SPOTLIGHT ON OBSTETRIC VIOLENCE: BUILDING A COMPELLING ARGUMENT FOR
SOCIAL CHANGE
Obstetric violence (OV) refers to rights violations and abuses experienced by pregnant women and birthing people1 while accessing healthcare during pregnancy, labour, childbirth and in the postpartum period. This form of gender-based violence presents a significant threat to the global health of women and children. Embrace, South Africa’s first social movement for supported and celebrated motherhood, believes that the key to ending obstetric violence lies in elevating the voices and experiences of mothers. Even though several organisations have been working to highlight the prevalence and impact of obstetric violence, this issue was not part of mainstream discourse until recently.
This learning brief looks at Embrace’s efforts to influence national maternity care policy, raising awareness about the prevalence of obstetric violence, and the urgent need for respectful maternity care in South Africa.
1 Embrace acknowledges that not all pregnant people identify as women, hence the use of inclusive language to recognise transgender and nonbinary persons who are also affected by obstetric violence.
Stop nutritional stunting of young children.
Build simple, loving connections for every child
Embrace aims to promote a connected and thriving start to motherhood for every new mother in South Africa. It is growing a nationwide peer support network and making sure moms’ voices are heard. Embrace’s mission is to tackle some of the structural and social dynamics that shape the experience of early motherhood.
BIRTH EXPERIENCES IN SOUTH AFRICA
The ‘First 1 000 Days’ is a crucial time for mother and child, spanning the time from conception to a child’s second birthday, when a baby’s brain develops faster than at any other time. What happens during this period plays a vital role in helping children grow up to be happy, healthy and welladjusted.2
As part of a campaign highlighting the voices and experiences of mothers during Women’s Month in 2018, Embrace initiated story sharing, inviting moms to participate in birth storytelling circles across South Africa. The Embrace team hosted the circles privately to ensure that the women telling their stories felt safe enough to share their experience.
A consistent theme was the huge effect of birth experience on mothering and the transition into new motherhood. Their experiences included: verbal abuse,
physical abuse (e.g. physically left to labour or push unattended; having legs held open; having nurses push or apply pressure to the abdomen during labour; being yelled at during labour), neglect, and lack of care.
This brought Embrace to the work of Rachelle Chadwick, a University of Bristol academic, who uses the term ‘obstetric violence’(OV) to describe abusive practices in obstetric care.
2 Ilifa Lanbantwana. 2017. The First 1 000 Days of Life Factsheet. Access at: http://ilifalabantwan
She acknowledges that the reasons for abusive treatment in South Africa 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”, but she maintains “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)”.3
Rumbi Goredema Görgens, Embrace operations manager says: “We acknowledge ‘obstetric violence’ is not necessarily a universal term, but for Embrace, it signifies the urgency of the problem and the obstetric part highlights the additional vulnerability involved in that phase of life where women are likely to experience it.”
THE CONSEQUENCES OF OBSTETRIC VIOLENCE
Perinatal4 depression poses significant health risks to mothers and their children.5 Embrace frequently partners with the Perinatal Mental Health Project (PMHP)6 which offers counselling and support services to pregnant and postpartum women. In 2020, they collaborated on a unique response to the COVID-19 pandemic in South Africa, Messages for Mothers (M4M), which aimed to provide answers to mothers’ pressing questions about the coronavirus.7 When PMHP was invited to write chapters on Maternal Mental Health and Respectful Maternity Care for the updated version of the national Maternity Care Guidelines, they invited NGOs, including Embrace, to contribute to the content, ensuring civil society voices could critique and improve the chapters before finalisation. Through PMHP, information from the Counting What Matters survey results was used in the National Department of Health (NDoH) webinar Maternal and Neonatal Health Guidelines series that introduced the new guidelines to over 1 000 maternity care providers from all over the country.8
Did you know?
