O bs te tr ic V io le nc e: A C on ce pt ua l A na ly si s in t he N ur si ng C on te xt 1 Gabriele Santos do Nascimento https://orcid.org /0000-0002-0872-9854 UNIFACISA , Centro Universitário, Brazil. gabriele.santos@maisunifacisa.com.br Vitória Ribeiro dos Santos https://orcid.org /0000-0003-3798-3453 UNIFACISA , Centro Universitário, Brazil. vitoria.santos@maisunifacisa.com.br Emanuella de Castro Marcolino https://orcid.org /0000-0002-6135-8853 UNIFACISA , Centro Universitário, Brazil. emanuella.marcolino@maisunifacisa.com.br Gleicy Karine Nascimento de Araújo-Monteiro https://orcid.org /0000-0002-4395-6518 Universidade Federal da Paraíba, Brazil. gleicy.monteiro@maisunifacisa.com.br Ana Márcia Nóbrega Dantas https://orcid.org /0000-0001-5729-8512 Universidade Federal da Paraíba, Brazil. amnd@academico.ufpb.br Renata Clemente dos Santos-Rodrigues https://orcid.org /0000-0003-2916-6832 Universidade Federal da Paraíba, Brazil. renata.santos@maisunifacisa.com.br Artículo Obstetric Violence: A Conceptual Analysis in the Nursing Context Received: 20/05/2022 Sent to peers: 19/07/2022 Approved by peers: 01/11/2022 Accepted: 09/11/2022 DOI: 10.5294/aqui.2022.22.4.8 To reference this article / Para citar este artigo / Para citar este artículo Nascimento GS, Santos VR, Marcolino EC, Araújo-Monteiro GKN, Dantas AMN, San- tos-Rodrigues RC. Obstetric Violence: A Conceptual Analysis in the Nursing Context. Aquichan. 2022;22(4):e2248. DOI: https://doi.org/10.5294/aqui.2022.22.4.8 https://orcid.org/0000-0002-0872-9854 mailto:gabriele.santos@maisunifacisa.com.br https://orcid.org/0000-0003-3798-3453 mailto:vitoria.santos@maisunifacisa.com.br https://orcid.org/0000-0002-6135-8853 https://orcid.org/0000-0002-4395-6518 https://orcid.org/0000-0001-5729-8512 mailto:amnd@academico.ufpb.br https://orcid.org/0000-0003-2916-6832 https://doi.org/10.5294/aqui.2022.22.4.8 https://doi.org/10.5294/aqui.2022.22.4.8 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2022.22.4.8&domain=pdf&date_stamp=2022-12-14 Theme: Epistemology Contribution to the subject: A conceptual analysis of phenome- na found in the professional practice that contributes to advancing Nursing as a science and profession. Analyzing the concept of “Ob- stetric violence” assists in clarifying the phenomenon, as it treats it in detail, identifying its essential attributes, antecedents, and conse- quents in the Nursing context. Discussion of the theme is relevant so that Nursing professionals have subsidies to identify the cases, en- sure better bonds with the patients, promote humanized, standard- ized, and good quality assistance, and guarantee women a dignified and safe service. In addition, it provides information and solves doubts about the theme and their rights because there is an evident need for changes in these professionals’ training and qualification in terms of the absence of procedures based on scientific evidence. O bs te tr ic V io le nc e: A C on ce pt ua l A na ly si s in t he N ur si ng C on te xt 3 Abstract Objective: To analyze the concept of “Obstetric violence” in the Nurs- ing context based on identifying its antecedents, attributes, and conse- quences. Materials and method: It is a conceptual analysis that follows the method proposed by the Walker and Avant model, which consists of eight stages. Six stages were used to contemplate the study objec- tive, namely: selection of the concept; delimitation of the analysis ob- jectives; identification of different uses of the concept in the literature; determination of the essential attributes; identification of the concept’s antecedents and consequents, and definition of the concept’s empirical references. Results: The sample was comprised of 22 studies. A total of 31 antecedents were evidenced: 24 attributes for physical violence; 35 for psychological/emotional violence; 6 for institutional and sexual vi- olence, and 5 for structural violence. Regarding the consequences, 39 elements were found. Conclusions: The study contributes to Nursing science, research, and clinical practice, providing scientific support with a deep discussion of the phenomenon and presenting the antecedents, attributes, and consequences of obstetric violence in detail. It enables Nursing professionals to recognize the empirical indicators of the con- cept; thus, it is likely that they will have more knowledge that will lead them to more precise Nursing care, in addition to subsidies to prevent obstetric violence. Keywords (Source: DeCS) Nursing; concept formation; obstetric violence; violence against women; women’s health. 4 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 22 - V O L. 2 2 N º 4 - CH ÍA , C O LO M BI A - O CT U BR E- D IC IE M BR E 20 22 | e 22 48 Resumen Objetivo: analizar el concepto de violencia obstétrica en el marco de la Enfermería, desde la identificación de sus antecedentes, atrib- utos y consecuentes. Materiales y método: se trata de un análisis conceptual, que sigue el método planteado por el modelo de Walker y Avant, el que consiste en ocho etapas. Para lograr el propósito del estudio, se emplearon seis etapas: selección del concepto; delim- itación de los objetivos del análisis; identificación de los usos del concepto en la literatura; determinación de los atributos esenciales; identificación de los antecedentes y consecuentes del concepto, y definición de las referencias empíricas del concepto. Resultados: la muestra estuvo compuesta por 22 estudios. Se evidenciaron 31 an- tecedentes: 24 atributos para violencia física; 35, para psicológica/ emocional; 6, para institucional; 6, para violencia sexual y 5, para violencia estructural. En cuanto a los consecuentes, se encontraron 39 elementos. Conclusiones: el estudio aporta a la ciencia de la En- fermería, la investigación y la práctica clínica, debido a que brinda soporte científico con discusión profunda acerca del fenómeno, además de presentar, de forma detallada, los antecedentes, atribu- tos y consecuentes de la violencia obstétrica. Lo anterior posibilita al profesional de enfermería reconocer los indicadores empíricos del concepto; así, es probable que cuente con más conocimiento que lo conduzca a una atención en Enfermería más precisa, además de subsidios para prevenir la violencia obstétrica. Palabras clave (Fuente: DeCS) Enfermería; formación de concepto; violencia obstétrica; violencia contra la mujer; salud de la mujer. Violencia obstétrica: análisis conceptual en el marco de la Enfermería O bs te tr ic V io le nc e: A C on ce pt ua l A na ly si s in t he N ur si ng C on te xt 5 Violência obstétrica: análise conceitual no contexto da enfermagem Resumo Objetivo: