Layers of inequality: gender, medicalisation and obstetric violence in Ghana.

Background: This study explored how gender inequalities in health systems influence women's experiences of obstetric violence in Ghana. Obstetric violence is recognised as a major public health concern and human rights violation. In particular, it reduces women's trust and use of health facilities for childbirth, thereby increasing the risks of maternal and neonatal mortality. In Ghana, obstetric violence is pervasive and normalised; yet, little is known about the gendered dynamics of this phenomenon.

Methodology: A qualitative study was conducted in eight public health facilities in Ghana. Specifically, semi-structured interviews were conducted with 30 midwives who work in the maternity units and 35 women who have utilised the obstetric services of the hospitals for childbirth. The midwives and women were selected using the purposive sampling technique. The transcripts of the interviews were coded using NVivo qualitative data analysis software and were thematically analysed. Secondary materials such as existing data on the medical profession in Ghana were utilised to complement the primary data.

Results: The study revealed that there are huge structural inequalities that keep women at the lower cadres of the health system. Five major themes depicting how gender inequalities contribute to women's experiences of obstetric violence emerged: gender inequality in the medical profession, unequally and heavily tasked, feminisation of midwifery, patriarchal pressures and ideologies, and gender insensitivity in resource provision. These inequalities impact the kind of care midwives provide, which is often characterised by mistreatment and abuse of women during childbirth. The study also discovered that patriarchal ideologies about women and their bodies lead to power and control in the delivery room and violence has become a major instrument of domination and control.

Conclusion: The hierarchical structure of the healthcare profession puts the midwifery profession in a vulnerable position, with negative consequences for maternity care (obstetric violence). The study recommends that gender-responsive approaches that address structural inequalities in health systems, women's empowerment over their bodies and male involvement in women's reproductive care are crucial in dealing with obstetric violence in Ghana.