Obstetric violence against women has become a normalised phenomenon in South Africa

Women’s increasing outcry about their abuse by healthcare professionals tells us the journey of seeking healthcare for becoming a parent is filled with ridicule, fear and assault. That expectant mothers are being violated in hospitals across South Africa signals an urgent need for systemic changes to women’s healthcare. 

Obstetric violence refers to the physical and/or psychological abuse of pregnant women and/or unnecessary or coerced medical interventions carried out by health systems. 

Obstetric violence also includes the denial of or neglectful healthcare services to pregnant women. A special March 2022 issue of the British Medical Journal, focusing on “understanding the mistreatment of women during childbirth to improve quality of care”, can be found here.

Gender-based violence (GBV) is receiving considerable attention during the Covid-19 global pandemic. President Cyril Ramaphosa, himself drew links between the pressures of the lockdowns and domestic violence and as early as July 2020 declared that South Africa faces a second ‘shadow’ pandemic of GBV.

Obstetric violence, however, which is a normalised form of hospital-based gender-based violence during childbirth, remains below the radar of public scrutiny and national prevention efforts. For instance, it was omitted from the 2018 Presidential GBV and femicide (GBVF) Summit declaration, and the National Strategic Plan on GBVF that followed it. 

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Our health systems have been under strain since the Covid-19 pandemic, reports have shown that women’s maternal health, in particular, has been neglected and has suffered. There is evidence that constraints to maternal health services around the world have resulted in increased maternal death. 

In this context of the pandemic, like domestic violence, it has been argued that obstetric violence has also increased.

Similar to other forms of GBV, it is reasonable to argue that obstetric violence is pervasively experienced in South Africa. The neglect and abuse of women during pregnancy and childbirth resulting in psychological and physical traumas has been described long before and since the Covid-19 pandemic. 

This is evidenced by a body of academic and government research spanning three decades, several human rights reports and numerous news articles. In the case of this particular form of GBV, the most commonly reported abuses are psychological, where verbal attacks judge and humiliate women and girls for their age, fertility choices, economic and diseases statuses. 

Physical abuses by health professionals include assault, for example, slapping women in the face and legs during childbirth. Women have also reported being dragged on the floor to a labouring bed, and being locked in a bathroom, abandoned during childbirth. 

Other physical abuse described in my, and others’ research is routine episiotomies, and the application of pressure to the abdomen during childbirth, which go against evidence-based clinical practice and guidelines. 

Physical forms of obstetric violence also include failure to provide clinical services, access to abortion care, and medical procedures and examinations being carried out without women’s informed consent. These medical procedures include vaginal exams, which when performed invasively, women have likened to sexual assault; coercive sterilisation, that a recent report by the Commission for Gender Equality found is performed in  South Africa on vulnerable populations; and finally coercive caesarean-sections, which have not been adequately investigated in South Africa. 

An overview of obstetric violence is outlined in a report submitted by the Commission for Gender Equality to the UN Special Rapporteur on Violence Against Women in May 2019.

These, often preventable and discriminatory, acts can result in trauma and post-partum depression. Women affected by obstetric violence may also suffer physical harm. These can include chronic pain, the loss of sexual pleasure, fertility, and even disability and death to the mother, foetus or newborn.

Contrary to how this problem is often portrayed in the media, nationwide evidence of violations of sexual and reproductive health rights makes it clear — this is not the result of a few health professionals’ malice or managers’ neglect. Rather obstetric violence is a systemic problem resulting from gender discrimination and inequality. 

Preventing this particular form of GBV, like all forms, requires accountability and coordinated consequence management interventions. Responsibility to ensure systemic solutions to protect women’s rights rests with government, health systems, professional associations, the Health Ombudsman and medical schools. 

The lack of action on the part of these duty bearers to date puts pressure on the responsibilities of others. Like in the case of suspected domestic violence, health professionals also have a role to play in assisting women to access support for this health system-related form of GBV. However, the dual loyalty health professionals have of simultaneous obligations, express or implied, to a patient and to a third party, often the state, can cause inaction. 

For this reason, it is important to highlight that through “common practice” health professionals are able to refer patients to duty-bearers, legal aid and other support services for obstetric violence, similar to the ways they might in a case of domestic violence. 

The Protected Disclosures Act (2017) safeguards health professionals to empower patients to gain support for violations of their rights by the health system. The Act protects health professionals who empower patients and/or report violations themselves, provided they do so within the prescribed manner, in good faith and are truthful. 

The Centre for Applied Legal Studies’ (Cals), Gender Justice Unit focuses on advancing women’s rights. This scope includes Sexual and Reproductive Health Rights. Cals is drawing attention to this particular form of GBV, through a ‘know your rights’ campaign to help increase women’s awareness of existing protections from this problem.

Our constitution, and in particular the bill of rights, aims to offer protections and solutions for the inequalities women live with disproportionately. The current global pandemic has brought a monolithic focus to health and healthcare systems. This has also brought to the surface the disproportionate burdens women face when accessing healthcare. Within this context, it is essential that health professionals and we as rights-based institutions emphasise the rights women have, how, and where they are being violated. DM/MC

Dr Jess Rucell is a specialist in international development and gender equality. She writes in her capacity as an Expert Adviser to the Centre for Applied Legal Studies. 

 

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