analisar o conceito de “violência obstétrica” no contex- to da enfermagem, a partir da identificação de seus antecedentes, atributos e consequentes. Materiais e método: trata-se de uma análise conceitual, a qual segue o método proposto pelo modelo de Walker e Avant, que consiste em oito etapas. Para contemplar o ob- jetivo do estudo, foram utilizadas seis etapas: seleção do conceito; delimitação dos objetivos da análise; identificação dos usos do con- ceito na literatura; determinação dos atributos essenciais; identi- ficação dos antecedentes e consequentes do conceito, e definição das referências empíricas do conceito. Resultados: a amostra foi composta de 22 estudos. Foram evidenciados 31 antecedentes: 24 atributos para a violência física; 35, para a psicológica/emocional; 6, para a institucional; 6, para a violência sexual e 5, para a violên- cia estrutural. No tocante aos consequentes, foram encontrados 39 elementos. Conclusões: o estudo contribui para a ciência da enfer- magem, a pesquisa e a prática clínica, uma vez que fornece suporte científico com discussão profunda do fenômeno, apresentando, de forma detalhada, os antecedentes, atributos e consequentes da vi- olência obstétrica. Isso possibilita ao profissional de enfermagem reconhecer os indicadores empíricos do conceito; assim, é provável que ele conte com mais conhecimento que o conduza a uma as- sistência de enfermagem mais precisa, além de subsídios para pre- venir a violência obstétrica. Palavras-chave (Fonte: DeCS) Enfermagem; formação de conceito; violência obstétrica; violência contra mulher; saúde da mulher. 6 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 22 - V O L. 2 2 N º 4 - CH ÍA , C O LO M BI A - O CT U BR E- D IC IE M BR E 20 22 | e 22 48 Introduction The obstetric violence (OV) phenomenon has several titles, such as violence during labor, cruel treatment during delivery, disrespect and abuse, institutional violence, and violence in cases of abortion and post-abortion, among others (1). The concept’s framework is not only found in the medical area but also in human rights and in other health professions. Such significant complexity generates semantic and conceptual discussions (2). Although a complex phenomenon, it is understood OV relates to the acts of violence committed during prenatal care, at delivery, in postpartum, and during the puerperium, in which there is dis- respect for women’s physical integrity and mental health, as well as loss of autonomy in terms of choices, feelings, or both (3). Since 2014, the World Health Organization (WHO) has considered OV a public health problem directly affecting women and newborns (4). Corroborating the WHO statement, a study carried out with 409 puerperal women at a specialized comprehensive hospital in the Amhara region, northwestern Ethiopia, evidenced that three out of four (75.1 %) women reported having suffered at least one type of OV during labor and delivery. The OV types were as follows: non-con- sensual care —260 women (63.6 %); undignified care —226 wom- en (55.3 %); physical abuse —192 women (46.9 %); non-confidential care —132 women (32.3 %); neglected care —52 women (12.7 %), and discriminated care —38 women (9.3 %) (5). It is noted that these numbers can be significantly higher due to women’s lack of under- standing to identify the acts of violence, which leads to the under- reporting of cases. The need for changes in care during pre-delivery, delivery, and birth, as well as professional training regarding the phenomenon, are essential to combat, minimize, or eradicate OV, an increasingly growing action (3). As essential players in a woman’s prenatal, delivery, and puerperi- um care, nurses should guarantee comprehensive care, emotional support, commitment to health, and exchange of knowledge and experiences, in addition to having scientific knowledge focused on the needs of each pregnant woman and evidence-based practices. To promote qualified, humanized, welcoming, and systematized as- sistance, it is indispensable to understand the OV phenomenon (6). Knowledge about the concept of OV needs to be expanded and im- proved, considering that there is no precise definition in the scientif- ic field (7), only complementary definitions, which makes it difficult to advance the knowledge of this phenomenon and its application. Despite the high recurrence of the phenomenon, no studies indi- cate its antecedents, attributes, and consequents, which hinders the professionals’ understanding, with the possibility of triggering O bs te tr ic V io le nc e: A C on ce pt ua l A na ly si s in t he N ur si ng C on te xt 7 consequences in the clinical practice (7). Thus, it becomes indis- pensable to clarify the concept. That said, the study presents the following guiding question: What are the essential attributes, antecedents, and consequents to determine the concept of OV in the Nursing context? In search of answers to the question, the study aims at identifying the es- sential attributes, antecedents, and consequents to determine the concept of OV in the Nursing context. Materials and Methods This conceptual analysis followed the method proposed by the Walker and Avant model (8), which consists of eight sequential or simultaneous stages. Six stages were used in this study, as they specifically contemplated the study object, with no need to build a model case or additional cases. Each stage is described below. l First stage: Selection of the concept — A concept that is im- portant and useful to deepen the theoretical developments in the area of interest should be chosen. l Second stage: Delimitation of the analysis objectives — In this stage, the researchers should define the analysis scope (8). l Third stage: Identification of different uses of the concept in the literature — A broad literature review is done using dictio- naries, thesaurus, available literature, and even friends and colleagues, identifying as many uses of the concept as pos- sible. In this initial phase, the analysis is not restricted to a single concept aspect. There is the possibility of considering all uses of the term in question. The authors indicate that it is necessary not to limit the research merely to the medical or nursing literature, as this can influence their understanding of the true nature of the concept (8). l Forth stage: Determination of the essential attributes — In this phase, the researchers must determine the attributes, which are words or expressions that characterize the phe- nomenon. In other words, they are the defining characteris- tics that express the phenomenon’s essence (8). l Fifth stage: Identification