From Human Rights Watch. Perhaps Mandi can add some insights to this.


  South Africa: Failing Maternity
Abuse, Poor Accountability Cause Needless Death and Suffering
 August 8, 2011

    A sonar scan is performed on a pregnant woman in South Africa.
    © 2008 AP Photo

    Related Materials:
 “Stop Making Excuses”<>
    The government admits that it has a big problem on its hands and wants
to do better. But for all South Africa’s good intentions, policies and
strategies on paper won’t save women’s lives without strong accountability
systems to make sure policies are carried out.
   Agnes Odhiambo, Africa women’s rights researcher at Human Rights Watch

(Johannesburg)  – A lack of oversight and accountability for recurrent
problems in the health system and abuses committed by health personnel
contributes to South Africa’s substandard maternity care and undermines one
of its top health goals: to reduce its high maternal death rate, Human
Rights Watch said in a report released today. South Africa’s maternal
mortality ratio has more than quadrupled over the past decade, making
accountability structures to improve oversight and correct health system
deficiencies all the more critical, Human Rights Watch said.

The 66-page report, “‘Stop Making Excuses’: Accountability for Maternal
Health Care in South Africa,” documents maternity care failures that include
abuse of maternity patients by health workers and substandard care in
Eastern Cape Province, putting women and their newborns at high risk of
death or injury. It examines shortcomings in the tools used by health
authorities to identify and correct health system failures that contribute
to poor maternal health. Eastern Cape has some of the worst health
indicators in South Africa, including high infant, child, and maternal
mortality rates. But analyses by government and other public health experts
show that other regions experience the same problems, including negative
attitudes by health workers, poor quality care, administrative and financial
management inefficiencies, and lack of accountability for health system

“The government admits that it has a big problem on its hands and wants to
do better,” said Agnes Odhiambo, Africa women’s rights researcher at Human
Rights Watch. “But for all South Africa’s good intentions, policies and
strategies on paper won’t save  women’s lives without strong accountability
systems to make sure policies are carried out.”

South Africa is unlikely to meet its commitment under the United Nations
Millennium Development Goals to reduce maternal deaths by 75 percent between
1990 and 2015.  Its maternal mortality ratio increased from 150 deaths per
100,000 live births in 1998 to 625 in 2007, with HIV playing a role in many
of the deaths, according to government reports. The UN estimates that 4,500
women die each year in South Africa due to preventable and treatable
pregnancy- and childbirth-related causes. South Africa can reverse this
trend, Human Rights Watch said.

The report is based on field research between August 2010 and April 2011
with maternity patients, families, community caregivers, health and human
rights experts, health workers, government officials, and representatives of
donor and international agencies.

A woman living with HIV who delivered at home with near-fatal consequences
told Human Rights Watch: “My uncle advised me to call the ambulance when
labor started but I did not want to go to the hospital. I was scared of how
I would be treated. I hear the nurses are very rude and they are too rough.
After giving birth I developed serious problems. I was bleeding too much and
I couldn’t breathe properly. Luckily the HIV treatment center took me to
hospital, and eventually I got treated.”

Human Rights Watch interviewed women who had experienced physical and verbal
abuse at the hands of public health workers, including pinching, slapping,
and rough handling during labor. They described treatment delays; nurses who
ignored calls for help; and facilities that denied referral letters for
pregnancy or childbirth-related problems, left women unattended for long
periods after delivery, discharged women inappropriately and sent them home
without pain medication or antibiotics, sometimes after Cesarean births, and
refused them admission, sometimes without examining them, when they were in

One community caregiver said she witnessed a woman experiencing
life-threatening, obstructed labor being rejected from a community health
center twice. The woman had an emergency Cesarean section when she finally
got care at a hospital.

Women also described widespread verbal abuse. They said that when they
sought care for pregnancy, nurses taunted them about enjoying sex or berated
them for getting pregnant knowing they were HIV positive, or told them they
did not deserve care because they were migrants. Others said nurses
ridiculed women when they said they were having labor pains or pleaded for
assistance. Some said hospital staff shouted at them for “messing up” when
they bled on the floor and ordered them to clean up the blood.

Some women, especially migrants with language barriers, said health workers
made little attempt to communicate with them and pressured them to undergo
Cesarean sections without informed consent. Others said hospital workers
demanded bribes or gifts. Many said that inadequate communication by
ambulance dispatchers meant that they could not reach a health facility to
give birth. Some families of women or newborns who died, or women who had
stillbirths, said they got little or no information about what caused the

“These abusive practices are a particular concern in South Africa, where
almost 87 percent of deliveries are in health facilities,” Odhiambo said.

