South African women are finally speaking out about abuse suffered at the hands of healthcare workers while giving birth, recounting horrific stories of appalling treatment from ruthless and often violent nurses in a sadly common form of gender-based violence.
“Women are not valued and treated with dignity, including when they are bearing the nation’s next generation of sons,” says Dr Jess Rucell, an expert adviser on gender justice at the University of the Witwatersrand’s Centre for Applied Legal Studies (Wits CALS).
She highlights the need for adequate resourcing, improved management and increased support for nurses and midwives if we’re to begin curbing widespread obstetric violence in this country. Moreover, she believes that health professionals who physically abuse pregnant and birthing persons, or deny them care, have to face consequences.
The country also needs to view obstetric violence as an endemic issue pervading the nation, instead of hyper-focusing on single acts of violence perpetrated by individual doctors or nurses.
“The National Department of Health’s (NDOH) 2021 Maternal, Perinatal and Neonatal Healthy Policy, which focuses on the structural drivers of obstetric violence, is a good starting point,” Rucell tells News24.
And yet, obstetric violence continues to be ignored and overlooked as a form of gender-based violence and femicide (GBVf), and a cursory glance at the damning statistics around the issue explains why.
One mother described her horrendous experience in the labour ward of a government hospital, when her baby started crowning as she struggled between contractions to remove her underwear. She was unassisted by a nearby nurse, who screamed at her to take off her panties before she killed her baby.
For the next 24 hours, the mother suffered severe emotional and physical abuse, and was even sexually violated, at the hands of hospital nursing staff.
In another case, a woman in labour and her husband arrived at a top private hospital, excited to welcome their daughter into the world. But nurses barely acknowledged their arrival and soon become exasperated and irritated by the first-time parents’ questions.
Her baby was delivered via a forceps birth and episiotomy without informed consent. As doctors wordlessly sliced an incision between her vaginal opening and anus to enlarge the opening for the baby, no one explained to the new mother what was happening, or asked if she were even okay with it.
But the staff’s cold demeanour meant the woman was reluctant to bring up her misgivings. “I was already unsure and unable to ask for help,” she said.
Her voicelessness resulted in a traumatic birth that left her both physically and emotionally incapacitated for weeks postpartum. She was silenced and shameful about her experience.
These two women are not the exception.
An ignored branch of GBV
Those who usually raise alarm bells about the broader scourge of GBVf, especially during commemorative times like Women’s Month, tend to focus on the prevalence of rape and intimate partner violence, and that a woman is killed every three hours in SA.
And while these conversations are crucial to formulating a solutions-based approach to combating GBVf in our lifetime (or by 2030, as government has set out to do), it is pertinent to include obstetric violence as part of that solutions-based approach.
Criminalisation is not the answer
Rucell does not believe criminalisation is the answer to obstetric violence, because it is a systemic issue.
Speaking at a seminar earlier this year on obstetric violence and women’s right to health, hosted by the South African Human Rights Commission and Wits CALS, Rucell said placing blame on individual health workers prevents solutions that would require society to challenge the “structural dimensions of misogynistic ideas about women”.
She urged proponents of change to consider the systemic nature of medicine, and how that affects the kinds of violence women experience at an institutional level.
“To address structural drivers, look at training, practice, the system, the mindset and how gendered misogyny and the perception of gender and pregnancy are influencing that. A law criminalising obstetric violence is not the answer.”
Similarly, gender activists have rubbished the stance of ANC members on chemically castrating rape offenders, deeming it not only ineffective as a deterrent, but also unconstitutional.
Rooted in colonialism
Speaking at the same seminar, author, sexual health activist and the United Nations special rapporteur on the right to health, Dr Tlaleng Mofokeng, drew a correlation between colonialism, racism and the genesis of obstetric violence.
“If you think about Latin America, Africa, and all the countries and regions that were previously colonised, a lot of that colonisation happened on the bodies of people who have the ability to be fertile,” she said, adding that violence against birthing people, including fertility and population control, needs to be analysed in the context of colonisation.