of the concept’s antecedents and consequents — They are useful to further refine the attri- butes. The authors define ‘antecedents’ as events or inci- dents that must occur or be present before the occurrence of the concept and ‘consequents’ as events or incidents result- ing from the occurrence of the concept. In other words, the results of the concept (8). l Sixth stage: Definition of the concept’s empirical references — It is the final stage of concept analysis. When a concept analy- sis is in its concluding phase, the question is how to measure 8 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 22 - V O L. 2 2 N º 4 - CH ÍA , C O LO M BI A - O CT U BR E- D IC IE M BR E 20 22 | e 22 48 this concept or determine its existence in the real world. They are categories or classes of observable phenomena that show the occurrence of the concept using an operational definition (8). In the first stage, the OV concept was selected considering the rel- evance in the professional practice and research of the authors of this study who investigate violence and vulnerability. The second stage is in line with the research objective. The third, fourth, fifth, and sixth stages were developed simultane- ously. In the third stage —Identification of the different uses of the concept in the literature, a systematic scoping literature review was carried out, as proposed by the recommendations outlined in the Joanna Briggs Institute Reviewer’s Manual (JBI [9]) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Exten- sion for Scoping Reviews checklist (PRISMA-ScR [10]). The review was registered in the Open Science Framework (OSF) platform at https://osf.io/682fr/. The research question —What are the essential attributes, an- tecedents, and consequents to determine the concept of OV in the Nursing context?— was determined through the PCC mnemonic, in which ‘P’ refers to participants (pregnant, parturient, and post- partum women). The first ‘C’ refers to the concept (OV, attributes, antecedents, and consequences) and the second one to the context (Nursing), following the PRISMA-ScR recommendations (10). As for the eligibility criteria, all types of studies related to pregnant, parturient, and puerperal women addressed the theme of OV. Its attributes, antecedents, and consequents linked to the Nursing area were included. In addition, studies of any nature, available in full without a time frame and in any language, were considered, exclud- ing duplicates indexed in more than one database. The search followed the recommendations proposed by the JBI (9) through three stages: the first corresponds to the initial search, developed in the Theses and Dissertations Catalog of Coorde- nação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), using the following health descriptors (DeCS): gestantes (pregnant women), parto (parturition), período pós-parto (postpar- tum period), violência (violence), and enfermagem (nursing) with crossings using the OR and AND Boolean operators. The second stage corresponds to the secondary search. It was con- ducted in the databases grouped according to the characteristics of each database, namely: LILACS (BVS), MEDLINE (PubMed), Scientif- ic Electronic Library Online (SciELO), American Psychological Asso- ciation PsycInfo and Institute of Education Sciences (ERIC), grouping the previously defined keywords. Therefore, the initial search string was as follows: (“saúde da mulher” OR parto OR “trabalho de par- to” OR “parto humanizado” OR “mulheres” OR “parto obstétrico”) O bs te tr ic V io le nc e: A C on ce pt ua l A na ly si s in t he N ur si ng C on te xt 9 AND (“violência contra a mulher” OR “violência” OR “obstetrícia” OR “violações dos direitos humanos” OR “exposição à violência”) AND (“enfermagem” OR “assistência à saúde” OR “humanização da assistência” OR “enfermagem obstétrica”). Subsequently, in the third stage, which consists of the list of ref- erences, the bibliographic references were analyzed and select- ed to choose the documents to be included and excluded from the study, as well as incorporating additional information. The selection of the relevant documents was carried out by two reviewers in a paired, thorough, and independent manner. Initial- ly, the titles and abstracts were read, excluding those papers that were incomplete or did not answer the questions established. Subsequently, the studies selected were read in full, excluding those that did not substantially portray the concept, antecedents, attributes, and consequences of OV in the Nursing context. Any and all divergences between the reviewers were discussed to reach a consensus, considering the study eligibility criteria and methodological rigor. The selection of the corresponding words in the databases resulted in 22 final articles according to the respective crossing strategy (Figure 1). Figure 1. Flowchart of the Summary of the Studies Source: Own elaboration. Total studies found (n = 4,237) Duplicated articles removed (n = 269) Studies selected to read their titles and abstracts (n = 3,968) Studies selected for complete reading (n = 98) Studies selected from the lists of references (n = 01) Final sample (n = 22) In cl u si o n Sc re en in g Id en ti � ca ti o n Studies excluded for not answering the research question or not meeting the inclusion criteria (n = 3,870) Studies excluded for not answering the research question (n = 76) LILACS (n = 782) MEDLINE (n = 3063) ScieLO (n = 317) PsycInfo (n = 44) ERIC (n = 31) 10 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 22 - V O L. 2 2 N º 4 - CH ÍA , C O LO M BI A - O CT U BR E- D IC IE M BR E 20 22 | e 22 48 After selecting the studies included to comprise the sample, the extracted data were analyzed according to the stages of determin- ing the essential attributes, identifying the antecedents and conse- quents of the concept, and defining the empirical references of it. The essential antecedents and consequents were critically analyzed and distributed according to what was addressed in the articles. The attributes were classified according to the OV typification. Only in the last stage the OV concept was extracted from the man- uscripts and transformed into a textual corpus for processing and analysis in the R Interface pour les Analyzes Multidimensionnelles de Textes et de Questionnaires (IR AMUTEQ) software. This program clearly structures the distribution of the vocabulary. By employing the similarity analysis, the results indicate the connection between the words, also distinguishing the common parts and the specifici- ties, resulting in a maximum tree (11). Consequently, it was possible