Obstetric violence has been shown to contribute to postpartum depression and anxiety and post-traumatic stress disorder. According to the Perinatal Mental Health Project, 1 out of 3 women who give birth in South Africa are at risk of a perinatal mental health condition, which is higher than the global average of 10-15%.9
3 Chadwick, Rachelle Joy. (2016). Obstetric violence in South Africa. SAMJ: South African Medical Journal, 106(5), 423-424. https://dx.doi.org/10.7196/samj.2016.v106i5.10708
4 Perinatal is the time from when one becomes pregnant up to a year after giving birth.
5 Pellowski JA, Bengtson AM, Barnett W, DiClemente K, Koen N, Zar HJ, Stein DJ. Perinatal depression among mothers in a South African birth cohort study: Trajectories from pregnancy to 18 months postpartum. J Affect Disord.;259:279-287. doi: 10.1016/j. jad.2019.08.052. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6851529/#:~:text=Perinatal%20 depression%20affects%2021%E2%80%9350,low%20and%20middle%2Dincome%20 countries
6 https://pmhp.za.org/
7 https://dgmt.co.za/learning-brief-messages-for-mothers/
8 Honikman, S. 2024. NDoH Webinar Maternal and Neonatal Health Guideline Series. https://knowledgehub.health.gov.za/system/files/2024-02/KH%20RMC%20 presentation%20for%20upload%20no%20film%2019.02.2024.pdf
9 Counting What Matters. Op.Cit.
CHANGING THE NARRATIVE: A TIMELINE OF EVENTS
2018 – NATIONWIDE PROTESTS
A crucial development in the public consciousness occurred when women and gender non-conforming people initiated ‘The Total Shutdown’ (TTS) intersectional movement against gender-based violence and femicide (GBVF), taking to the streets of South Africa on 1 August 2018 (Women’s Month) in protest. Dr Jess Rucell, a researcher and advocacy expert on sexual and reproductive health rights and part of the TTS movement, says that while OV has been documented in public health literature in South Africa since 1998, and it is widely known amongst clinicians, there had not been public debate about the problem until recently.
Embrace believes that the key to ending this form of GBV in South Africa lies in elevating the voices and experiences of mothers, and bringing their stories into the rooms and spaces where policies are made.
2022 - OBSTETRIC VIOLENCE NAMED AT PRESIDENTIAL SUMMIT ON GBV
In 2021, Embrace began consulting with Dr Rucell who, along with women from various sectors, had pushed for obstetric violence to be officially recognised at South Africa's first Presidential Summit. Through this relationship with Dr Rucell, and her role as a member of the 2022 Presidential GBVF Summit Planning Committee (PSPC), Embrace took the lead in planning the second Presidential Summit.
This led to Embrace, along with other like-minded organisations such as the Women’s Legal Centre, the Centre for Applied Legal Studies (CALS) and Section 27, facilitating a breakaway session or Action Caucus on Pregnancy, Sexual and Reproductive Health and Rights.
Dr Rucell, who is a gender justice expert at CALS, noted: “That issues of GBV facing pregnant women and birthing people have been included in both days of the President’s Second Summit is the success of the TTS movement and the organisations that have continued to prioritise the rights of mothers. In 2018 obstetric violence was omitted from the first National Summit on GBVF, its Declaration, and as a result the National Strategic Plan on GBVF. Our success in 2022 means the state can no longer ignore the abuse of pregnant women and must take meaningful steps to stop harming women seeking health services.”
This group influenced the summit’s resolutions to include the following:
“We want to put a loudhailer to the cause so it becomes clear that this is happening across a spectrum of healthcare experiences with different practitioners and also at different points in the journey to motherhood.”
Rumbi Goredema Görgens, Embrace operations manager
A resolution to strengthen health system accountability through co-opting senior government officials, like ministers and MECs, to serve in key committees related to the implementation of the national strategic plan.
