Disrespect and abuse in maternity care: individual consequences of structural violence

Disrespect and abuse of patients, especially birthing women, does occur in the health sector. This is a violation of women's fundamental human rights and can be viewed as a consequence of women's lives not being valued by larger social, economic and political structures. Here we demonstrate how such disrespect and abuse is enacted at an interpersonal level across the continuum of care in Tanzania. We describe how and why women's exposure to disrespect and abuse should be seen as a symptom of structural violence. Detailed narratives were developed based on interviews and observations of 14 rural women's interactions with health providers from their first antenatal visit until after birth. Narratives were based on observation of 25 antenatal visits, 3 births and 92 in-depth interviews with the same women. All women were exposed to non-supportive care during pregnancy and birth including psychological abuse, physical abuse, abandonment and privacy violations. Systemic gender inequality renders women excessively vulnerable to abuse, expressed as a normalisation of abuse in society. Health institutions reflect and reinforce dominant social processes and normalisation of non-supportive care is symptomatic of an institutional culture of care that has become dehumanised. Health providers may act disrespectfully because they are placed in a powerful position, holding authority over their patients. However, they are themselves also victims of continuous health system challenges and poor working conditions. Preventing disrespect and abuse during antenatal care and childbirth requires attention for structural inequalities that foster conditions that make mistreatment of vulnerable women possible.