Introduction
Obstetric violence is a form of aggression toward women who use maternal health services, including pregnancy, childbirth, postpartum care, and even abortion-related situations. This type of violence is manifested through mistreatment, abuse, and disrespect toward patients by health care professionals (WHO, 2014; Tobasía-Hege et al., 2019). Among the various practices that can be classified as obstetric violence are excessive or unjustified cesarean section, improper management or neglect of the patient’s pain, derogatory comments, humiliation, discrimination, and even disregard for humanized childbirth (Bitencourt 2023; Yalley et al., 2024).
Obstetric violence can lead to various adverse outcomes for the mother, not only at the physical or psychological level but also at the social level. Among the adverse consequences are postpartum depression and emotional or psychological trauma (Martinez-Vázquez et al., 2022), difficulty in bonding between the mother and newborn (Leite et al., 2023), and, above all, loss of trust in the health care system, resulting in less use of these services in future situations requiring medical intervention (Taghizadeh et al., 2021). 
In line with this, the prevalence of obstetric violence can vary depending on different health care systems, regions, or the population’s perception and tolerance. In high-income countries, this prevalence can reach up to 63% (Fraser et al., 2024). However, very high rates have also been reported, such as in Peru, where 97.4% of postpartum women have experienced some form of disrespect during childbirth (Montesinos-Segura et al., 2018). Therefore, this common practice may go unnoticed during patient care, leading to short-term and long-term adverse outcomes (Perera et al., 2022).
Due to the impact of obstetric violence and its nature as a behavior of health care professionals, various countries (e.g. Venezuela, Argentina, Bolivia, México) have enacted legislation or regulations to change the statistics and provide comfort to all users of obstetrics and reproductive health services (Williams et al., 2018).
Through a documentary analysis with a bibliometric approach, it is possible to conduct a global mapping of scientific production and identify the most prolific countries (Öztürk et al., 2024). Moreover, this mapping allows for exploring research trends and whether they relate to implementing health policies or regulatory frameworks in different countries. This study aimed to conduct a bibliometric analysis of global scientific output on obstetric violence to inform future research directions.

Materials and Methods

Study design
This study has a descriptive and observational design based on previously published secondary data with a bibliometric approach.

Sources of information
The data were collected from the Scopus bibliographic database via a systematic search. Compared to other databases, such as Dimensions or Google Scholar, Scopus offers higher-quality content with journals of significant impact. Unlike these alternatives, Scopus does not include grey literature, ensuring a more curated selection of academic publications. However, compared to Web of Science, Scopus provides a broader range of documents, as the latter’s stricter indexing criteria may lead to the exclusion of relevant studies. In bibliometric studies focusing on citation analysis, relying on a single database is ideal. This approach ensures that citations are drawn from within the same dataset, maintaining quality and comparability across the documents analyzed. This methodological rigor enhances the reliability of bibliometric evaluations (Singh et al., 2021).

Data retrieval
On the main page of Scopus, we accessed the advanced search option and entered the developed search strategy. The search strategy was developed using the terms “violence” and “pregnant woman” or “childbirth,” excluding possible terms that could cause confusion, such as “partner violence”: (TITLE ( obstetric OR midwife* OR childbirth OR partum OR “delivery labor” )) AND ( TITLE (abuse OR disrespect OR violence OR mistreatment OR “abuse during childbirth” OR “abuse during partum”)) AND NOT (TITLE (drug* OR substance OR “birth cohort” OR nicotine OR domestic OR intimate OR sexual OR “child abuse” OR “workplace” OR partner OR interpersonal OR newborn* OR gender OR “fear of childbirth” OR “lesser-known”)). The document search was carried out on October 15, 2024.
The search strategy was designed based on the principle of exhaustiveness, aiming to cover as much relevant literature as possible. To achieve this, general and frequently used terms related to the study topic, such as “abuse” and “disrespect,” were identified. These terms were selected because, despite their generality, they represent broad concepts that encompass multiple dimensions of the issue at hand (Dekkers et al., 2022). 

