By Rachelle Chadwick and Marion Stevens
We know that gender and sexual violence are major problems in South Africa. We know that we have shockingly high rates of rape, domestic violence and femicide. What is not always recognised however is a different form of violence against women. This is violence that is perpetrated predominantly by women and which targets other women when they are in one of their most vulnerable moments. We are talking here about birth violence that happens to women during labour and when they are giving birth to a new life. While reports of abuse in maternal health services have been fairly widespread since the early 1990s, these incidents are often not framed as a form of violence against women. Some view these incidents as the work of a few bad apples and not indicative of wider attitudes. We know from writing on the issue that the factors involved are complex and multiple, including an over-burdened public health system, lack of resources, highly stressed staff and health-care providers and a long apartheid legacy that still marks our healthcare system. We appreciate the point made by others [i] that healthcare-workers, nurses and midwives need to be validated, supported and cared for so that they can do the work of caring for women during labour and birth. This is important. At the same time, however, we feel that something about this issue is being squashed and silenced.
Shouting at and insulting women, engaging in forms of physical violence such as slapping and rough treatment and deliberately shaming, humiliating and neglecting women during one of the most vulnerable moments of their lives is unacceptable. It is unacceptable regardless of work-loads, lack of support or difficult working conditions. That our healthcare system and society at large continues to largely ignore, and in some cases tolerates these abuses, is indicative of a much wider problem of gender relations in South Africa. Of course it is not simply women in general who are the recipients of such abuse. Privileged and middle-class women, protected by their resources and cultural capital, usually escape gross mistreatment. Other forms of obstetric violence (such as unnecessary caesarean section) however do still occur in the private healthcare system. However, it is predominantly poor and marginalised women (including teenage and HIV-positive mothers) that are targets of violence.
Abuses often seem fuelled by normative ideas about who is a ‘good’ and a ‘bad’ mother. Being poor and coming to a public health clinic without appropriate baby clothes and supplies often automatically marks a woman as a ‘bad mother’ who is then sometimes punished by healthcare providers through insults or deliberate shaming. [ii] Other forms of violence, often not recognised or reported, are institutional in nature and involve the shoddy treatment of women in general in public sector health clinics. Examples include dirty toilets, spatial arrangements at maternal obstetric units which do not allow for any privacy during birth and which often preclude women being allowed to have a partner or companion with them during labour, lack of basic supplies such as blankets, pillows and cutlery (one woman told of how all the women had to share one mug) and not being offered any food after going through the exhausting process of labour and birth [ii].We have to ask serious questions about this mistreatment of women. Why has the National Department of Health (NDoH) been so reluctant to address these problems despite evidence of abuses reported since the 1990s? What does this mistreatment and abuse say about how our society sees and values women?
Thankfully there are signs that efforts are being made to begin to address these issues. There have been calls for increased accountability and institutional reform by some academic obstetric departments (such as the University of Cape Town). The Human Rights Watch also pulled no punches in their report on maternal health abuses in 2011, which was tellingly titled, ‘Stop making excuses’ [iii]. Pressure on various fronts has led to some notable recent actions, including the passing of a policy in 2013 by the Western Cape Department of Health (WCDoH) called the ‘Code of Practice for Patient-Centred Maternal Care’. There has also been the introduction of a new national mobile health programme, ‘Momconnect’ which will enable women to directly report abuses. A hotline has also been set up in the Western Cape to make complaints (0860 142 142). At the same time, however, the NDoH has not widely supported or allocated funding for attempts being made in the Western Cape to address these problems. There thus still seems to be a shocking lack of will by governmental bodies to tackle abuse and violence in maternal healthcare settings.
We have to begin to ask why? Perhaps it is difficult or disturbing to recognise a form of violence against women that is perpetrated largely by women ‘caregivers’. Perhaps wider societal attitudes and discriminatory stances towards poor and marginalized women regard the ‘care’ received in public health settings as ‘good enough’ for them. Maybe wider society and government just don’t care about how low-income women are treated. Maybe society in general fails to value women’s reproductive labours and life-giving efforts. Maybe we just don’t value mothers or the precious new lives that they give birth to? One thing is certain – the ways in which women are treated during the vulnerable time of labour and birth says a lot about wider societal and governmental attitudes towards women. We need to confront and expose these unacceptable attitudes. As a nation we can no longer simply ignore or tacitly tolerate these abuses.
- Honikman, S . & Meintjies, I. ‘Nurses are stressed, ill-treated, burdened’, Cape Times, 9 September 2011.
- Rachelle Chadwick, ‘The right to dignity in childbirth’, National Research Foundation Report, 2013.
- Human Rights Watch, ‘Stop making excuses: accountability for maternal health in South Africa’, 2011.
Rachelle Chadwick is a lecturer and Research Career Fellow in Gender Studies (School of African & Gender Studies, Anthropology & Linguistics) at the University of Cape Town. She has a PhD in Psychology from the University of Cape Town. Rachelle is a recipient of a National Research Foundation Research Career Advancement Award and is currently working on a new research project titled, ‘Intimate ethnographies of giving life: the bodily-emotional worlds of childbearing for low-income South African women and their partners’. She has published research articles and book chapters in the areas of qualitative methodology, gender theory, sexuality, childbirth, embodiment, narrative resistance and reproductive health.
Marion Stevens has a background as a midwife, in medical anthropology and in public and development. She has worked in the area of sexual and reproductive health and HIV/AIDS for some 20 years. She is currently the coordinator of WISH Associates (Women in Sexual and Reproductive Rights and Health) a network of nine South African consultant activists and a research associate at the African Gender Institute at the University of Cape Town.