Childbirth abuse is rife. So why don’t we see it? - TimesLIVE

An online training course on respectful maternity care — which may become compulsory for all staff working with pregnant women — is set to be launched on September 22 on the health department’s Knowledge Hub platform, says the health department.

The course consists of three lessons, which include embedded videos, and takes about three-and-a-half hours to complete, says Fikile Ndlovu, the deputy director-general for maternal health. Health workers will be able to complete it on their own time, at a pace that suits them, says Ndlovu.

“We wish to make it a mandatory course for not only midwives but all health service providers working in maternity settings because respectful care starts with attitude from all officials, whether a security at the gate, assistant nurses or cleaners in the wards up to midwives and doctors,” Ndlovu told Bhekisisa.

It’s long overdue, the March findings from a commissioned by the DG Murray Trust and Embrace survey on obstetric violence, and conducted by Social Surveys Africa, in KwaZulu-Natal and Gauteng show. Over the past 10 years, an estimated 1.79-million women — 60% of everyone who gave birth in these two provinces — had been mistreated by health workers during labour, whether physically, emotionally or verbally.

Only one in three women who were mistreated — from being slapped to being shouted at, examined roughly or ignored during labour — knew that health workers’ behaviour was wrong, and only 7% reported it.

Although the survey ran only in two provinces, it can give a window into what is happening at a bigger scale, seeing that KwaZulu-Natal and Gauteng are the two most densely populated provinces in the country and represent a mix of urban and rural healthcare settings.

Three-quarters of women in the birthing survey said they weren’t allowed to have someone with them during the birth, and four out of 10 said there weren’t curtains between them and the next patient.

Obstetric violence — which is a catch-all phrase for any form of abusive behaviour towards women during labour — is not new in South Africa. In fact, almost 30 years ago, researchers from the South African Medical Research Council (SAMRC) looked into what could be behind health workers’ offensive attitudes to women giving birth.

Yet little has changed in three decades, with similar accounts of being slapped, shamed or shouted at during labour surfacing in the recent survey as in the research from the late 1990s.

Women who’ve faced mistreatment “have real pain that they still feel so acutely, even though they gave birth years ago”, says Julie Mentor, who leads Embrace, an advocacy organisation for mothers under the umbrella of the DG Murray Trust and which was the first to put numbers to the issue of obstetric violence in a big way. “We’ve sat with grandmothers, crying while telling us about what they’ve experienced — and devastated that nothing has changed for their own daughters.”

“Violence during childbirth won’t be rooted out without leadership from the top,” says Rachel Jewkes, a specialist researcher at the SAMRC and who was the lead author on the first paper on obstetric violence in South Africa close to three decades ago. “It ought to be something that’s much easier to fix than a lot of other problems in health facilities,” she explains. “It doesn’t cost anything to not insult people and slap them.”

We’ve seen before how powerful knowing the size of a problem can be — and how solid evidence can help leaders make decisions that can change people’s lives.

So we dived into the data from the survey to unpack what the numbers mean. Here’s what we found.

Just over 1.79-million women being abused during childbirth in the past 10 years in two provinces is a big number. But what does it really mean, we wondered.

So we translated the figure to a daily count. Our sums showed that around 2.98-million women had a baby in those 10 years, which works out to 817 deliveries each day. In 490 of those, women were treated disrespectfully. It’s 12 out of every 20 people giving birth per day.

In the past 10 years in KwaZulu-Natal and Gauteng, 12 out of every 20 women were abused during childbirth every day (Bhekisisa Staff) Two-thirds of women didn’t know that they had been mistreated. That means that out of every 12 women who faced abuse during childbirth in a day, only four realised that health workers’ behaviour was wrong.

But even more alarming: only 7% of women who experienced obstetric violence reported the event. It’s one out of 12, which means that 11 out of 12 cases of abuse become invisible.

In a country where gender-based violence — which includes obstetric violence — has been classified a national disaster, the number highlights how “normal” mistreatment seems to be.

Says Jewkes: “Women experience abuse in so many different domains of their life that they likely have very low expectations of good treatment.”

During the survey, respondents were asked whether they experienced physical, verbal or emotional abuse — or any combination of these — and also to describe what form of mistreatment they faced.

The results showed that the different forms of abuse happened almost in equal measure, and that one type of violent behaviour often went with another. For example, being slapped could go with being shouted at or made fun of and being belittled. Moreover, each woman likely experienced, on average, four incidents during her labour.

The survey was of course just a snapshot of what is likely happening on a bigger scale. So when we extrapolated the number of incidents from here to the total of 1.79-million women, we calculated that more than 7.7-million occurrences of mistreatment probably took place in the past 10 years in KwaZulu-Natal and Gauteng — just over 2,100 incidents every day.

More than a third of women said they had a procedure done against their will — either because they weren’t asked for their permission beforehand or because they were pressured into agreeing to it.

At about four out of 10 cases, episiotomies — during which a cut is made between the vagina and the anus, ostensibly to prevent vaginal tears — were the bulk of these procedures. Yet evidence shows it’s needed only in very few cases and so both the World Health Organization and the health department say it shouldn’t be a go-to choice for health workers during a delivery.

But studies show that these cuts are often made — in one regional hospital in South Africa in about 20 out of 100 women despite serious vaginal tears occurring in fewer than one out of 200 uncomplicated deliveries — and that health workers don’t always know what the guidelines around this procedure say.

Experiences like these erode trust in the health system. Apart from being “deeply traumatising”, mistreatment during labour can also influence things like whether a mother later takes her baby for vaccinations or health checks, or goes for check-ups herself during another pregnancy, says Mentor. “And understandably so. Why would you want to go back to a place that has abused you?”

Improving women’s experiences of childbirth can improve maternal and child health altogether, says Mentor. But where do you start in a system that’s struggling to give people quality care consistently, especially with the purse being under pressure?

“It’s partly a matter of ‘cutting your coat according to your cloth’,” University of Cape Town health economist Susan Cleary told Bhekisisa previously.

With 75% of women in the birthing survey saying that they weren’t allowed to have someone with them during the birth, and four out of 10 saying there weren’t curtains between them and the next patient, could fixing these things be a place to start?

Having a partner during childbirth is something that “should be fixed and is fixable”, says Jewkes. It’s a way to create accountability without having to implement any new system or spend extra money. Moreover, it’s written into the national guidelines for maternity care already, stating explicitly that “a birth companion can assist women in addressing situations when they are not being treated respectfully.”

Yet there’s still some resistance among maternity staff to allowing a woman’s birthing buddy into the labour room, says Mentor, almost as if it’s something optional. Space, privacy or unruly behaviour may be seen as barriers, “but if we start from the position of every woman being entitled to having a companion, then suddenly you start getting a lot more creative around making it happen”, she says.

Jewkes agrees. Setting up a system that holds people accountable, like for example insisting that health facilities report on the proportion of women who had a partner with them during labour, could go a long way, she says. “Just because you might look at the system and think it’s hard to get it right, doesn’t mean it’s not worth trying seriously to change it.”