not heard the term obstetric violence during initial training, even after completing internships in the area of obstetrics and gynecology. Another data presented shows that less than 35% of students from different countries were able to correctly select the definition of obstetric violence from four options of different types of violence30. It can be inferred that the fragility and superficiality of the approach to the topic during health training may also be related to the students’ (lack of) knowledge.
Corroborating the superficial contact with this object of study in the academic environment, it is identified that the conceptual dimension was not present in the possible central core of the students’ representation. This suggests that these representations might still be in formation and not yet crystallized in the social thought of this group. This finding may be related to the deficit in addressing the topic during the initial training period, even in the final semesters of the course.
To confirm this circumstance, however, it would be necessary to conduct centrality tests as a possibility of verifying whether the elements of aggression and abuse, constituents of the conceptual dimension of the students’ representation, could be confirmed as central elements, considering their M.O.E. Thus, further studies could be conducted to corroborate this understanding.
The study has limitations related to the fact that students in the final semesters did not participate in clinical internships in maternity hospitals due to restrictions caused by the COVID-19 pandemic, which reduced their understanding of childbirth care. Additionally, there is a lack of publications concerning the social representations of nursing students regarding obstetric violence, which hindered the expansion of the discussion. Based on this, we encourage the development of more research to reflect on the social representations of health science students about this type of violence.
FINAL CONSIDERATIONS
This study presented the apprehension of the representational structure of nursing students about obstetric violence, which is centered on disrespect, suffering, and violation. These terms are present in the possible central core. Disrespect represents social thought based on the values and judgments of students regarding the actions of professionals, and suffering brings the emotional burden of these students through their conceptions regarding the feelings of women regarding childbirth care that violates their rights.
Disrespect pervades professional practices that prevent women from having a positive experience during childbirth. The violation of rights is understood to be characterized by the different forms of obstetric violence, which, combined with the lack of humanization of professionals, causes suffering and negative repercussions for women.
Healthcare professionals’ practices are largely centered on theoretical and practical content addressed during the initial training. Providing moments of reflection and discussions based on scientific evidence about obstetric violence at university can have a positive impact on the future of nurses and especially on maternal and childcare.
Bringing this topic up for discussion can directly contribute to expanding and underpinning teaching, research, extension and training actions for health courses, including nursing courses, as these are professionals with the potential to directly work with women during childbirth. Likewise, it will contribute to raise awareness about issues related to obstetric care for the mother-child binomial, identifying the need for humanized practices and comprehensive care.
The concepts, images, values and opinions of the group of belonging constitute theoretical and methodological material for researchers of Social Representation Theory. It is expected that, through the understanding of students’ representations, there will be greater reflection on the approach to obstetric violence during initial training, to prevent and combat this type of violence.
In this context, it is suggested that universities promote spaces for discussions on the topic, with the introduction of specific and cross-sectional content, aimed at better preparing students for future professional practices, thus, obstetric care can be consolidated and strengthened to favor respectful care for women, and to provide a positive experience at all stages of childbirth.
Acknowledgment
To the Bahia State Research Support Foundation (Fundação de Amparo à Pesquisa do Estado da Bahia - FAPESB) for granting the master’s degree scholarship.
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Source: Research data, 2022