Selection criteria
All documents retrieved from the search were included, excluding those obtained outside the study period (2000–2024). The metadata was also reviewed to ensure all documents were included in the bibliometric analysis. There were no exclusions based on document type (editorial, letter, original article, review, case report, book or book chapter, or conference paper). This study included all documents retrieved from Scopus, ensuring comprehensive coverage. Unlike dimensions, Scopus excludes grey literature, such as monographs or unpublished essays, focusing solely on peer-reviewed and citable documents with citation metrics. Although the EQUATOR Network does not provide a specific guideline for bibliometric studies, it includes preliminary tools that support methodological transparency in this type of research. Our approach aligns with these principles, emphasizing replicability and clarity (EQUATOR Network, 2024).

Data analysis 
The bibliometric analysis was conducted using Biblioshiny, an interactive application integrated into the RStudio environment, and VOSviewer software, version 1.6.20 (van Eck & Waltman, 2010) for graph generation. First, the dataset was exported in comma-separated values file (CSV) format from the Scopus database after applying the defined search strategy and filters. This dataset was then imported into RStudio software, version 4.4.2, where the bibliometrix package (Aria & Cuccurullo, 2017) was loaded, and the biblioshiny () command was used to launch the interactive interface.
Within the Biblioshiny environment, several analyses were performed. The annual scientific production was evaluated using a second-order polynomial regression model to capture non-linear trends in the data over time. A polynomial equation is a mathematical expression that represents the sum of terms consisting of variables and coefficients, where the degree (n) determines the highest power of the variable in the equation. For this analysis, a second-degree polynomial (n=2) was used, as it effectively models variations in growth rates over time. The coefficient of determination (R²) was calculated to assess the proportion of variation explained by the model and to evaluate the model’s goodness of fit (Ledolter, 2008).
For the keyword co-occurrence analysis, terms and keywords used by the authors were analyzed, including emerging or trending keywords by year, with a minimum co-occurrence threshold of 5 times. This analysis allows the identification of thematic clusters and relationships within the literature. Country productivity and collaboration were assessed descriptively by analyzing the absolute number of documents per country and visualizing international collaboration networks. In the collaboration analysis between authors, a minimum of 3 co-authored articles was required to establish a collaborative link. A descriptive analysis of the 10 most cited documents was also conducted, reporting variables such as the number of citations, lead author, journal, and document type.
The VOSviewer software generated graphical representations, such as co-occurrence networks and thematic maps. The co-occurrence and co-authorship analyses were elaborated step by step to ensure clarity and reproducibility. These steps included configuring thresholds, such as a minimum of 5 co-occurrences for keywords and three articles for author collaborations, to focus on meaningful relationships and patterns. 

Results
A total of 463 documents were captured during the study period. No documents were found between 2001 and 2004. From 2005, there was steady production, and from 2015 onward, consistent growth was observed. Over the entire period, 18.35% of production was increased, with a determination coefficient of 0.95 (Figure 1).



Regarding author keywords, the co-occurrence analysis showed that “obstetric violence” was the most frequently used term, with clusters of keywords such as “abuse, disrespect, and mistreatment” (blue); “maternal care, reproductive justice, and reproductive rights” (red); and “humanized childbirth, nursing, midwives, obstetrics, and violence” (green) (Figure 2A). The trending terms are “obstetric violence,” with a maximum of 168 appearances in 2022; “birth,” with 73 appearances in 2021; “mistreatment,” with 48 appearances in 2020; and “abuse and disrespect,” with 32 appearances in 2019 (Figure 2B).



Regarding the most productive countries, 54 authors were from the United States, 41 from Brazil, and 25 from Spain. Regarding collaboration networks, Switzerland reports 11 collaborative documents with Ghana, Guinea, and Nigeria, the countries with the most collaborations. This rate was followed by Ghana with Guinea, Nigeria with Ghana, Nigeria with Guinea, Sweden with Australia, Sweden with Myanmar, the United States with Kenya, and the United States with Sweden, each with 9 collaborative documents (Figure 3).



