Anyone who has witnessed childbirth, in any setting, in any kind of room, knows the power and energy inside that experience. There is nothing contained about it that can fit neatly in a box and labeled “standard.”
And yet obstetric medicine has spent well over a century trying to contain birth anyway. The business of medicine tries to manage it, schedule it, and move it through a system built for efficiency instead of a body doing exactly what it was built to do.
The more we try to control a birth experience, the worse our outcomes get. Look at the March of Dimes morbidity and mortality data and rates of unnecessary cesareans. Look at PMAD rates. The evidence points the same direction every time: control is not care.
In Who Benefits When Obstetric Violence Has No Name?, I introduced the concept analysis my co-authors and I published in the Journal of Advanced Nursing, Reframing Obstetric Violence Culture: A Concept Analysis (Runyon, Irby, Rojas Landivar, & Pascucci, 2025). That piece was about naming the problem. Now let’s look at what you can do about it.
Here’s the finding that matters most if you’re standing at a bedside right now. According to the literature, we’re all clinicians who’ve been instructed, received orientation, and worked within this culture. All of us. That’s not an accusation but a hopeful starting point. And it means all of us have the opportunity, I’d argue the duty, to disrupt it.
This post walks through how obstetric violence culture took root, what it looks like in practice, who it hurts, and what the research says actually works to counter it, including the countercultural roles nurses are already occupying on your unit right now.
How Obstetric Violence Culture Took Root in Hospitals
Obstetric medicine inside hospitals was not built by women, or for women. It was built by men who experimented on enslaved Black women without anesthesia, who moved birth out of homes and communities and into institutions designed for control and disguised as safety, and who decided the person giving birth was a body to be managed and saved rather than a human being to be supported.
That is the foundation modern obstetric care still sits on.
None of us wake up and decide to perpetuate harm. But we inherit these systems, train inside them, and grow through orientation and the powerful hierarchy, learning what is praised and tolerated. We learn, often without anyone saying it out loud, when to look the other way through shame, and which shortcuts get rewarded when the unit is slammed and short-staffed.
The literature calls these the antecedents, the building blocks that had to exist before obstetric violence culture could take hold. The culture looks different than it did in the late 1800s, but the roots have not moved.
Understanding how something took root is the only way to actually pull it out, which is why it’s important to name a problem first.
4 Signs of Obstetric Violence Culture on Your Unit
The concept analysis identifies four attributes of obstetric violence culture. None of them require malicious intent. That is exactly what makes them so hard to name, and so normalized, and so easy to walk past on a busy shift.
Disbelief of violence looks like a patient saying she was held down during a procedure she never consented to, and the response being some version of “that’s not how we do things here.” Her experience gets treated as impossible before anyone investigates it.
Blaming the victim looks like a traumatic birth getting explained away. She was too anxious. Non-compliant. She didn’t bring a doula. She didn’t advocate for herself hard enough. The system stays clean. She carries the blame.
Revictimization looks like a patient reporting harm and then being asked to relive it, justify it, and prove it, often against inconsistent clinician charting full of microaggressive language, to the same institution that caused the harm in the first place. The reporting process becomes the second wound.
Disempowerment looks like information delivered with key details left out, veiled in language about doing what’s best for the baby. Decisions made without her. Her questions minimized, or met with “this is very normal.” She leaves not fully understanding what happened to her own body, or why.
Sit with that list for a second. Does anything on it feel familiar from your own unit? That reaction, whatever it is, is worth paying attention to.
Who Obstetric Violence Culture Hurts (It’s Not Just Patients)
We tend to talk about obstetric violence as something that happens to patients. It does, but it doesn’t stop there. The research documents three directions the harm ripples outward.
Birthing people carry mistrust of the healthcare system, birth trauma, PTSD, and often a decision to avoid care in future pregnancies. Underneath that is the self-blame and internalized silence that sets in when no one believed them the first time.
Clinicians carry moral distress and secondary traumatic stress, the specific kind of injury that comes from witnessing harm you could not stop, inside a system that told you it was normal. That injury is a documented driver of why clinicians leave the workforce altogether. (I wrote more about what that toll actually looks like at the bedside in Causes of Nurse Burnout: Trauma Takes a Toll and Debriefing at the Bedside.)
Systems utilize institutional silence, including retaliation against whistleblowers, outcomes data that gets attributed to patient factors instead of culture, and a workforce burning out for reasons no retention strategy has ever actually addressed.
Darcie Robert, Perinatal Senior Consultant with the HHS Perinatal Improvement Collaborative, put it plainly after hearing this research presented at AWHONN National this year: “Culture change is the most challenging obstacle standing between where we are and solving maternal mortality and severe maternal morbidity. Naming the culture is the first step.”
Obstetric violence culture is a systems problem. It requires a systems response. The good news, and the reason this series exists, is that systems can be disrupted.
How to Disrupt Obstetric Violence Culture
The concept analysis also identifies four countercultural interventions, and they map directly onto the four attributes above.
Validate that the violence exists, instead of defaulting to disbelief. Support the survivor instead of protecting the system. Make trauma-informed care the standard instead of the exception. Center patient autonomy as non-negotiable, not as a nice-to-have when time allows or it’s not overwhelmingly sticky inside the system’s current policies and routine.
None of that is radical, but all of it requires intention.