“There’s no policy to say women must be slapped or pinched between the thighs because they are not pushing enough (during labour). But it is in practice, and a lot of the practices that have become embedded in the health sector often find their inspiration from colonial acts, policies and laws,” she added.
A rite of passage for doctors and nurses
An opinion piece by final-year medical student Regan Boden corroborates Mofokeng’s assertions. The trainee recalls the first time he saw someone hit a birthing woman – how he recoiled at the sound of the midwife’s open palm hitting a labouring mother, and how it would not be the last time he witnessed such abuse.
Boden highlights hospital culture among the myriad reasons why pregnant and women giving birth are abused, denoting it as a rite of passage for trainee health workers wanting to become doctors or midwives.
“(H)er experience – and my inaction – illustrates so clearly how health workers are shaped by their environment. Plus, there’s nothing in the state system that will stop me from becoming like this,” wrote the future doctor.
Look to the dying mothers
Rucell notes that health systems reflect and reinforce society’s dominant social and cultural processes.
Against this backdrop, she highlights a country’s maternal mortality rate (MMR) as a key indicator of a country’s well-being, and a barometer for the quality of life in that country.
“While South Africa’s MMR has decreased since democracy, it has remained high when compared with other countries,” she tells News24.
Statistics South Africa says SA's national MMR decreased from 105.9 deaths per 100 000 live births in 2019, to 88 deaths per 100 000 live births in 2020. This decline compares well against the global mortality rate (211 deaths per 100 000 live births), but remains concerning when compared with the MMR of higher-income countries, to which we should aspire.
A report by the Gates Foundation pegs North America’s MMR at 32 deaths per 100 000 live births, and Australasia’s MMR at three deaths per 100 000 live births).
Looking at solutions, Rucell said viewing GBVf “through the lens of equality” will mitigate the factors driving maternal death in South Africa, including the abuse by health systems of pregnant and women giving birth.
Empty promises, or sustainable solutions?
Responding to renewed calls from activists, the Department of Women, Youth & Persons with Disabilities (DWYPD) said in January that obstetric violence (including rampant forced sterilisation) would be included in the National Strategic Plan (NSP) on GBVf.
The initial draft of the NSP largely focused on direct forms of GBVf, like murder, rape and intimate partner violence, which is why DWYPD spokesperson Shalen Gajadhar promised that obstetric violence would “find expression in the framework” of the NSP.
“It is essential towards government’s 2030 vision of zero GBV,” he noted.
This commitment has yet to come to fruition, echoing sentiments that the state has failed to meet commitments made at the 2018 Presidential Summit on GBVf.
‘Accountability, acceleration, amplification NOW’
However, The Presidency and the DWYPD are gearing for another national summit, aimed at amplifying accountability on GBVf. This is in conjunction with a spate of local and regional summits that have taken place in the past month.
The Presidential Summit on GBVf 2 on 1-2 November under the theme of Accountability, Acceleration, Amplification NOW seeks to track the Presidency’s progress in implementing the NSP on GBVf.
“This offers the ideal opportunity to evaluate where we have made an impact, where we need to re-evaluate our efforts against impact and, based on new research, where we need to adjust our approach to responding to GBVf,” said Gajadhar.
Rucell, who had been a member of the Presidential Summit Planning Committee on GBVf 2022, seems positive about the upcoming summits but notes that, since the 2018 summit and the establishment of the draft NSP on GBVf, the state has not adequately implemented its action plan to end GBVf.
“Legislation to bind the state to its action plan on GBVf needs to be expedited, and the inter-ministerial committee (on GBVf) needs to make their efforts transparent, so the public can hold them better accountable to their responsibility,” she said.
Advocacy for a more dignified experience
As for those on the ground directly affected by GBVf, much hinges on what is discussed, committed to, and implemented at and after the upcoming Presidential Summit.
Those whose trauma would be acknowledged by sustainable change include obstetric violence victims like the two women mentioned above.
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See more from MedicalBrief archives:
Impact of obstetric violence on young doctors learning to deliver babies
Pregnant women suffer “obstetric violence” in health systems
Abuse of women by healthcare professions demands urgent intervention
16 Days of Activism: SASOG calls health care professionals to action