Maverick Citizen

BHEKISISA CENTRE FOR HEALTH JOURNALISM OP:ED

Obstetric violence and the cruel culture of collusion that devastates young doctors

Obstetric violence and the cruel culture of collusion that devastates young doctors
Obstetric violence and abuse by healthcare professionals remain below the radar of public scrutiny and national prevention efforts, according to the author. (Photo: vice.com/Wikipedia)

Health workers-in-training say they feel forced to abuse birthing patients as part of a dark rite of passage on the road to becoming a doctor or midwife. This final-year medical student explains how these experiences can shape the country’s future doctors. 

It was nearing midnight on day one of my rotation in the maternity ward of a state hospital in a coastal South African town. I was drenched in sweat.

Eight hours into my shift, I was helping a young woman, about 23, to deliver her first child. It was only the third childbirth I’d ever been part of.  

Next to the bed, a monitor showed the foetal heart rate slowing down. The unborn baby wasn’t getting enough oxygen. But the woman was tired and in pain, and I watched her body go limp between pushes as her energy waned. 

If the baby wasn’t born soon, there could be irreparable brain damage. Even death. 

Thwap! The sound of the midwife’s open palm hitting the patient’s face.

All of us — me, the other student doctor and the assistant midwife — were stunned into silence. 

It was the first time I saw someone hit a birthing woman, but not the last.   

Why do health workers become violent? 

When a pregnant woman or someone giving birth is hurt, abused or humiliated — whether with words or actions — it’s called obstetric violence

The term also covers any unwanted medical procedure (such as sterilisation or vaginal examination without consent), or denying the woman pain medication. Even breaching doctor-patient confidentiality falls under this umbrella. 

It happens all over the world, and research shows that adolescents, women in low-income settings and those with a low social standing are especially vulnerable. 

South Africa is no exception.

In 2011, Human Rights Watch spoke to 157 women in the Eastern Cape, who told horrific stories of the cruelty they experienced at the hands of health workers. One woman’s pleas for help were ignored for hours while staff discussed their plans for Christmas lunch. Another was accused of lying about being in labour and sent home.

That report is 11 years old now, but anecdotes continue to pile up

Explanations for why this type of abuse happens, however, are difficult to pin down.

Workplace pressure is one of many reasons, says Veronica Mitchell, a facilitator at the University of Cape Town’s obstetrics and gynaecology department. 

State health workers are subjected to difficult, sometimes even humiliating, work conditions themselves, often driven by a dearth of staff and equipment. 

This stress is even worse where babies are being delivered since there’s a much bigger risk of permanent complications (such as cerebral palsy) than there is in other parts of the health sector. Not to mention the threat of costly court cases that can go on for years. 

It’s not hard to imagine that a midwife who was providing compassionate care at one moment might be overwhelmed by the stress of unmeetable demands the next — and lash out at the women she attends.

There’s also hospital culture to consider. 

Local trainee health workers told researchers in 2021 that they felt they had to copy their superiors and “collude” to become a doctor or a midwife, a sort of rite of passage. 

This links to research showing that power hierarchies could be at play between someone who is assumed to be at a higher level of authority and a subordinate — for example between doctors and midwives — which then filters down to the patient because the healthcare worker is trying to establish some sense of authority

Moreover, because mistreatment of women in labour shows up in many different forms — from physical abuse such as being hit to verbal abuse and subtler forms of disrespect such as being ignored or denied care — it’s difficult to act on behaviour that’s out of line. 

In my experience, the nebulous nature of obstetric violence and the dynamic within the health system make it really hard to report abuse towards patients. 

However, with the Office of Health Standards Compliance (OHSC) set up under the National Health Amendment Act of 2013, to make sure that facilities adhere to expected standards and flag those that don’t, patients and health workers in South Africa now have a clearer route to report mistreatment than when the Human Rights Watch report was published in 2011. 

In theory. 