Here is what the research and a decade of working inside hospital systems have both taught me: disruption does not happen at the policy level alone. It happens at the bedside, in real time, by clinicians who have language for what they are looking at and a framework for what to do about it.
That is where the avatars come in.
Culture change is the most challenging obstacle standing between where we are and solving maternal mortality and severe maternal morbidity. Naming the culture is the first step.
Darcie Robert, Perinatal Senior Consultant with the HHS Perinatal Improvement Collaborative
Meet Your Countercultural Avatars
We identified six countercultural archetypes, roles that nurses and clinicians already occupy, often without knowing it. These are the people already disrupting obstetric violence culture in the specific ways the literature says matter. Naming them does two things. It lets you recognize where you are already part of the solution, and it shows you where you might want to grow next.
Three of the six sit along what we call the more focused domain.
The Mindful Seeker is doing the internal work. Unlearning their biases. Questioning what they were trained to accept as normal.
The Brave Ally sees what is happening to the person next to her. She steps in and stands by her colleagues, in the moment, not after the fact.
The Bedside Guardian protects the sacred space of the patient’s room. Consent is her top priority. Her patient leaves feeling seen, safe, and heard.
Do any of these three sound like you? Or like someone on your unit you’d recognize immediately?
AWHONN Nurses Respond: The Data Behind the Framework
We didn’t just share this framework theory. We tested it twice, live, in front of more than 300 labor and delivery nurses and nurse leaders combined, at AWHONN Maryland in April and AWHONN National in June. The polling data backs up what the concept analysis predicted
Before we introduced a single avatar at AWHONN National, we asked the room a blunter question. Have you ever felt overwhelmed by creating change when you’re at max capacity? Stayed silent because you feared retaliation? Had to choose between unit peace and patient autonomy? Of 185 nurses who answered, 52 said yes to feeling overwhelmed at max capacity, 26 said yes to staying silent out of fear, and 22 said yes to being forced to choose between peace and autonomy.
Then we asked how nurses navigate their own bias, how they show up for colleagues in the face of the status quo, and how they see their role protecting patient dignity, using paired statements on a sliding scale. In every domain, the more advanced statement won, and it wasn’t close. On navigating bias, “my nervous system practice is my constant, I have an internal compass to orient and anchor” outscored “I’m starting to see the care gap and I’m unlearning,” 127 to 72. On showing up for colleagues, a statement describing a nurse who facilitates debriefs and mentors others on trauma-informed care outscored the Brave Ally language, 121 to 63. On protecting patient dignity, a statement about being ready to rewrite the protocols that perpetuate structural injustice outscored the Bedside Guardian language, 130 to 62. We saw the same lean seven weeks earlier at AWHONN Maryland, where the colleagues domain split 88 to 39 and the clients domain landed in an exact tie, 64 to 64. Different rooms, same pull. A lot of nurses who see themselves as Brave Allies or Bedside Guardians right now are straining toward something past it.
The pin-drop activity data made that concrete. When we asked the National room to drop a pin on their strongest avatar right now, one single cluster pulled 66 pins, more than a third of the 193 nurses who answered and well ahead of any other box on the grid. It sits one level past where Brave Ally lives. Bedside Guardian still pulled a real cluster of its own, close to two dozen pins split across two adjacent spots, echoing the 15-pin cluster it pulled in Maryland.
Then we asked a different question. Not where you feel strongest right now, but where you want to grow. Of the 166 nurses who dropped a pin, 95 of them, well over half the room, landed in a single box we haven’t named for you yet. It sits at the far end of the clients-and-community row, past Bedside Guardian. That is not a coincidence twice.
Nurses in the room felt it too. “The session helped to identify strengths and opportunities and helped provide actionable steps,” Kristen Hammerer wrote after Maryland. Havilah Mangalapati, a new nurse that day, put it simply: “As a new nurse, it showed me how I can advocate for my patients or my colleagues.” And from National, Sarah Bressler, a Nurse Professional Development Specialist at HUMC, wrote that the session “gives you the tools and inspiration you need to bring back to your practice and truly advocate for your patient.”
The other three avatars, including the two that pulled those numbers, sit along a more expanded domain, and they are just as real. I’m not naming them in this post. I’d rather introduce them properly, with the same depth these three got, in a follow-up. If your team wants all six sooner than that, and wants to work through them together the way these rooms full of AWHONN nurses did, that conversation belongs at your unit level, not in a blog post. I bring this exact framework into hospitals as a live presentation and team workshop, “I’m Not Just a Nurse, I’m a Disruptor,” built for the people who are tired of doing things the way they’ve always been done. You can see how that looks as a keynote or a full-team session on my speaking and workshops page.
Where to go from here
Knowing the problem is step one. Knowing who you already are inside the solution is step two.
If you want a place to start noticing this in your own practice before your next shift, grab my free guide, 10 Hidden Signs of Trauma in Labor, over on the resource library. It is built for exactly this moment, the one where you’re standing at the bedside wondering whether what you just saw was normal, or whether it was something worth naming.
Save this post. Share it with the colleague on your unit who is also done with the status quo. And stay tuned for more ways to name what’s going on in perinatal healthcare and understand why and what can be done about it.
Citation: Runyon, M. C., Irby, M. N., Rojas Landivar, P., & Pascucci, C. (2025). Reframing Obstetric Violence Culture: A Concept Analysis. Journal of Advanced Nursing. https://doi.org/10.1111/jan.70323