to observe the terms that operationally define the concept of OV. It is worth noting that, as it is a review, it was not necessary to sub- mit this study to any research ethics committee. Results The sample comprised 22 studies from the national and internation- al literature published in journals devoted to Nursing or other relat- ed areas between 2013 and 2021 (Table 1). Table 1. Classification of the Articles Included in the Review Author Title (in its original language) Year Type of study Aguiar JM, D’Oliveira AFPL, Schraiber LB (12) Violência institucional, autoridade médica e poder nas maternidades sob a ótica dos profissionais de saúde 2013 Qualitative research Silva MG, Marcelino MC, Rodrigues LSP, Toro RC, Shimo AKK (13) Violência obstétrica na visão de enfermeiras obstetras 2014 Experience report Souza AB, Silva LCS, Alves RN, Alarcão ACJ (14) Fatores associados à ocorrência de violência obstétrica institucional: uma revisão integrativa da literatura 2016 Integrative literature review Antunes TCS (15) Violência obstétrica expressa no contexto das enfermeiras de uma maternidade pública do município do Rio de Janeiro 2017 Descriptive, exploratory, and qualitative Oliveira VJ, Penna CMM (16) O discurso da violência obstétrica na voz das mulheres e dos profissionais de saúde 2017 Interpretive, with a qualitative approach Zanardo GLP, Calderón M, Nadal AHR, Habigzang LF (17) Violência obstétrica no Brasil: uma revisão narrativa 2017 Literature review Marrero L, Brüggemann OM (18) Violência institucional durante o processo parturitivo no Brasil: revisão integrativa 2018 Integrative review Moura RCM, Pereira TF, Rebouças FJ, Costa CM, Lernades AMG, Silva LK A et al. (19) Cuidados de enfermagem na prevenção da violência obstétrica 2018 Integrative literature review Perera D, Lund R, Swahnberg K, Schei B, Infanti JJ (20) ‘ When helpers hurt’: Women’s and midwives’ stories of obstetric violence in state health institutions, Colombo district, Sri Lanka 2018 Field work Miranda FL, Velloso GS, Lima PO, Rangel SC, Almeida HF, Pinheiro MLP et al. (21) Violência obstétrica: percepções de enfermeiros obstétricos em uma maternidade de Minas Gerais 2019 Descriptive and exploratory, with a qualitative approach O bs te tr ic V io le nc e: A C on ce pt ua l A na ly si s in t he N ur si ng C on te xt 11 Author Title (in its original language) Year Type of study Nascimento SL, Pires VMMM, Santos NA , Machado JC, Meira LS, Palmarella VPR (22) Conocimiento y vivencias de violencia obstétrica en mujeres que han vivido la experiencia del parto 2019 Descriptive and of a qualitative nature Souza ACAT, Lucas PHCS, Lana TC, Lindner SR, Amorim T, Felisbino-Mendes MS (23) Obstetric violence: Integrative review 2019 Integrative review Campos VS, Morais AC, Souza ZCSN, Araújo PO (24) Conventional practices of childbirth and obstetric violence under the perspective of puerperal women 2020 Qualitative, descriptive, and exploratory Castro ATB, Rocha SP (25) Violência obstétrica e os cuidados de enfermagem: reflexões a partir da literatura 2020 Literature review Menezes FR, Reis GM, Sales A AS, Jardim DMB, Lopes TC (26) O olhar de residentes em enfermagem obstétrica para o contexto da violência obstétrica nas instituições 2020 Descriptive and exploratory, with a qualitative approach Mena-Tudela D, Gasch- Cervera A , Alemany-Anchel MJ, Andreu-Pejó L, Gonzálzes-Chordá VM (27) Design and validation of the PercOV-S Questionnaire for measuring perceived obstetric violence in nursing, midwifery and medical students 2020 Instrumental design Pascoal KCF, Filgueiras TF, Carvalho MA , Candeia RMS, Pereira JB, Cruz R AO (28) Violência obstétrica na percepção de puérperas 2020 Field study Paula E, Alves VH, Rodrigues DP, Felicio FC, Araújo RCB, Chamilco R ASI et al. (29) Obstetric violence and the current obstetric model, in the perception of health managers 2020 Descriptive and exploratory, with a qualitative approach Ribeiro DO, Gomes GC, Oliveira AMN, Alvarez SQ, Gonçalves BG, Acosta DF ( 30) Obstetric violence in the perception of multiparous women 2020 Qualitative, of a descriptive and exploratory nature Silva MI, Aguiar RS ( 31) Knowledge of nurses of primary care about obstetric violence 2020 Descriptive- exploratory, with a qualitative approach Texeira PC, Antunes LS, Duamarde LTL, Velloso V, Faria GPG, Oliveira TS ( 32) Percepção das parturientes sobre violência obstétrica: a dor que querem calar 2020 Descriptive and exploratory, with a quali-quantitative approach Zancheta MS, Santos WS, Souza K V, Pina VR, Hwu H, Stahl H et al. ( 33) Amplifying voices on obstetric violence: Recommendations for advocacy by an obstetric nurse 2021 Exploratory research Source: Own elaboration. Regarding the analysis of the empirical indicators, the term ‘woman’ was identified as the most prevalent in the documents, followed by ‘autonomy,’ ‘body,’ ‘reproductive processes,’ ‘deliv- ery,’ ‘natural process,’ ‘medicalization,’ ‘abusive,’ ‘unnecessary,’ ‘pathologization,’ ‘medication abuse,’ ‘body appropriation,’ ‘de- humanized,’ ‘postpartum,’ ‘assistance,’ ‘ability,’ ‘decision,’ ‘health professionals,’ ‘loss,’ and ‘physical integrity’ (Figure 2). The antecedents related to OV were organized (Table 2), repre- senting the main risk factors that led to the occurrence of these instances. Antecedents associated with the women themselves, health professionals, institutions, and legislation were identi- fied. The most frequent elements were ‘unfavorable financial conditions,’ ‘black-skinned women,’ and ‘lack of knowledge about the theme.’ 12 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 22 - V O L. 2 2 N º 4 - CH ÍA , C O LO M BI A - O CT U BR E- D IC IE M BR E 20 22 | e 22 48 Figure 2. Similarity Analysis Source: IR AMUTEQ, 2021 (11). Table 2. Concept Analysis Antecedents Antecedents of the OV concept Elements Numbers of the references Frequency Unfavorable financial conditions (12, 15, 17, 18, 20, 23, 26, 27, 29, 30) 10 Black-skinned women (12, 15, 17, 18, 20, 23, 26, 30, 32, 33) 10 Lack of knowledge about the theme (15-18, 22, 25, 26, 28, 31, 32) 10 Inadequate infrastructure (13-16, 20, 21, 23, 26) 8 Lower schooling levels (15, 17, 20, 23, 26, 27, 32) 7 Unqualified professionals (14, 15, 21, 22, 26, 27, 29) 7 Naturalization and perpetuation of the practices (12, 15, 17, 24-26) 6 Precariousness in terms of materials and resources (12, 14, 15, 23, 26, 33) 6 O bs te tr ic V io le nc e: A C on ce pt ua l A na ly si s in t he N ur si ng C on te xt 13 Antecedents of the OV concept Elements Numbers of the references Frequency Women’s lack of knowledge in relation to their sexual and reproductive