The cruel collusion that devastates young doctors learning how to deliver babies

• Women who experience this type of abuse are less likely to return to health services when they need it out of fear of how they’ll be treated.
• There are ways to report such acts at facilities, but they’re rarely used. Only 1.6% of SA’s state facilities have used the early-warning system at the office of health standards compliance (OHSC), which is tasked with making sure that facilities clear a certain bar of quality, and to flag those that don’t.
• SA’s domestic violence action plan and treatment guidelines don’t mention abuse of pregnant or birthing people (also called obstetric violence), nor is there any law that makes this type of abuse a criminal act.

It was nearing midnight on day one of my rotation in the maternity ward of a state hospital in a coastal SA 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 birth 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 patient, but not the last.  

Why do health workers become violent?

When a pregnant person 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.

SA is no exception.

In 2011, Human Rights Watch (HRW) 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 are 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 health-care 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 dynamics in the health system make it really hard to report abuse towards patients.

However, with the 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 SA now have a clearer route to report mistreatment than when the HRW 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 it finds. 

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 SA’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 SA at the moment: obstetric violence is a fact of the health system. It happens every day, but there’s no official trace of it — as if 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 — illustrate 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 it 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.

Though 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.

SA doesn’t yet have any laws that would make obstetric violence a criminal offence, but calls for it to be considered are mounting 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. — Additional reporting by Joan van Dyk and 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 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.