07 Sep 2016
September 7, 2016

Obstetric Violence in South Africa

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GUEST EDITORIAL South African Medical journal
424 May 2016, Vol. 106, No. 5dscn3146

Abusive practices in obstetric care settings have been reported in
the USA since the 1950s. However, it is only since the 2000s that this
issue has been identified as a worldwide health and social problem. [1]
The mistreatment of women and girls during childbirth has been
documented in a range of global contexts, including high-income
countries[2-3] and middle- to low-income countries.[4-6] There hashttp://ninobirth.org/?p=735
recently been growing international attention to this problem,[7,8] and it
has been recognised that abusive treatment is connected to poor uptake
of maternity services and poor maternal and infant health outcomes
in some settings. For a long time, the importance of respectful and
dignified care during labour and childbirth has been a ‘blind-spot’ in
global health agendas,[7] but calls for action and accountability are now
becoming difficult to ignore.[5,7,8] Current debates and global activism
are increasingly drawing on the concept of ‘obstetric violence’ to
contextualise and address patterns of mistreatment of women and girls
during labour and childbirth. This editorial introduces this concept
and explores its potential relevance in the South African (SA) context.

Introducing the concept of obstetric violence
A range of terms have been used to describe violence against women
and girls during labour and birth, including childbirth abuse, ‘birth
rape’, mistreatment, and most recently obstetric violence. A wide
range of problematic practices have been associated with these terms,
including neglect, verbal and emotional abuse, physical abuse, sexual
abuse, lack of confidential and consensual care, and the inappropriate,
non-evidence-based use of medical interventions, including routine
episiotomies, routine inductions, preventing labour companions, and
unnecessary caesarean sections.[9,10] The concept of obstetric violence
emerged in the 2000s in Latin America and Spain as an extension of
the activist struggle to humanise and demedicalise childbirth and
empower women and girls during pregnancy, labour and birth. It
emerged as a legal term in Venezuela in 2007 and was adopted by
Argentina in 2009 and by Mexico in 2014. Perpetrators of acts of
obstetric violence are subject to criminal liability in these countries,
which usually amounts to a fine and a signed acknowledgement of
wrongdoing on the part of the practitioner and/or the institution.
In Venezuelan law, published in Article 15 of the ‘Organic Law on
the Right of Women to a Life Free of Violence’, obstetric violence is
included as one of 19 different forms of punishable violence against
women and is defined as:
‘… the appropriation of the body and reproductive processes of
women by health personnel, which is expressed as dehumanized
treatment, an abuse of medication, and to convert the natural
processes into pathological ones, bringing with it a loss of
autonomy and the ability to decide freely about their bodies and
sexuality, negatively impacting the quality of life of women’.[9]

The use of the controversial term ‘obstetric violence’ over more
neutral labels such as ‘mistreatment’ is part of a deliberate move
to confront problematic practices, which have often been hidden,
invisible and unacknowledged, as forms of violence. For activists and
practitioners in Latin American contexts, aggressive, humiliating
and disrespectful treatment of women and girls during labour and
birth is part of broader and entrenched gender violence and social
inequalities of race, class, age and ethnicity. Medical interventions
(most notably routine episiotomies and unnecessary caesarean
sections) that are used excessively are also defined as examples of
‘obstetric violence’.

Lack of accountability for abuses in the SA context
Not surprisingly, medical practitioners have been hostile to the
concept of obstetric violence and its legal implications in the
Latin American context, fearing that it potentially criminalises
routine medical treatment.[5] The move to tackle abuse in maternal
healthcare settings by adopting legal routes should, however,
be recognised as partly the result of the failure of the medical
establishment to confront these issues and hold healthcare
professionals and institutions of care accountable for unacceptable
practices. This is the case in Latin America and also increasingly
in SA. As a result, calls for legal action and the criminalisation
of abusive practices by healthcare professionals are now gaining
ground in the SA context.[11] While it is true that the roots of
abusive treatment (in SA and other contexts) are complex,
including health system inadequacies, an insufficient emphasis on
an ethics of care in midwifery training, poor working conditions,
healthcare professional overload and historical legacies of
inequalities, there is also no excuse for failure to hold individuals
and institutions accountable for practices that dehumanise,
degrade and cause harm to women and girls in some of their most
vulnerable moments (i.e. labour and childbirth). Efforts to change
institutional cultures that condone medicalised forms of violence
and abuse need to be led by medical practitioners, professional
associations and institutional boards.

A form of gender violence?
In the medical literature, debates about mistreatment are often
predominantly framed in relation to quality-of-care issues and the
failure of evidence-based obstetric practice. Often the assumption
is that informing and training practitioners about evidence-based
medicine (i.e. the benefits of labour companions) is enough to
change practices on the ground. In the SA context in particular,
achieving changes in practice has proved extremely difficult.[12]
Reports of abusive mistreatment of women and girls in obstetric
contexts date back to 1998,[13] yet little seems to have changed
almost 20 years later, with recent research finding the same patterns
of mistreatment in public sector facilities.[6] There is no doubt that
there are significant structural impediments to changing practices
(i.e. spatial configurations of obstetric facilities that discourage
privacy and women’s right to a labour companion). At the same
time, we need to acknowledge the abusive treatment of women
and girls in maternity services as a form of gender violence[5,8,14]
that reflects the broader societal devaluation of women and girls
and the normalisation of violence against them (particularly
marginalised and impoverished women and girls). Violence in
obstetric contexts in SA is multilayered and complicated by the
fact that it includes both individual acts of abuse and structural
components such as degrading spatial configurations that lead
to lack of privacy and impede the use of labour companions. We
need to address both obvious forms of violence where there is a
clear individual ‘perpetrator’ (i.e. physical abuse of patients and
intentional emotional abuse) and structural forms of violence
(demeaning attitudes towards poor women and girls, authoritative
power of obstetric knowledge, infrastructural problems) that create
the conditions for individual abuse.
SA could learn a great deal from what is happening in Latin
America and Spain, where activism and action against abusive
treatment during labour and childbirth have been framed within

a broader rhetoric of women’s rights to lives free from all forms of

violence and abuse. In these contexts, high rates of medicalisation

are also recognised as sources of abuse.[5,9] In the SA context, there
has been a lack of attention to potential abuses in private sector
facilities, with the predominant assumption that mistreatment and
abuse is only a problem in public sector maternity services. This
is surprising, given that the private sector in SA has one of the
highest rates of caesarean section in the world, with estimates
ranging between 40% and 82%.[15,16] Such estimates are far above
the rate of 15% recommended by the World Health Organization
and raise concerning questions about levels of unnecessary medical
intervention in private sector obstetrics in SA. The silence on this
issue is itself worrying, and the time is ripe for further investigation
and debate regarding practices in the private sector.

Regardless of the roots of abusive treatment, it is important to strive
for accountability on all levels – in respect of the state, medical
institutions, training programmes and individual practitioners.
The use of violence in the form of coercive practices, physical
and emotional abuse, lack of consent, intentional humiliation,
the withholding of medical attention and care during labour and
childbirth as a form of punishment, and the unnecessary use
of medical interventions are unacceptable and reflect entrenched
systems of gender and class marginalisation in SA. The medical
establishment needs to recognise forms of abuse during labour and
childbirth as more than the actions of a few misinformed individuals
and to address wider systemic sexism and classism in medical
training, established protocols and attitudes towards childbearing
women and girls.
Rachelle Joy Chadwick
Gender Studies Section, School of African and
Gender Studies, Anthropology and Linguistics,
Faculty of Humanities, University of Cape Town,
South Africa

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