rights (20, 22, 23, 30, 32) 5 Ethnic minorities (15, 18, 20, 27, 32) 5 Adolescents (12, 15, 20, 30) 4 Work overload (14, 20, 23, 26) 4 Non-existence of specific legislation addressing OV (17, 23, 24) 3 Lack of knowledge about own body and the delivery-physiological processes (15, 24, 25) 3 Impunity of acts (12, 16, 21) 3 Stress/Authoritarianism on the part of the professionals (15, 23, 30) 3 In abortion situation (15, 26) 2 Homosexuals (15, 32) 2 Inmates (15, 30) 2 High number of children (12, 30) 2 Immigrants (15, 20) 2 Professionals’ low wages (14, 16) 2 Sex workers (30) 1 Drug users (30) 1 Living on the street (30) 1 Protestants (32) 1 Single women (15) 1 Unwanted pregnancy (15) 1 HIV-positive women (15) 1 Family culture (25) 1 Women with no companion (30) 1 Source: The authors’. The attributes identified were organized according to the ty- pologies (Table 3). The following terms stood out in physical vi- olence: ‘episiotomy/episiorrhaphy,’ ‘unwarranted cesarean sec- tions,’ ‘oxytocin use;’ in psychological/emotional violence, the most prevalent attributes highlighted were ‘humiliations’ and ‘providing false information or omitting information.’ In turn, institutional violence had the following as its main attribute: ‘not allowing the presence of a companion;’ the sexual violence typology had ‘repetitive vaginal touch examination’ as an attri- bute; finally, the ‘lack of human and material resources’ attribute stands out in structural violence. 14 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 22 - V O L. 2 2 N º 4 - CH ÍA , C O LO M BI A - O CT U BR E- D IC IE M BR E 20 22 | e 22 48 Table 3. Concept Analysis Attributes Attributes of the OV concept Physical violence Elements Numbers of the references Frequency Episiotomy/episiorrhaphy (13, 14, 17, 18, 20, 22-26, 28, 32) 12 Unwarranted cesarean sections (12, 13, 15, 17, 18, 20, 22, 25, 26, 28, 32, 33) 12 Oxytocin use (13, 15, 18, 22, 23-26, 32) 9 Kristeller maneuver (15, 18, 22, 23, 25, 26, 27, 32) 8 Lithotomy position at birth (17, 18, 23-25, 28, 29, 32) 8 Unnecessary interventions or procedures or performed without due consent (14, 15, 17, 21, 27, 28, 30, 33) 8 Denial of any type of pain relief (14, 17, 18, 25, 29, 30, 32) 7 Restriction to the bed (18, 23-25, 26, 29, 30) 7 Trichotomy (17, 22, 23, 25, 26, 30, 32) 7 Not using analgesics when indicated (12, 15, 16, 21, 27, 31, 33) 7 Aggressions (12, 14, 15, 18, 24, 27) 6 Performance of enema (15, 17, 22, 25, 28) 5 Prohibition of eating or drinking (23, 25, 32) 3 Excessive medicalization (14, 17, 21) 3 Amniotomy (23, 24, 32) 3 Preventing skin-to-skin contact (15, 17, 32) 3 Trivialization of pain (20, 30) 2 Use of forceps (25, 32) 2 Prolonged bed rest (22, 32) 2 Valsalva maneuver (23, 24) 2 Causing pain (12, 18) 2 Walking in the last stage of delivery (30) 1 Not allowing immediate mother-infant contact immediately after birth (29) 1 Invasive procedures performed on newborns that show good vitality (15) 1 Psychological/Emotional violence Elements Numbers of the references Frequency Humiliations (14, 17, 18, 23, 25, 27, 28, 31, 32) 9 Providing false information or omitting information (15, 18, 19, 23, 24, 29, 30, 32) 8 Threats (16, 18, 25, 28, 30, 31) 7 Yelling (14, 16, 18, 25, 31, 32) 6 Abandonment (18, 20, 24, 26, 32) 5 Disrespect (12, 26, 27, 28, 30) 5 Reproaches (14, 16, 18, 31, 32) 5 Imposition of decisions/values (15, 18, 19, 26) 4 Rude manners (12, 30, 31, 32) 4 Curses (14, 18, 25) 3 Disqualification of the woman’s choices (18, 30) 2 Denial of care (18, 26) 2 Trivialization of the woman’s suffering or needs (18, 20) 2 Teasing (15, 17) 2 Devaluation of women complaints (15, 24) 2 Impatience (26, 30) 2 O bs te tr ic V io le nc e: A C on ce pt ua l A na ly si s in t he N ur si ng C on te xt 15 Embarrassment (18) 1 Hostile treatment (17) 1 Irony (17) 1 Coercion (17) 1 Disrespect towards beliefs and cultures (15) 1 Judgment (26) 1 Lack of welcoming (29) 1 Coldness (15) 1 Harshness (15) 1 Ironic phrases (26) 1 Harsh speeches (26) 1 Authoritarian behaviors (16) 1 Derogatory words (16) 1 Mockery (28) 1 Moralistic speeches (30) 1 Changes in the tone of the voice (23) 1 Coarse treatment (18) 1 Offenses (27) 1 Pejorative comments (26) 1 Institutional violence Elements Numbers of the references Frequency Not allowing the presence of a companion (12, 14, 15, 17, 23-26, 28, 29, 32, 33) 12 Pilgrimage in search of assistance (15, 18, 25) 3 Refusal of admission to health institutions and retention of women and their newborns in the institutions (27, 32, 33) 3 Not allowing breastfeeding (15, 32) 2 Not having the opportunity to get to know the maternity ward and the professionals who will assist them (19) 1 Difficulty accessing prenatal services or poor- quality care (15) 1 Sexual violence Elements Numbers of the references Frequency Repetitive vaginal touch examination (15, 18, 22, 25, 28, 32) 6 Invasion to the woman’s privacy (17, 26, 27, 33) 4 Sexual abuse (17, 30-32) 4 Sexual harassment (17) 1 Unnecessary exposure of intimacy (30) 1 Breast clinical examination without due consent and without information (15) 1 Structural violence Elements Numbers of the references Frequency Lack of human and material resources (18) 1 Inadequate infrastructure (18) 1 Insufficient number of beds (18) 1 Imposition of institutional routines (18) 1 Shortage of professionals (12) 1 Source: The authors’. 16 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 22 - V O L. 2 2 N º 4 - CH ÍA , C O LO M BI A - O CT U BR E- D IC IE M BR E 20 22 | e 22 48 The main OV consequences found in the literature were organized (Ta- ble 4). It was observed that the interventions performed caused sig- nificant physical and psychological sequelae for women’s life and mar- ital and maternal relationships, as well as traumas. In addition, they had consequences for the newborns, which could lead to their death. The following stand out among the consequents: ‘maternal and child morbidity and mortality,’ ‘loss of the woman’s autonomy at delivery,’ ‘emotional and psychological harms,’ and ‘physical harms.’ Table 4. Concept Analysis Consequents Consequents of the OV concept Elements Numbers of the references Frequency Maternal-child morbidity and mortality (13-17, 19, 25, 26, 28, 30) 10 Loss of the woman’s autonomy at delivery (15-17, 23-26, 29, 32) 9 Emotional and psychological harms (12, 14, 22, 25-28, 32) 8 Physical harms (12, 14, 26, 27, 28, 30, 32) 7 Pain (15, 26, 27, 32) 4 Repercussions for the woman’s sexual and reproductive health (14, 15, 27, 32) 4 Negative influence on the pregnancy and delivery physiological process (21, 29, 31) 3 Third- and fourth-degree perineal laceration (14, 15, 22) 3 Infection (14, 15, 22) 3 Hemorrhage (14, 15, 22) 3 Trauma (16, 32) 2 Depersonalization of the woman (29, 30) 2 Urinary and fecal incontinence (14, 22) 2 Fetal distress (24, 32) 2 Fear (15, 18) 2 Insecurity (15, 18) 2 Negative effects on the mother-child bond (15, 25) 2 Negative impact on women’s quality of life (25) 1 Discrediting women and their physiological ability to give birth (21) 1 Loss of privacy (16) 1 Child’s developmental inability (28) 1 Early hospitalization of women (32) 1 It can lead to surgical delivery (32) 1 It impairs blood flow and oxygen to the infant (32) 1 It hinders and increases duration of labor and pain intensity during contractions (32) 1 Low self-esteem (32) 1 Loss of trust in the professionals (32) 1 Tachysystole (24) 1 Hypertonia (24) 1 O bs te tr ic V io le nc e: A C on ce pt ua l A na ly si s in t he N ur si ng C on te xt 17 Consequents of the OV concept Elements Numbers of the references Frequency Uterine hyperstimulation, uterine rupture or both (24) 1 Loneliness (18) 1 Loss of the uterus (27) 1 Stress (27) 1 Edema (15) 1 Episiorrhaphy endometriosis (15) 1 It makes it difficult to initiate breastfeeding, as well as duration of exclusive breastfeeding (15) 1 Respiratory problems for the newborn (15) 1 Difficulty in the care targeted at the newborns and their development (15) 1 Intensification of the difficulty to access health services (14) 1 Source: Own elaboration. Discussion The expressions or terms presented using the similarity analysis evidence that the phenomenon can occur during prenatal care, delivery, the puerperium, in case of abortion, and when there are violations of the woman’s human rights and integrity, loss of autonomy and decision-making. The findings of this research point to empirical indicators that operationally define the con- cept of OV, which contributes to clarifying the phenomenon and providing theoretical support for nurses to timely identify the occurrence and intervene appropriately. The category of the antecedents identifies that, for the occur- rence of OV, several factors involved are related not only to the woman but to the entire pregnancy-puerperal process. The fol- lowing stand out, unfavorable financial conditions, skin color, schooling level, lack of knowledge about the theme, inadequate infrastructure, precariousness in terms of materials and resourc- es, and unqualified professionals. Black-skinned women (12, 15, 17, 18, 20, 23, 26, 30, 32, 33) with unfavorable financial conditions (12, 15, 17, 18, 20, 23, 26, 27, 29, 30), lower schooling levels (15, 17, 20, 23, 26, 27, 32), and ethnic minorities (15, 18, 20, 27, 32) are targets more prone to violent practices, mainly routine interventions and absence of a com- panion. In addition, many women of low socioeconomic status with low schooling levels had limited access to prenatal consul- tations, which further led to disinformation about labor and de- livery (34). In a study carried out with nine low-income and black-skinned wom- en in northeastern Brazil, physical, verbal, and institutional OV in- stances were reported. There were practically no reports of respect 18 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 22 - V O L. 2 2 N º 4 - CH ÍA , C O LO M BI A - O CT U BR E- D IC IE M BR E 20 22 | e 22 48 for women during delivery and minimal obstetric interventions (2). The greater a woman’s vulnerability, the ruder and more derogatory the treatment she was offered (35). Secondly, adolescents (12, 15, 20, 30), sex workers (30), drug users (30), homeless women (30), homo- sexuals (15, 32), and inmates (15, 30) are more prone to negligence and omission of care (30). A research study conducted with Chilean women evidenced that those with low schooling levels, minors, homosexuals, and indige- nous reported more OV cases, mainly those treated in the public health system (36). Lack of knowledge about the theme (15-18, 22, 25, 26, 28, 31, 32) was a significant finding of an OV antecedent. A study conducted in In- dia with 305 women identified that 257 suffered some disrespect and abuse; of this total, 89.1 % answered “no” when asked about any treat- ment they considered humiliating. This reveals that this type of vio- lence is seen as something normal when knowledge is inadequate (37). However, when understanding the act, the answers were notably different, as revealed by a survey carried out in Spain, in which 17,541 questionnaires were delivered, 38.3 % realized that they had suffered OV and 44.4 % perceived that they were subjected to un- necessary or painful procedures, of which 83.4 % were not asked for their due informed consent (7). Naturalization and perpetuation of the practices (12, 15, 17, 24-26), an OV antecedent, such as pain related to delivery (38), is also as- sociated with a lack of knowledge on the topic. It is believed that delivery is a painful process, naturalizing the unfavorable situations experienced by the women and not recognizing some procedures as violence but common and routine situations (39). Knowledge about the body and the physiology of delivery favors the reduction of vulnerability, the fight against OV and women’s empowerment, ensuring their rights and autonomy and counter- acting abusive actions performed by professionals. The following stand out among the antecedents related to health pro- fessionals and institutions: unqualified professionals (14, 15, 21, 22, 26, 27, 29), work overload (14, 20, 23, 26), the professionals’ low wages (14, 16), stress/authoritarianism on the part of the professionals (15, 23, 30), inadequate infrastructure (13-16, 20, 21, 23, 26), precariousness in terms of materials and resources (12, 14, 15, 23, 26, 33) and impunity of acts (12, 16, 21). Due to a lack of training and adequate working conditions —especially associated with insufficient materials and resources, obstetric care quality becomes increasingly dehuman- ized, causing emotional stress and overload in professionals (40). The professionals’ inability to offer qualified assistance, which allows for predicting violence and intervening, reflects a society that has al- ways naturalized violent behaviors and procedures as non-violent. In O bs te tr ic V io le nc e: A C on ce pt ua l A na ly si s in t he N ur si ng C on te xt 19 addition, the professional-user hierarchy, with unilateral author- ity, tends to lead professionals to verbalize and perform violent techniques or both without noticing that they are, in fact, vio- lent (41). Therefore, it is fundamental that professionals know the OV antecedents, attributes, and consequents to provide good quality care throughout the