The office hasn’t released any reports that mention obstetric violence, even though “act of harm to patient” is a category  listed in the compliance body’s early-warning system to monitor practices that do not offer an acceptable standard of care.

That could be because very few of the country’s state hospitals are using this reporting tool (between October 2019 and December 2020 reports were received from only 1.6% of public sector health facilities). 

Or, the OHSC just isn’t publishing what they find.  

The reports of the Health Ombud’s office, which sits in the OHSC and has to investigate complaints, don’t explain how the level of risk of a case is decided (ranging from low to extreme) — and only a few of the complaints the office assessed last year were resolved within 12 months.  

There’s no evidence of the scourge of this type of abuse in South Africa’s planning documents either. 

The country’s first action plan on gender-based violence, for instance, and the most recent national guidelines for maternity care make no mention of obstetric violence or disrespectful maternal care either. 

This all fuels the situation we have in South Africa at the moment: obstetric violence is a fact of the health system. It happens every day, but there’s no official trace of it — like women’s stories of abuse are being written with disappearing ink. 

It also means no one’s keeping track of how this type of abuse affects outcomes such as the rate at which women die as a result of birth or pregnancy. In fact, research shows that mistreatment at any stage of a woman’s pregnancy or during birth can make them less likely to go to health facilities when they need help in the future — and not only for gynaecological care.

Mitchell agrees: “Mothers often arrive at birthing facilities already in labour because they’re scared of how they might be treated.”

Why I’ll never forget this patient

Back in the maternity ward, the bewildered young mother realised what had happened to her. 

She burst into tears. The assisting midwife pulled on the slapper’s shoulder and whispered something that I couldn’t make out. 

And that was the last I ever heard of it. 

Minutes later her baby was born (thankfully, healthy) and no one ever spoke of it again.

I wasn’t equipped to understand what I’d seen. So I just carried on as if I hadn’t.  

I don’t know much about this patient. Public sector maternity wards don’t leave doctors a lot of time to get to know patients. Still, I’ll never forget her. 

She’ll stick with me because her experience — and my inaction — illustrates so clearly how health workers are shaped by their environments. 

Plus, there’s nothing in the state system that will stop me from becoming like this. 

Thoughts as I prepare to take an oath to do no harm 

One way that some health workers try to change the system is by endeavouring to treat patients kindly in every encounter, in that way reclaiming a sense of duty and control. 

Changing small things could already make a difference, such as having curtains around a woman’s bed in hospitals where there’s a lack of privacy or a companion to support her during labour, and talking her through the process in a simple and supportive way.

Another could be to teach midwives and other health workers more about respectful childbirth practices, such as through training programmes, offering modules on empathetic care and helping student doctors, like me, to know where our rights lie and how we can support patients, even in seemingly small ways.

It’s not only for the benefit of the patient; it can also protect young health workers from the moral injury that the system can cause. 

Moral injury happens when health workers feel they’ve failed their patients, either by not being able to prevent harm, or when they witness behaviours that flout their own moral beliefs. 

But I think it’s also time for a bigger move. 

In the seven years leading up to 2014, five Latin American nations outlawed obstetric violence

In Bolivia, for instance, such laws have led to obstetric violence being included in the government’s surveys to track violence against women. 

In Argentina, the country’s health ombud now has an official plan to guide interventions in facilities where people report these indignities. 

And in 2015, a civil society organisation called Las Casildas set up a platform where people could share their stories, called the Obstetric Violence Observatory. One of the first things they did was to put together a survey asking women about their experiences during childbirth, and close to 5,000 people submitted their responses. For the first time, there was a large set of data that linked directly to the law in that country about obstetric violence. 

Some cases have also gone to court, such as in Argentina and in Kenya, where, in 2018, the court ruled in favour of a woman who was neglected during labour, then beaten by nurses who found her unconscious on the floor. 

