Given the grave impact of birth trauma on a mother's ability to parent, and the subsequent ripple effect of violence on society at large, it's hard to imagine how the abuse of people in labour at the hands of healthcare workers has become the rule and not the exception.
News24 chats to stakeholders in the community, and hears from the Department of Women, Youth and Persons with Disabilities, about a way forward.
It was no doubt a shocking revelation for some when News24's parenting site shared a statement detailing the epidemic of obstetric violence in South African hospitals. But for many, it was sadly affirming.
Since the publication, our editors have been inundated with letters from pregnant and labouring mothers who had been admonished, laughed at, ridiculed, abused and ignored during labour.
We received first-hand accounts from women who underwent episiotomies without knowledge or consent. One reader – fearful and in pain – had an IUD forcibly inserted despite pleading with (and screaming at) the attending doctor to stop the procedure. Another's waters would have been broken had her husband not intervened, all so that labour might be expedited before the nurses went on lunch.
We received emails from husbands, close friends and family members writing on behalf of mothers who have yet to get over their trauma. Mothers who were left unattended for several minutes immediately after birth, while their baby lay at the receiving table across the room, also unattended.
One reader was given a sedative against her will before she'd had a chance to see her baby. Another was told that she was being given a sedative, which was actually medication to stop her milk flow without her knowledge.
Jesika mourns the loss of her little boy who lived with brain damage for seven years. She believes that if the nurses around her had been sufficiently attentive during her labour, if they had listened to her pleas or taken action when her broken waters were tinged with green (a sure sign of infection), then perhaps her son would have been born healthy. Perhaps he would have lived.
'We could die there, with them just watching'
Nokuthula was left to labour alone for hours, passing out momentarily from the pain. Eventually, she was woken by a nurse and ordered to pack her things. Drenched in sweat and weak from exhaustion, the labouring mother was made to carry her bags to the labour ward while the hospital staff looked on.
Directly after birth, which happened with minimal medical support, Nokuthula was made to get out of bed to make room for someone else.
"This is not the kind of treatment you expect from a nurse, a woman. I decided there that I would never fall pregnant again. We could die there with them just watching," she tells News24.
'Nurses are also part of a victimised system'
As a collective, we might feel that nursing as a vocation is a thing of the past. That nurses who felt a calling to help people have been replaced with embittered robots merely going through the motions. That may be so for some healthcare workers, but Pretoria-based researcher Kerigo Odada reminds us that this particular epidemic is systemic – a legacy issue with deeper roots.
"As much as we want to focus on the interpersonal violence perpetrated by service providers, we must remember that they are also part of a victimised system as a result of poor health financing and a lack of resources," says the researcher, who specialises in obstetric violence.
When viewed as a form of structural violence (which prevents groups of people from having their basic needs met), obstetric violence reflects as a form of abuse ingrained in South Africa's legacy of oppression.
According to Odada, this is indicative of the fact that obstetric abuse, while still prevalent in private institutions, largely affects societies where basic amenities –water, power, education, infrastructure, investment – are at a loss.
"Lack of access to quality maternal health services is a problem. The best solution would be to create an enabling environment for both parties involved, which requires a lot of investment," she says.
Odada believes that to comprehensively address obstetric violence, stakeholders (including government) would need to consider some of the key determinants of health, which include availability, accessibility and acceptability. Doing so would be the first step to ensuring that pregnant persons and service providers are able to operate in an environment conducive to both parties.
'The world will soon have no more medical staff'
One nurse who wrote to News24 said, "I am a single mother and can't afford a bond on my own. We don't earn the salary that doctors earn, but we save most of our clients' lives." She added how disheartening it has been to continue seeing negative coverage about nurses and their care.
"If a group of nurses in a particular uniform mistreats patients, the whole nursing world is painted as insensitive, inhumane. Everyone has the basic human right to raise concerns about poor client care, but please specify the medical institution, ward and nurse's name, otherwise the world will soon have no more medical staff because of all the negative publicity."
'We need to encourage women to come forward'
Healthcare activist and former Netcare Communications Director Kerishnie Naiker agrees that a positive starting point in curbing the scourge of obstetric violence is for perpetrators to be reported.
"We need to encourage women who have suffered harm and mistreatment within maternity care to come forward, even if they do so anonymously. I suggest that they mention the days they were in hospital, recall the shortcomings and possibly provide the names of staff members to ensure that the relevant people get taken to task," she says.
Citing the South African Medical Association, the Medical Research Council, the Health Professionals Council of South Africa, the South African Nursing Council, and the Department of Health (DoH), Naiker insists that the plethora of medical organisations in South Africa adopt a genuine and consequential approach to such crimes.
"I appreciate that their hands are full and they have much else to address. However, when situations or incidents like these come to the fore, we cannot ignore them. The more we ignore them, the more "acceptable" they become. The more nurses, doctors and midwives do not face the consequences of their criminal and unethical actions, the more they will continue," she asserts.
'The department is not responsible for implementation'
Despite confirming receipt of our questions, the DoH failed to respond by the time of publication. However, the Department of Women, Youth and Persons with Disabilities noted that their ministry has been in consultation with the DoH on the matter, providing "strategic guidance and leadership".
Spokesperson Shalen Gajadhar told News24 that the Department of Women is working to incorporate obstetric violence "and issues like forced sterilisation" into the framework of the National Strategic Plan on Gender Based Violence and Femicide, "as it is essential to the 2030 vision of zero gender-based violence".
However, Gajadhar added that the department is not responsible for implementation insofar as actioning steps to transform the maternal health sector.
"Our mandate is to regulate socioeconomic empowerment for women, youth and persons with disabilities, hence the monitoring role we playing in ensuring that the DoH addresses the issues comprehensively with all key stakeholders internally and externally," said the spokesperson.
He added that, in terms of the current status of government action on obstetric violence, the DoH had established a panel of independent experts from various fields to further investigate the matter and "to better understand the nature and extent of the complaints" as a way to inform corrective action.
"A joint submission on the Programme of Action is being developed for presentation to both Ministers [of Health and Women, Youth and Persons with Disabilities]," said Gajadhar. He added that, when it comes to implementation, any actionable steps to begin curbing obstetric violence needs to be endorsed "by all relevant parties", even at provincial level.
Bring humanity back to birthing
But slow are the sands of time in this particular hourglass. Mothers continue to to be victimised while government departments work to agree on a course of action. As a result, family units suffer and, by nature of the ripple effect, so does our society.
Naiker agrees, attributing the widening gap between public and private healthcare to a lack of governmental action. "There's all this song and dance about matters, but implementation lags behind and then doesn't happen at all. Time, effort and money is spent on meetings and conferences rather than action to bring about favourable change," she says.
Naiker remains grateful to nurses and medical staff who are passionate about their vocation and show respect to their patients adding, however, that change will have to start at the top.
"Government, leaders, healthcare professionals and every healthcare staff member needs to recognise right from wrong. To recognise acceptable versus unacceptable conduct and to recognise that when you treat patients in an inappropriate manner – when you hit, ridicule, humiliate or force them to comply with what you want just to make your job easier – it is criminal, illegal and unacceptable. Every person deserves their right to informed consent and their right to health and life."
Odada adds that society needs to bring humanity back to obstetrics.
"The pathologisation of the female body has removed humanity from birthing. That's something that needs to come back. Birthing shouldn't just be about another body that needs to pass through the system. Medical service providers need to take a human rights approach to obstetric care. Can we bring back humanity to the birthing process?"
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