pregnancy-puerperal process. The attributes, which are essential characteristics of the phe- nomenon, were grouped according to the type of violence into physical, psychological or emotional, institutional, sexual, and structural, which allowed for a better understanding of OV. Among the attributes included in the category of physical OV, in- terventions and procedures that are unnecessary or performed without due consent (14, 15, 17, 21, 27, 28, 30, 33) stand out, as well as oxytocin use (13, 15, 18, 22-26, 32), episiotomy and episiorrha- phy (13, 14, 17, 18, 20, 22-26, 28, 32), Kristeller maneuver (15, 18, 22, 23, 25-27, 32), constant use of forceps (25, 32), denial of any type of pain relief (14, 17, 18, 25, 29, 30, 32) whether by means of non-pharmacological methods or not, restriction to the bed (18, 23, 24-26, 29, 30), prohibition of eating or drinking (23, 25, 32), enema (15, 17, 22, 25, 28), trichotomy (17, 22, 23, 25, 26, 30, 32), which includes unnecessary removal of pubic hair, and manda- tory lithotomy position at birth (17, 18, 23-25, 28, 29, 32), which causes increased pain and slows down the delivery process. These attributes are mentioned in several interviews with women in maternity hospitals in the Czech Republic (42). In another re- search study carried out in a hospital in Azuay, Ecuador, the wom- en also reported these attributes they characterized as types of physical violence (43). These studies corroborate the results found in the current one, validating the essence of the phenomenon. Some women point out another perception about the Kristeller maneuver and oxytocin administration. In a research study carried out with 57 puerperal women in the central area of the Huasteca region of San Luis Potosí, Mexico, it was reported that these procedures are an act of gratitude towards the mothers at delivery, as they help the infant to descend more quickly and minimize moments of prolonged suffering (44). However, when episiotomy and episiorrhaphy were mentioned (44), the women’s reports of actually feeling OV were unanimous, mainly in cases where they were not informed. This agreement is observed in several pieces of scientific evidence (16, 43, 44). Despite the efforts to seek humanization in obstetric care, the following is clearly noticeable: predominance of interventional procedures such as excessive medicalization (14, 17, 21), trivializa- tion of the pain felt by the women (20, 30), not using analgesics when indicated (12, 15, 16, 21, 27, 31, 33), forcing parturient women to walk in the last stage of delivery (30) without their consent, 20 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 22 - V O L. 2 2 N º 4 - CH ÍA , C O LO M BI A - O CT U BR E- D IC IE M BR E 20 22 | e 22 48 prolonged bed rest (22, 32), aggressiveness (12, 14, 15, 18, 24, 27), and performing an amniotomy (23, 24, 32) and the Valsalva maneuver (23, 24), which refers to encouraging voluntary push, with unequal power relations between professionals and women prevailing (16). Physical violence is more prevalent because it is more easily iden- tifiable among women, as shown by a research study carried out at a public hospital in North Shewa, Amhara, Ethiopia. It was pointed out that 100 % (435) of the women identified some of these attri- butes that characterize OV related to physical characteristics (45). The following attributes stand out in the psychological OV category: humiliation (14, 17, 18, 23, 25, 27, 28, 31, 32), teasing (15, 17), providing false information or omitting information (15, 18, 19, 23, 24, 29, 30, 32), yelling (14, 16, 18, 25, 31, 32), threats (16, 18, 25, 28, 30-32), disqualifi- cation of women’s decisions (18, 30), denial of care (18, 26), abandon- ment (18, 20, 24, 26, 32), embarrassment (18), imposition of decisions/ values (15, 18, 19, 26), trivialization of women’s suffering or needs (18, 20), reproaches (14, 16, 18, 31, 32), ironic phrases (17), and coldness (15). The harms caused by psychological OV go beyond the physical as- pect, leaving emotional and psychological scars for a long time, un- dermining the emotional realm and bringing about consequences that negatively interfere with the puerperal period, a delicate mo- ment for puerperal women (46). It should be noted that these prob- lems can lead to postpartum depression (47). In an analysis of the notifications of pregnant women in Brazil be- tween 2011 and 2018, with 2,033,026 cases, the type of violence with the highest incidence was physical (61.9 %), followed by psychologi- cal (31.2 %) and lastly, sexual (27 % [48]). The incidence of reports that mention the essential characteristics of the phenomenon, that is, the attributes, is considerably high. A multicenter survey carried out in the United States with 2,138 women indicates that one out of six (17.3 %) mentions some type of abuse, such as yelling, disrespect, unknown or erroneous informa- tion, denial of care, embarrassment, and loss of decision-making autonomy. It is believed that more women have suffered psycho- logical violence, although they could not identify it (49). From the institutional category perspective, the attribute with the highest incidence was not allowing the presence of a companion (12, 14, 15, 17, 23-26, 28, 29, 32, 33). Brazilian women are supported by the Companion Law (Law 11,108) of April 7th, 2005, which allows for the presence of a companion during delivery, childbirth, and the immedi- ate postpartum period, either in private or public health services (50). Although supported by law, qualitative studies (51, 52) still notice reports of Brazilian women who claimed they were not allowed to have a companion and accepted so due to lack of information, even with distress. O bs te tr ic V io le nc e: A C on ce pt ua l A na ly si s in t he N ur si ng C on te xt 21 In the sexual OV category, the most characteristic attributes were a repetitive vaginal touch (15, 18, 22, 25, 28, 32), invasion of privacy (17, 26, 27, 33), sexual abuse (17, 30-32), and unnecessary exposure of intimacy (30). Repeatedly touching the vagina can cause harm, such as inciting premature birth and infection in the infant (53) and inducing pain and discomfort. In a study, Mexican women mentioned that they feel unnecessarily invaded in their privacy and exposed, with sever- al touches practically at the same time, reporting that there seems to be no communication between the health professionals (44). A shocking report in a research study conducted in northern Brazil reveals that the health professional performed the vaginal touch examination and asked all the students present to repeat the procedure, causing