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Op-ed: Obstetric violence – A war waged in the shadows

- Sheena Swemmer

Head of the Gender Justice programme, Sheena Swemmer, explains the importance of acknowledging a particular form of institutional gender-based violence

[This op-ed was published by the Daily Maverick under the title ‘Obstetric violence: A war against women that is being waged in the shadows’]

Obstetric violence is violence that occurs against pregnant or birthing individuals and includes physical, emotional, psychological, and even sexual violence committed by healthcare practitioners, such as doctors, nurses and midwives.

During this year’s iteration of the “16 Days of Activism for No Violence Against Women and Children” campaign, it is important to acknowledge that gender-based violence permeates private and public spaces. In order to have a country that is safe for women and children, both forms of violence must be acknowledged and adequately addressed.

Police Minister Bheki Cele recently announced a 7.1% increase in the number of rape cases reported in South Africa within a three-month period. Disturbingly, child homicide rates had also increased, by 31.7%. President Cyril Ramaphosa decried the rise in criminal offences related to women and children and stated that we “are in the grip of a relentless war being waged on the bodies of women and children that, despite our best efforts, shows no sign of abating”.  

What is missing from the crime statistics, the coverage of stories related to gender-based violence during this period, and the president’s description of the “war” waged on women’s bodies, is the acknowledgement of the public and institutionalised forms of violence that occur in our hospitals against some of the most vulnerable individuals in our country, which is violence against women or birthing people, known as “obstetric violence”.

Obstetric violence is violence that occurs against pregnant or birthing individuals and includes physical, emotional, psychological, and even sexual violence committed by healthcare practitioners, such as doctors, nurses and midwives. Obstetric violence is prevalent and pervasive in South Africa, despite its lack of recognition by our legal system and government.  

The Medical Research Council, for example, completed a study in 1997 around obstetric violence in Cape Town. Some of their findings included that birthing women were neglected, and suffered verbal or even physical abuse at the hands of nurses when they “failed to comply with instructions”. The authors said nurses would slap women and tell them to “clean up their mess” after they had just given birth. 

The abuse and violence perpetrated by healthcare practitioners continues unabated in 2021. In the past year, the Centre for Applied Legal Studies and Women Affected by Mining Communities United in Action have presented various workshops on obstetric violence to communities across South Africa. Women bravely recounted stories of the violence they have endured during the birthing process which has included: nurses using their fingernails to tear open mothers’ vaginas, women being refused pain medication despite numerous requests, being sent to purchase their own medical supplies while in active labour, having procedures performed on them such as sterilisations without their consent, having their personal medical information (such as HIV status) discussed openly within the ward, as well as being admonished by healthcare practitioners for having a child when HIV positive. 

With the above examples of the violence women endure daily in our healthcare facilities, it is not dramatic to employ the president’s words to describe the current status quo as that of a war being waged against birthing women in South Africa by our healthcare practitioners. 

But what should be done? 

First, we need proper acknowledgement that this is a form of gender-based violence that is pervasive within our hospitals. Obstetric violence is already acknowledged as a form of gender-based violence internationally, with the UN Special Rapporteur on violence against women, its causes and consequences penning a report in 2019 which explicitly acknowledged that “mistreatment and violence against women during reproductive health care and facility-based child birth is a serious violation of women’s human rights”.  

Furthermore, this type of disrespectful and abusive treatment includes “outright physical abuse, profound humiliation and verbal abuse, coercive and unconsented medical procedures (including sterilisation), lack of confidentiality, failure to get fully informed consent, refusal to give pain medication, gross violations of privacy, refusal of admission to healthcare facilities, neglecting women during childbirth”.  

Yet, although there is international recognition of obstetric violence as a form of gender-based violence and thus a form of gender discrimination, South African law is so far silent on the existence of obstetric violence. 

South Africa requires proper legislation and policy to be put in place which acknowledges that the egregious acts associated with obstetric violence target a vulnerable group in our society and are discriminatory. Once this is acknowledged, the law can then reflect obstetric violence as an act of gender-based violence rather than what we currently have, which is that obstetric violence is seen as medical malpractice.  

The issue with medical malpractice is that it fails to deal adequately with very serious violations of women’s rights that occur during acts of obstetric violence. Medical malpractice cannot, at this point in time, properly respond to some of the consequences of obstetric violence that victims have expressed feeling.

For example, some women have explained feeling that they are no longer women; some are filled with shame and have not told their partners or family members that they cannot have more children; some women’s partners have left them after they could not give birth to further children or after their genitals had been so badly damaged that they can no longer have pleasurable sex or any sex at all; other women explain how demeaning it was to be told by nurses that they are too old to be giving birth, while younger women explain the indignity of having medical personnel lecture them about being too young to be pregnant.  

Monetary compensation around violations that cause psychological and emotional trauma as well as gross indignity is insufficient and signifies that these violations are seen as trivial by our legal system. Laws thus need to be able to reflect that harm is understood in such a way as to extend beyond the mere recognition of physical harm and include the devastating personal, psychological, emotional, social and spiritual damage that the violations have caused.  

Policy must focus on promoting healthcare in South Africa which is aligned with human rights principles and especially principles that safeguard against the commission of gender-based violence and discrimination. There must be a movement away from the strict paternalism inherent in the healthcare system, to an open and communicative system that reflects a dedication to the principle of the inherent value of the individual patient.  

Ultimately, with legislative and policy changes we can begin to reconstruct our healthcare system into one which reflects the values of the Constitution and is dedicated to the provision of care for birthing women.