To ensure the protection of women during pregnancy and childbirth by taking decisive action against perpetrators of GBVF, including forced sterilisation, ensuring redress for victims of obstetric violence, and ensuring that Chapter Nine institutions (for example, the Public Protector, South African Human Rights Commission, Auditor-General and Commission for Gender Equality) as well as Health Professionals and Nursing Councils intervene to guarantee investigations into allegations of GBV and coerced/forced sterilisation.
To recognise that the Constitution considers pregnant persons as particularly vulnerable and at risk of GBVF, and demand action from the state to protect and enable the rights of pregnant persons, including victims/survivors of obstetric violence.10
2022 – ADVOCACY THROUGH VISUAL MEDIA
In 2022, Embrace partnered with filmmakers Makhulu Media,11 a social change media agency, to hold a series of workshops for women willing to share their first-hand experiences of OV and process their trauma with other women attending the workshops. This evolved into a short documentary titled “Push Comes to Shove” – four stories of women who’ve experienced obstetric violence. The story themes include forced sterilisation, denial of mental health treatment, discrimination against pregnant teenagers, lack of aftercare, sexual harassment and verbal abuse. Through research and interviews, the documentary shows that OV is a common yet preventable barrier to women’s right to quality and dignified healthcare.
The documentary is not open access. “It is only shown in as far as it facilitates a conversation about obstetric violence, because we didn’t want it to be exploitative,” explains Goredema Görgens. It was released during 16 Days of Activism against GBV in 2022.12 Makhulu helped distribute the film through Sunshine Cinema,13 its solar-powered cinema network which partners with grassroots organisations to use film and post-screening discussions to highlight social change issues. Prior to each screening, the four participants were given the opportunity to cut their story from the documentary if they wished.
2023 – BUILDING EVIDENCE THROUGH QUANTITATIVE AND QUALITATIVE DATA
Building on the exposure from the 2022 Presidential Summit, Embrace began gathering evidence to support its advocacy efforts to end OV in South Africa. During the 16 Days of Activism period in 2023, Embrace launched Counting What Matters: The Embrace Birth Experience Survey on its social media platforms. It also sent out a newsletter and open call to partners, movements and coalitions across the country to share the survey with women in their network. The anonymous survey was online for two weeks and took less than five minutes to complete. In total, almost 500 people completed the survey.
The birth experience survey results14 show that one in two women experienced some form of obstetric violence. Embrace acknowledges that there was likely to be a selfselection bias here, with women who had bad experiences during childbirth more likely to respond. Nevertheless, Embrace aims to use these results to advocate for nationally representative research and for the implementation of the new Respectful Maternity Care (RMC) guidelines by all clinicians in South Africa.
11 https://makhulu.co.za/
12 During the United Nations 16 Days of Activism, people around the world unite to raise awareness about gender-based violence, challenge discriminatory attitudes and call for improved laws and services to end violence against women for good.
13 https://sunshinecinema.org/
“My first experience as a teenage mom was daunting, to say the least. I was petrified and that feeling was not alleviated by the nurses at all. I was scolded and I felt so useless in that moment, but I did my best to shut off the noise and fill my thoughts with my sole responsibility to my baby”
Anonymous Survey Response
BIRTH EXPERIENCE
SURVEY SA, 2023
482 completed the digital survey.
47% were treated in private facilities; 43% in public; and 10% were home births.
53% experienced some type of disrespect and abuse.
45% said their experience affected their mental health.
22% said confidence in bonding and ability to care for their baby was affected.
86% did not report the abuse to the management; 14% tried, to no effect.
14 Ibid.
LESSONS LEARNT
A decade ago, obstetric violence was not a familiar term in South Africa, and even now, many are unaware of its prevalence. For the most part, cases of such violence that are reported and investigated move through our judicial system as individual cases, often treated as matters of medical malpractice or negligence by individual clinicians or healthcare institutions. How does one go about building a systemic argument for social change when there is no clear political strategy to address the systemic nature of the problem?