discomfort, invasion of privacy and ex- posure of the woman’s intimacy (53). This scenario proves to be totally inhuman to the woman. That is a reality not only in Brazil but also in other countries, such as Iran, where the prevalence of sexual OV stands out in relation to the other types. This assertion is indicated in a study conduct- ed with 725 women, in which 14.8 % suffered sexual violence, 9.9 % were victims of psychological violence, and 6.5 % of phys- ical violence. Domestic sexual abuse was also very evident (48). Finally, the structural OV attributes refer to precarious assistance or omission to the detriment of the infrastructure (18), lack of hu- man and material resources (18), lack of beds (18), imposition of institutional routines (18) and shortage of professionals (12). This is more likely to occur in public institutions before the woman’s hospitalization, affecting both her and the professionals, which entails overload and undignified working conditions (18). These attributes are proven through diverse evidence in prac- tice. During data collection, nurse-researchers noticed a deficit in terms of equipment and a lack of necessary maintenance, es- pecially in the public sector, in addition to communication diffi- culties between professionals and the absence of adequate signs in the environment (14). In the category of the OV phenomenon consequents, resulting events or incidents were detected, such as loss of women’s au- tonomy, emotional and psychological harms, and maternal and child morbidity and mortality. When a woman loses her autonomy during delivery (15-17, 23-26, 29, 32), her primary role is obliterated, in addition to her deci- sion-making power. For this gap, it is recommended that wom- en look for a support network during prenatal care to acquire knowledge (54). 22 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 22 - V O L. 2 2 N º 4 - CH ÍA , C O LO M BI A - O CT U BR E- D IC IE M BR E 20 22 | e 22 48 The formation of groups of pregnant women in southern Brazil showed that those who regularly participated in the meetings were able to enjoy significant autonomy and were willing to argue and impose their wishes, showing greater awareness of the delivery moment (55). Other terms presented as OV consequents were emotional and psychological harms (12, 14, 22, 25-28, 32), fear (15, 18), insecurity (15, 18) and loneliness (18). These terms corroborate a research study conducted in north- eastern Brazil, in which the puerperal women mentioned having suffered emotional and psychological consequences, resulting in frustration, anger, anguish, and impotence. In the interviews, it is possible to see hints of postpartum depression and trauma after the episiotomy procedure. Consequently, the same women reported that these problems affected their sex lives (52). In the findings of the current study, episiotomy, an OV attribute, re- fers to the following consequences: third- and fourth-degree peri- neal laceration (14, 15, 22), infection (14, 15, 22), intense bleeding (14, 15, 22), urinary and fecal incontinence (14, 22), edema (15), and epi- siorrhaphy endometriosis (15). Although uncommon, episiorrhaphy endometriosis is more prevalent in women who have undergone at least one episiotomy and in cases of vaginal deliveries with curet- tage to avoid hemorrhages and uterine subinvolution (56). Procedures considered routine and standardized in health services, without indication, can cause or intensify pain (15, 26, 27, 32), physi- cal harm (12, 14, 26-28, 30, 32), and unnecessary suffering. In view of this, the importance of dialogue between professionals, especially nurses, and pregnant women is emphasized, in addition to provid- ing fundamental information about the pregnancy-puerperal pro- cess and encouraging self-knowledge about their bodies, role, and decision-making power (57). An important OV consequence is maternal and child morbidity and mortality (13-17, 19, 25, 26, 28, 30) during labor and the puerperium, mainly due to cesarean sections without indication, which intensi- fies the likelihood of respiratory problems for the newborn (15) and triples the mother’s mortality risk, in addition to the possibility of also causing loss of the uterus (27). OV can lead to maternal morbidity and mortality due to several fac- tors, such as adverse events related to aggressive management of vaginal and cesarean deliveries, neglect to perceive the suffering ex- perienced by the woman, hostility, negligence, and delay in assisting women who are having an abortion —spontaneous or desired— and not allowing the presence of a companion (51). Finally, it is crucial that nurses are aware of the OV phenomenon and duly trained and able to identify it and intervene in a timely O bs te tr ic V io le nc e: A C on ce pt ua l A na ly si s in t he N ur si ng C on te xt 23 manner, offering humanized, comprehensive, empathetic, and qualified assistance. It is believed that this concept analysis contributes to Nursing sci- ence, research, and clinical practice, considering that it provides scientific support with a deep discussion of the phenomenon, presenting the OV antecedents, attributes, and consequents in detail. This enables nurses to recognize the empirical indicators of the concept; thus, it is likely that they will have a greater knowl- edge that will lead them to more precise Nursing care in the clin- ical practice. As a limitation, we cite non-elaboration of the model case and additional cases; however, there was an in-depth analysis of em- pirical bases and compliance with methodological rigor. Conclusions In this research, it was possible to analyze the OV concept, identifying 76 related attributes, 31 antecedents, and 39 conse- quents. The study made it possible to contribute greater clarity to the phenomenon, offering theoretical and scientific support for nurses to identify OV cases and contributing to the evolution of Nursing epistemology. The multidimensionality of the topic studied was comprehen- sively observed, as it presents several typifications, each with their respective essential characteristics, in addition to their multiple antecedents and consequents in the scenario of OV during the pregnancy-puerperal period. Conflict of interest: None declared. Funding: There were no funding sources. References 1. Mena- Tudela D, Cervera-Gasch A , Andreu-Pejó L, Ale- many-Anchel MJ, Valero-Chillerón MJ, Peris-Ferrando E et al. Perception of obstetric violence in a sample of Spanish health sciences students: A cross-sectional study. Nurse Educa- tion Today. 2022;110:105266. 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