OPEN LETTER | Protecting women from obstetric violence starts with calling it what it is

Dear ministers Aaron Motsoaledi, Sindisiwe Chikunga, Enoch Godongwana and Thembi Simelane:

Every year in South Africa, the country dedicates 16 days to activism against gender-based violence (GBV) to raise awareness about the scourge and to catalyse change. GBV takes various forms; some are better understood, reported and tracked than others.

Obstetric violence is a lesser-known form of GBV that has gone unchecked for too long. It includes verbal abuse (such as bullying, coercion or humiliation) and physical abuse (including assault, sexual abuse and medical interventions without informed consent). Neglect, breaches of confidentiality, discrimination and emotional abuse are also forms of obstetric violence — all of which are violations of human rights.

However, obstetric violence is so far below the radar of senior government officials that accurate national statistics about the extent and impact of obstetric violence are difficult to source. We tried to fill this gap with a small-scale survey of 482 participants within our network of mothers and found that 1 in 2 women experienced some form of obstetric violence. While not nationally representative, these findings offer a troubling glimpse into the prevalence of this issue.

Obstetric violence affects women and girls when they are most vulnerable and is committed by those working in our clinics and hospitals — public and private. Preventive measures have been sorely lacking — until now. The national department of health’s new Maternal and Perinatal Care Guidelines, an update on the version published in 2016, include a chapter on Respectful Maternity Care (RMC). This inclusion presents a powerful opportunity to tackle obstetric violence.

From what is known and understood about obstetric violence, it disproportionately affects adolescent girls who are shamed or dismissed by healthcare providers, women with disabilities whose needs are often ignored, women living with HIV and Aids who face stigma and neglect, women from low-income communities and undocumented migrant women who are treated as outsiders.

Ministers, your departments are pivotal to recognising obstetric violence as a form of GBV in health policies and legislation. Additionally, the allocation of adequate funding to address service delivery gaps in reproductive healthcare and ensuring sufficient capacity is key to implementing Respectful Maternity Care in our clinics and hospitals — especially in rural and under-resourced facilities.

A recent case in Pretoria involving a midwife who faces charges for alleged negligence and ongoing reports of forced sterilisations in public health facilities underscore the severity and recurring nature of this problem. From what is known and understood about obstetric violence, it disproportionately affects adolescent girls who are shamed or dismissed by healthcare providers, women with disabilities whose needs are often ignored, women living with HIV and Aids who face stigma and neglect, women from low-income communities and undocumented migrant women who are treated as outsiders.

The emotional, physical and psychological impact of obstetric violence, like other forms of GBV, are long-lasting. The trauma does not simply go away when the incident is over. It can colour all future interactions that a person has with the healthcare system.

Most women who have experienced obstetric violence report negative psychological symptoms such as anxiety, stress and depression. Others have reported physical or negative health complications as a side effect of the abuse. Obstetric violence can also result in death. All of this highlights the personal toll of obstetric violence and tells us that the system is allowing these things to happen.

At its core, obstetric violence stems from power imbalances, gender dynamics and racial/social prejudices entrenched in our healthcare system. Historical inequities, professional hierarchies and colonial legacies create the conditions for obstetric violence to take place unabated.

We need a co-ordinated government response

There is no better time for the government to introduce the new maternity care guidelines. But it’s not enough. Addressing this problem requires a co-ordinated effort to deal with the systemic issues that are allowing obstetric violence to continue. Resource shortages, overworked staff and underfunding threaten to render these new guidelines aspirational rather than implementable. In rural and underserved areas, the challenges are even greater, worsening disparities in the quality of care women receive.

Healthcare workers are caught in a web of systemic pressures, including overwhelming caseloads and inadequate support. Under these conditions, neglect and mistreatment of women and girls seeking reproductive healthcare are normalised. This tells us that obstetric violence is not only a matter of patient rights but also one of improving workplace conditions for healthcare providers. The fundamentals established by Respectful Maternity Care serve as a framework to prevent obstetric violence by promoting patient-centred care grounded in dignity and autonomy. These fundamentals must, however, be supported by adequate investment in training, mental health support for healthcare providers, and infrastructural improvements, to turn the tide on obstetric violence.

Minister of health Dr Aaron Motsoaledi, we urge you to prioritise the development and implementation of comprehensive, skills-based training for healthcare workers, including training on empathy and trauma-informed care as well as competence assessments, supportive supervision and mentoring, and for performance reviews to include KPIs linked to respectful maternity care.

Minister of women, youth and persons with disabilities Sindisiwe Chikunga, we call on you to champion the rights and protection of women and pregnant persons from obstetric violence, including from coerced or forced sterilisation, and to ensure better access to psychosocial support services for survivors of obstetric violence.

Minister of finance Enoch Godongwana, we acknowledge that austerity measures are the order of the day, and that you allocated a three-year total of R848bn to health in the most recent Medium-Term Expenditure Framework (MTEF). However, the implementation of Respectful Maternity Care has not been costed, making it unclear whether the budget adequately addresses RMC needs. We urge you to allocate sufficient funds to tackle inequities in maternity care — an issue of rights and justice — through targeted investments in RMC guidelines, including healthcare worker training, infrastructure improvements, essential supplies and addressing staff shortages.

And minister of justice and constitutional development Thembi Simelane, we need your department to formally recognise obstetric violence as a form of GBV, with clear definitions, protections and recourse for victims in South Africa's legal framework.

Government must establish and enforce rigorous accountability mechanisms at all levels of the healthcare system to ensure the effective implementation of the guidelines, publishing regular progress reports to ensure transparency and accountability.

If the government gets this right, we will be able to adopt uniform standards of care that transcend regional disparities, ensuring that all birthing individuals — regardless of geographic or socioeconomic status — receive dignified treatment.

Signed by:

Julie Mentor — Embrace Movement for Mothers
Rumbi Goredema Görgens — Embrace Movement for Mothers
Nonkululeko Mbuli — Embrace Movement for Mothers
Dr Sheena Swemmer — Centre for Applied Legal Studies, University of the Witwatersrand
Asiphe Funda — SECTION27
Khuliso Managa — Women’s Legal Centre
Prof. Simone Honikman — Perinatal Mental Health Project, Centre for Public Mental Health, University of Cape Town
Prof. Tracey Feltham-King — Critical Studies in Sexualities and Reproduction (CSSR), Rhodes University
Dr Veronica Mitchell — Research Fellow, Women's & Gender Studies Department, Faculty of Arts, University of the Western Cape
Prof Lorena Nunez Carrasco — School of Social Sciences, University of the Witwatersrand
Kerigo Odada — reproductive justice researcher

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