The 10 most cited articles are “The mistreatment of women during childbirth in health facilities globally: A mixed-methods systematic review” by Meghan A. Bohren (2015), published in PLOS Medicine, with 900 citations. This article is a systematic review. In second place is the study titled: “The giving voice to mothers study: Inequity and mistreatment during pregnancy and childbirth in the United States” by Saraswathi Vedam (2019), published in Reproductive Health, has 444 citations (Table 1 shows all 10 articles).



The journal with the most registered documents was BMC Pregnancy and Childbirth, which contained 28 published documents, followed by Midwifery, which included 16 documents. Among the 10 journals with the most documents, 50% focused on sexual, maternal, or reproductive health, while the rest focused on public health (Figure 4A). The most prolific author is M. A. Bohren, with 22 documents, followed by J. P. Vogel, with 13 documents (Figure 4B). They also had the closest collaborations, while other collaboration networks include Mirzania M, Antoushzadeh S, Khajavi A, and Bohren MA (Figure 4C, blue), as well as between Vogel JP and Tuncalp O (Figure 4C, green) and the network between Irinyenikan TA, Adu-Bonsaffoh K, Balde MD, and Maung TM (Figure 4C, red).




Discussion
This study conducted a bibliometric analysis of global scientific output on obstetric violence, focusing on visualizing emerging patterns, identifying key terms and trending topics, and mapping collaborative networks. When evaluating the scientific literature on obstetric violence in Scopus, a significant increase has been observed since 2014. On September 14, 2014, the World Health Organization (WHO) issued a statement on preventing and eliminating disrespect and abuse during childbirth in health facilities (WHO, 2014). Although a direct relationship between these events cannot be established, a global statement may have created the need for professionals to understand this issue better because they observe certain behaviors related to “obstetric violence.” Evidence generation must occur in all countries to allow the problem to be understood, and ideas and solutions can be proposed based on the reality of each country. Also, no studies related to this topic were found between 2001 and 2004. This finding could be attributed to the low academic priority of the topic during that period, limitations in the database coverage for those years, or a lag in the development of key terms that later established their relevance in the scientific literature. This gap reflects the historical and academic evolution of the subject.
The term “obstetric violence” is not found within the Medical Subject Headings (MeSH); therefore, there are various ways this issue is presented in the reviewed studies. Terms such as “mistreatment during childbirth,” “disrespect and abuse,” or “abuse in maternal care” are some examples of how the same problem can be addressed using different expressions. Coining a term sparks intense debate because those involved in knowledge generation may have different concepts. For example, Leite et al. (2024) and Lévesque and Ferron-Parayre (2021) found the term “obstetric violence” appropriate, as it encompasses many forms of aggression toward users (patients) of obstetric services. However, Lévesque and Ferron-Parayre (2021) also noted that health professionals could have “resistance” when using this term.
On the other hand, Chervenak et al. (2024) argued that the term is too strong and primarily refers to the intentional use of force to cause harm or injury to a victim. This ongoing debate means that no universal “thesaurus” is used by all researchers addressing this topic. Despite the lack of consensus regarding the term, the Virtual Health Library of Colombia and the Latin American and Caribbean Center on Health Sciences Information (BIREME) have included the term “obstetric violence” within their health sciences descriptors or DeCS (BIREME, 2021).
Regarding visualization, the United States and Brazil have the highest number of corresponding authors in Obstetric Violence documents. The United States is one of the most prolific scientific-producing countries in most thematic areas worldwide (McCarthy 2019). Although it does not report the highest prevalence or frequency of mistreatment of patients using health care services, it has the largest scientific output on this topic. Moreover, the American College of Obstetricians and Gynecologists (ACOG) has not yet defined a formal concept for this term, only briefly mentioning it in a comment (American College of Obstetricians and Gynecologists, 2021). On the other hand, Brazil has shown significant growth and interest in the subject, even implementing a law in 2017 that defines the concept of “obstetric violence” (Oliveira Dias & Mori Machado, 2018), giving more significance to humanized childbirth, promoting respect for women, and reducing unnecessary interventionist practices (Rezende, 2023).
The cooperation between Guinea, Ghana, Nigeria, and Myanmar stands out among the collaboration networks, which can be explained by the similarities between their populations and health care providers. In these countries, “obstetric violence” can be measured so that there are not many differences in responses or perceptions (Khalil et al., 2022). A similar situation may occur in Latin America, although a collaboration network of more than 5 documents was not found among the countries in the region. It could be due to the different legislative systems or government regulations that limit the concept of “obstetric violence” (Tobasía-Hege, 2019). However, countries with cultural similarities must find appropriate ways to measure or capture these harmful practices.
The article titled “the mistreatment of women during childbirth in health facilities globally: A mixed-methods systematic review” by Bohren et al. was the most cited (900 citations as of the search date), published in 2015 in PLOS medicine (Bohren et al., 2015). The study compiles original studies and organizes the findings to identify the various domains addressed. This is one of the main strengths of systematic reviews because they gather, summarize, and evaluate the evidence, making it more readily usable by readers, researchers, or those responsible for making decisions based on the best available evidence (Owens, 2021).
On the other hand, 5 observational studies are among the most cited (Table 1). Given that obstetric violence is an intangible concept (as it deals with perceptions of violence), observational studies are more feasible for objectively assessing obstetric violence. Various questionnaires and instruments have been developed in different countries, regions, or populations with specific characteristics (Mena-Tudela et al., 2020; Paiz et al., 2022). 
The theme addressed in this study has significant physical, psychological, and social implications, emphasizing the importance of ongoing research. These impacts often manifest as health complications, mental distress, or societal challenges, which underline the need to fill existing gaps in the literature. Strengthening research in this area will help guide future investigations and contribute to addressing these multifaceted issues effectively.

