As a young house officer on a 3-month obstetrics/gynecology posting, I witnessed some doctors and midwives shouting at and smacking the legs of women during their childbirth. Their violence was committed under the pretense of helping women push out the baby without complications, but what I saw did not sit well with me.
This week I was reminded of those experiences when I read the findings of a new study published by The Lancet. One third of new mothers report abuse during childbirth in Ghana, Guinea, Myanmar and Nigeria, including 35 percent who experienced physical abuse; 75 percent who faced surgical enlargement of the vagina to ease delivery without their consent; 56 percent who did not consent to a caesarean section and 5 percent of women and their babies who were detained in the health facilities because of inability to pay their bills. Younger women with no education and younger women with some education were most likely to be abused.
This is not new. Abuse of women during childbirth is ubiquitous and happens in every country. In Ethiopia, 84 percent of respondents in a survey reported violation of the right to information, informed consent and choice of position during childbirth. In 2018, Sally Gimson shared her experience of not receiving the standard dose of anesthesia before cesarean section in Germany. She regained consciousness due to the excruciating pain before more anesthesias was given. The doctors pretended they did nothing wrong.
In Canada, 24 percent of 410 women who responded to a survey about their childbirth experience at St. Joseph’s Health Centre in Toronto said that they did not feel that their bodily autonomy was honored and respected.
In the U.S., there is a racial dimension to abuse of women during childbirth — women of color with low socio economic status are more likely to be mistreated than white women of the same social class. The abuses experienced by women in America include, loss of independence, being shouted at, being threatened, being ignored, and receiving no response to requests for help.
The 21st century health-care delivery must be safe, effective, patient-centered, timely, efficient and equitable. Women suffering from any forms of abuse in the hands of health workers should not be tolerated. When women get bad deals at hospitals, they could be discouraged from undergoing facility-based delivery during their subsequent pregnancies. When women deliver in the absence of skilled health workers, there are usually dire consequences, including deaths.
The mistreatment of women during childbirth must end, and these are strategies that can help.
First, train all doctors and midwives on respectful maternity care. According to the World Health organization, respectful maternity care encompasses care to all women, which preserves their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labor and childbirth. Women and their loved ones must be informed of their rights once they register for antenatal clinics, reiterate these rights throughout pregnancy and during birth.
Their loved ones in the room should be encouraged to speak out if they see abuse happening and the woman is in too much pain or occupied to respond. In addition, health facilities should set up a complaint mechanism that is known to women and their families. Beyond having these processes in place, health facilities must be seen to attend to complaints, conduct investigations and give feedback on actions taken to women and their families.
Second, use technology to empower women and their families to report cases of abuse and rate the quality of care received in health facilities. There are many apps to provide health information to a pregnant woman, detailing expectations during pregnancy and childbirth. However, there are hardly any apps that empower the woman to report cases of abuse. Globally, there are 9.3 billion mobile devices.
In some African countries, more people have access to mobile phones than clean water. The availability of mobile phones should be harnessed and used as a powerful tool for maternal health accountability. For instance, women can send text messages to report cases of abuse to hospital management and other regulatory agencies. For women who own smartphones, apps and other web-based platforms can be used to document and report abuse.
Third, improve the social status of women by ensuring all girls are in school and women are economically empowered. The Lancet study found that that women with little or no education were the most abused. In the U.S., women of color were more abused than white women.
Based on 2016 data, 131 million girls were out of school globally — this is equivalent to the combined populations of France and the United Kingdom. Deliberately enrolling all girls in school and making primary and secondary education free and compulsory could reverse this trend. Government, donors, civil society and the private sector should also scale interventions that empower women economically.
Lastly, when cases of abuse of women during childbirth are reported, health regulatory agencies must investigate and enforce penalties. Rights and safety of women must be protected at all times and adequately compensated when harm is committed.
The woman is the most important stakeholder in the process of childbirth. Her rights must be respected. She must be allowed to give birth with dignity, without suffering any harm.
Dr. Ifeanyi M. Nsofor M.B.B.S is the CEO of EpiAFRIC and director of policy and advocacy at Nigeria Health Watch. He is a current 2019 Atlantic Fellow for Health Equity at George Washington University and a 2018 New Voices Fellow at the Aspen Institute. Follow him on Twitter: @ekemma.