Systemic or structural violence is harm that people suffer from structures and institutions which sustain violence and reproduce it. Systemic violence often has specific vulnerable groups as its primary victims, with women and people of colour among the most disproportionately affected groups.

South Africa already sees systemic violence in the form of gender-based violence perpetrated against women in workplaces, schools and universities, where policies and procedures can create insurmountable burdens on victims and, in some instances, protect perpetrators.

We also see violence against women entrenched, sustained and reproduced in our policing and our criminal justice system. Systemic gender-based violence (GBV) is deeply entrenched within our society’s social, cultural and economic structures. It is perpetrated not only by individuals but also perpetrated and retained or protected by those in power, such as institutions and the state.

Recently, obstetric violence has been acknowledged as a form of GBV perpetrated against pregnant women and other birthing people. In November 2022, obstetric violence was officially recognised as a form of gender-based violence at the Presidential Summit on GBV and Femicide.

Obstetric violence is a form of structural GBV which occurs in healthcare facilities; it is perpetrated predominantly against women and can take the form of denial of care, assault and neglect during childbirth as well as forced or coerced medical procedures (such as sterilisation or c-sections) when women seek health services during pregnancy and birth.

Although obstetric violence was only recently acknowledged as a form of systemic GBV in national policy, as early as 1998, a study by Rachel Jewkes, Naeemah Abrahams and Zodumo Mvo revealed abuse of pregnant women committed by nursing staff in the Western Cape.

Read more in Daily Maverick: “Mothers speak out about traumatic births and gender-based violence at health facilities”

Obstetric violence was thrust into public awareness in 2020 when the Commission for Gender Equality (CGE) released a report which exposed the forced or coerced sterilisation of about 48 women living with HIV and Aids at public healthcare facilities in the country.

The recent release of the Office of the Health Ombud’s investigation into the Rahima Moosa Hospital continues to highlight the pervasiveness of obstetric violence in South Africa’s healthcare system while focusing on some of the most egregious forms of obstetric violence within the country. The report explains how the ombud was prompted to investigate the facility due to public outrage around a video published by New24, which showed pregnant women sleeping on the hospital’s floor.

The ombud found that during the time of the incident, there were 39 beds in the ward, and 20 pregnant women were given chairs to accommodate them. The ombud found that based on the evidence gathered of pregnant women having to sit on chairs and sleep on the floor, it was concluded that they were not attended to in a manner that was consistent with the “nature and severity of their health condition”.

Furthermore, one doctor indicated that they had to examine pregnant women while the women sat on chairs (due to the lack of beds), and patients would only be assessed if there was a complication. This was confirmed by another healthcare practitioner who said clinical decisions were based on what was written in the file, without examining the patient.

Why is this type of treatment or lack of treatment considered as a form of systemic obstetric violence? As stated before, systemic violence emerges from individuals, institutions and the state. In terms of obstetric violence, it is not only isolated to mistreatment or neglect by a singular healthcare practitioner, but is anchored and retained through the actions and inactions of individuals who oversee the running of our healthcare facilities, such as hospital CEOs, provincial MECs and even the minister of health.

Violations recreated

Obstetric violence will remain pervasive so long as we have systems that retain the status quo. Funding can be a space where systemic violence is preserved. We can see this insofar as a lack of funding for healthcare which is aimed to assist pregnant women with their particular health-related conditions, will continue to recreate violations of these women through the lack of facilities and services.

Rahima Moosa Hospital is an example of this preservation of systemic violence through a lack of funding and mobilisation of resources. In the ombud’s report, it is highlighted that there were numerous infrastructure challenges in the hospital, including the collapse of the sewerage system, leaking pipes and dilapidated buildings. The ombud recommends that Gauteng premier Panyaza Lesufi oversees the refurbishment of the hospital within six months.

Read more in Daily Maverick: “Obstetric violence and the cruel culture of collusion that devastates young doctors”

Another area of preservation of systemic violence in the form of obstetric violence is through the failure to implement policy around maternal healthcare. The Guidelines for Maternity Care in South Africa from the Department of Health extensively canvasses maternal healthcare at various types of healthcare facilities.

Pernicious status quo

However, as with many policies and laws within the country, the existence of a policy or a law does not necessarily equate to the proper implementation of such.

For example, in the National Health Act 61 of 2003 and the Sterilisation Act 44 of 1998 there is an obligation on healthcare practitioners to establish that a woman has given her informed consent around sterilisation. Yet, in the instance of the CGE report, we see that medical procedures are being performed against women without their informed consent.

We also arguably see the Department of Health’s implicit entrenchment of the status quo of violence against pregnant women through its inaction around providing recourse for the CGE women who were forcefully or coercively sterilised, despite historical undertakings to do so.

Almost three years after the CGE’s report into the forced or coerced sterilisation of women living with HIV and Aids, the victims wrote to the President to request urgent assistance and access to recourse. Unfortunately, these women have not seen justice for the systemic violence they endured at the various public healthcare facilities.

Equally unfortunately, during this time the pregnant women of Rahima Moosa Hospital join the ranks of victims of pervasive obstetric violence in the country, with no clear road to justice in sight. DM