Conclusion
Obstetric violence is an emerging field with various terms used to describe this harmful practice. The United States and Brazil have the most corresponding authors, and collaboration networks are primarily developed between neighboring countries. The bibliometric visualization of the documents revealed the most frequently cited studies and the journals hosting these publications. There is a need for research from other countries to disclose the situation of this issue, which may exhibit different characteristics due to cultural, systemic, or legislative differences in each region.

Strengths and limitations
This study has several strengths, particularly its focus on an emerging area of maternal health and health care services gaining considerable global importance. Another significant aspect is the inclusion of all documents in a database known for its extensive coverage and adherence to adequate quality standards. Additionally, analyzing collaboration networks helps visualize the need to strengthen cooperative work among countries with similar healthcare systems, populations, and legislation.
Although the chosen bibliographic database has strengths, we must note that we were limited to only one database, excluding scientific production specific to regions or countries through other search engines or indexers (e.g. SciELO, OpenAIRE, African Index Medicus). It is also worth mentioning that a bibliometric study does not directly evaluate the quality of the studies; thus, highly cited studies are not necessarily of high quality or scientific rigor. Nevertheless, this study provides a general overview of research on obstetric violence globally, allowing us to understand its evolution, trends, and directions.

Ethical Considerations

Compliance with ethical guidelines
In this study, no tests were conducted on animals or humans. It is based on a secondary analysis with bibliometric analysis. It is impossible to identify the primary survey participants. Due to the nature of the secondary data and the confidentiality of the participants, approval from an Ethics Committee for the protection of research participants was not required.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Conceptualization and supervision: Victor Roman-Lazarte; Methodology, investigation, resources, data curation, writing, and final approval: All authors; Software, formal analysis, and visualization: Victor Roman-Lazarte, and Frank Mayta-Tovalino; Validation, project administration, and funding acquisition: Frank Mayta-Tovalino.

Conflict of interest
The authors declared no conflict of interest.



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