Here’s what we’ve learnt from Embrace and its allies as they continue to influence policies on maternity care in this country:
ESTABLISH TRUST AND STAY CONNECTED TO YOUR AUDIENCE
Embrace understands that many do not wish to talk about their birth experiences, online or otherwise. The first step was to establish trust and a safe space in order to build a connection with the moms. Goredema Görgens says: “It must start with meeting people where they are at. If we had just gone in and had a social media campaign and written a policy brief, it would have resonated, but not for long. We are determined to stay in touch and have a long-term impact.”
Embrace connects to moms through the birth storytelling circles, monthly mom meetups as well as through running campaigns such as Mother’s Day Connect, whereby people celebrate moms and nursing staff in maternity wards in public hospitals on Mother's Day.15 Embrace also connects through an email and WhatsApp line where moms can share their experiences. “We are just listening to moms and hearing their stories, because no one else really is," says Embrace's Goredema Görgens.
FIND THE RIGHT CHAMPIONS TO PARTNER WITH
The partnerships that Embrace has secured with organisations working on the same problem but coming at it from different angles have been invaluable. For example, Embrace approached Dr Rucell because of her expertise on obstetric violence. Dr Rucell was involved in the planning of the Second Presidential Summit on GBVF and understood where Embrace could effectively contribute to its planning. She says: “I had already mapped out that landscape, knew all the various stakeholders and seen what was needed. I could just say ‘These are key opportunities needed to get policymakers and the women's movement to take this issue seriously. I think you are in a good place to seize them, what do you think?’”
Similarly, when CALS was developing a popular education booklet for pregnant women, Embrace was the right partner to help develop the language and framing. “It is very important because lawyers or researchers aren't adept at being community organisers. Embrace's community-based focus can assist because they work with pregnant women every day,” explains Dr Rucell.
This also applies to Embrace contributing to PMPH’s work on the NDoH’s Maternity Care Guidelines 2021. By being part of a loose coalition, these organisations can all work in different ways, directing their strengths towards solving a challenging and intersectional issue.
GATHER EVIDENCE TO SUPPORT YOUR CASE
We don’t yet have the statistics on how many mothers experience obstetric violence and birth trauma in South Africa. Without this data, it is easy for those in power to minimise the abuse that people go through during pregnancy, birth and postpartum periods. It also allows them to ignore the scale of the problem. Embrace launched their birth survey to illustrate that obstetric violence is a systemic issue affecting pregnant women in both public and private facilities across South Africa.
Embrace also harnessed the ethnographic power of visual media – a qualitative form of data collection. In this way, it was able to get its message to diverse communities by partnering with Makhulu Media and its distribution network, Sunshine Cinema, which facilitated the screenings and discussions on the short documentary.
WHAT’S NEXT?
Obstetric violence continues to occur across our healthcare system with rights violations and abuses commonly experienced by pregnant women and birthing people accessing healthcare.16 This form of GBV presents a significant threat to the health of women and children.
Counting What Matters was an informal “people’s survey” that sought to understand the extent and nature of the problem experienced by those in the broader Embrace network. Embrace hopes to commission a larger, nationallyrepresentative study in 2024, which captures experiences across public and private sectors for a more robust understanding of the prevalence of obstetric violence in South Africa.
Embrace is also currently fundraising for a state of Motherhood Report, like the South African Child Gauge17 or State of South Africa’s Fathers.18 The report will showcase innovative solutions that deliver respectful maternity care and provide financial support to vulnerable mothers.
This learning brief was written by Daniella Horwitz and edited by Rahima Essop. It was made possible through contributions from Embrace, the Perinatal Mental Health Project (PMHP) and Centre for Applied Legal Studies (CALS).
16 Ibid.
17 Annual review of the situation of the country’s children is published by the Children’s Institute (CI), University of Cape Town. https://ci.uct.ac.za/sites/default/files/content_migration/health_uct_ac_za/533/ files/Child%2520Gauge%25202021_110822.pdf
18 The report promotes a nuanced approach to fatherhood for improved support for families in South Africa. https://genderjustice.org.za/publication/state-of-south-africas-fathers-2021/
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