Although legislation isn’t enough to stamp out abuse in maternity wards completely, it does give people a way to pursue their reproductive rights, write legal researchers in the journal of the Royal College of Obstetricians and Gynaecologists. At the very least, these are ways to acknowledge that this happens to women in the first place. 

South Africa doesn’t yet have any laws that would make obstetric violence a criminal offence, but calls for it to be considered are starting to be voiced and researchers say the country’s legal system could allow for such laws

But in the meantime, everyone who assists a woman during labour, including those in leadership positions, has the responsibility to make mistreatment during childbirth become obsolete, Mitchell says. 

As for me, my plan is to respect the oath I’m going to take in December — a pact to do no harm. I know that will be difficult.

I’m likely to have too many people to treat and not enough time or equipment to help them as much as I’d like to, on what could be the worst day of their lives. 

Under such circumstances, I’m not sure that I’ll have the moral courage to choose what’s right over what’s easy. DM/MC  – Additional reporting by Joan van Dyk & Linda Pretorius. 

Regan Boden is a final-year medical student at the University of Cape Town. He spent a month with Bhekisisa between June and July of 2022 as part of his degree, which allows fifth and sixth-year students to pick any elective related to the field of medicine or research. 

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

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Comments - Please in order to comment.

  • Hermann Funk says:

    This kind of abuse does not only take place in maternity wards. An overseas student, here for his practical training, told me that badly injured people arriving at the emergency ward are often let lying in pain for hours before they receive any medication, while the staff is having coffee/tea or just casual conversations.

  • Alice Walsh says:

    My sister-in-law did her training at a few public hospitals and shared similar experiences of obstetric neglect. She related the habit of ‘finishing tea’ rather than getting a child born in time to prevent brain damage that would not only be devastating to the mother but also costs the government absurd amounts of money for the life of that child.
    I can sympathize with health care workers in under-staffed, under-equipped environments, the onset of compassion fatigue coupled with the expectations or ‘rite of passage’ attitude – all leads to some kind of survival tactic in such conditions.
    Another friend works in law and deals with an extraordinary amount of medical negligence cases that costs government money that would make health workers swoon.

    My comment is really just: why is this money being spent on supporting negligence and mistreatment patients, after the fact, when it could be used to support staff, give incentive for better care, kinder practice and prevent such cases of indifference or assault in the first place.

  • Dennis Bailey says:

    Look when we have a president(s) that break their oath of office, we should not be surprised to find medics doing the same. We live in democratic anarchy. The people have chosen it. Viva, ANC, Viva.

  • Sheda Habib says:

    When working in a hospital, is a job taken because jobs are scarce and individuals take the work on, to provide a hungry family at home, then we can expect that dedication commonly attributed to teachers, nurses, firemen, etc. no longer applies.
    I am sure, but have nothing to back me up, that the higher the employment rate, in a free democratic society, then the lower the type of abuse discussed above.
    I see many police, daily, falling short of serving the citizens, because the money in the job takes precedence over the dedication to serve and protect.
    Employment vs Unemployment over Dedication vs Income

  • Michael Silberbauer says:

    All women should expect respectful, quality obstetric care, but often the system falls short. Structured intervention and behavioural change are essential for improving matters, and some positive interventions have taken place in South Africa and elsewhere. I would recommend that anyone trying to make a difference in this area should go through these documents and their reference lists – they should be easily accessible via their DOI codes:-

    “A before-and-after study of women’s experience of childbirth in Tshwane” 10.1186/s12961-020-00615-8, 10.4102/phcfm.v12i1.2560

    “Operationalising health systems thinking” 10.1186/s12961-020-00615-8

    “Improving perinatal outcome indicators” 10.7196/SAMJ.2019.v109i2.13429

    “Systems thinking: A turning point for improving respectful obstetric care ” 10.7196/SAMJ.2018.v108i11.13312

    “Mothers’ experiences of childbirth in midwife obstetric units” 10.1186/s12978-017-0411-5

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