Mistreatment of maternity patients not only causes unnecessary suffering but
also contributes to poor maternal health outcomes, Human Rights Watch said.
Ill-treatment drives women away from seeking care. Abuses can lead to delay
in diagnosis and treatment, and in turn to increased morbidity and mortality
that is more costly to the health system.

Human Rights Watch called on the national and Eastern Cape provincial
governments to do more to identify barriers to quality health care and to
use that information to strengthen the health system.

The report found that the state fails to provide oversight and
accountability for abusive staff and system failures. It said that complaint
procedures in the Eastern Cape, which have the potential to address this
challenge, do not function properly.

Maternity patients told Human Rights Watch that they knew little about their
rights as patients or how to file complaints, and that they hesitated to
complain to officers in charge of facilities for fear of retaliation. Others
said they had little confidence that their complaints would be investigated
and systemic changes made.

Health facilities often fail to respond to complaints or provide redress.
Few have quality assurance officers to handle complaints. Some nurses said
they worked under such difficult conditions and so are unable to facilitate
complaints. These failings contribute to continued mistreatment of maternity
patients, shield abusive staff, undermine the public healthcare system as a
whole, and stymie progress on improving maternal health care, Human Rights
Watch said.

The report identified failure by health authorities to address systemic
problems that give rise to complaints, and which contribute to poor
maternity care, as the main shortcoming of Eastern Cape’s patient complaint
procedures. Some health workers resent the complaints system, seeing it as
punitive, and discourage or interfere with patients’ rights to make

South African health workers indeed work under very trying circumstances,
but the challenges they face do not justify abuse or interference with
patient complaint mechanisms, Human Rights Watch said. Health workers need
support to do their jobs well, and reforms needed to allow them to do so
should be informed by patient experiences, the report noted.

The maternity care failures and ineffective complaint mechanisms in Eastern
Cape undermine the right to a remedy, under national and international law.
They contribute to violations of the rights to life, health, and freedom
from cruel, inhuman, and degrading treatment, Human Rights Watch said. The
national government and its provinces have a legal obligation to uphold
these rights under international and regional human rights treaties.

Human Rights Watch called on the South African national and Eastern Cape
provincial governments to condemn physical, verbal, and other abuse of women
seeking maternity care, and to take immediate steps to strengthen
accountability to ensure women’s right to safe and dignified maternity care.
It urged both national and provincial governments to improve complaint
procedures to solicit needed information and provide remedies; ensure that
health workers are involved in devising strategies to address systemic
problems that lead to complaints, and develop systems to assess patterns of
complaints and address systemic problems.

“The point of the complaint system is to show that South Africa cares enough
about women’s lives to fix the problems,” Odhiambo said. “When
accountability and oversight mechanisms don’t function, South Africa is
ignoring the insights of the people who know best what’s wrong with maternal
health care: the maternity patients themselves.”

*Giving Birth Under Abusive Conditions

Abeba M.*
Abeba M., a refugee from Ethiopia living in Port Elizabeth, developed severe
high blood pressure when 28 weeks pregnant and went to a district hospital
for treatment. She soon left because nurses treated her badly, but returned
after her condition worsened. Her whole body was swollen and she was in
great pain, but a scan for diagnosis and further treatment was delayed 10

On the day of the procedure, she was weak and experiencing blurred vision.
“The nurses swore at me and insulted me,” she said. “Now you are saying you
are sick and next year you will come with another pregnancy. This is not a
place to enjoy or be on holiday.” When she used a cushion for her aching
back, she was told to go to a private hospital where she would “be treated
like a queen,” and she was ordered to clean up her “mess” when she bled on
the floor.

Abeba was afraid that she and her fetus would die. When she called for help
one night and said she was in serious pain, a nurse said, “I know, and what
do you want me to do?” Abeba said the nurse continued “playing a gospel song
on her cellphone and dancing.” Abeba did not complain because she said she
did not know to whom to complain or believe the case would be investigated.

*Babalwa L.*
Babalwa M.’s private doctor referred her to a district hospital for
obstetric care because she had serious asthma. But when she went into labor
in June 2010, she hesitated to go to the hospital because she feared the
nurses would “quarrel me and send me back home without help,” as happened to
other women she knew.

After about 12 hours of labor, Babalwa went to the hospital but health staff
did not examine her for about an hour and a half. When a nurse finally did
examine her, Babalwa said, “The sister said I was lying about being in labor
and sent me to the waiting area.” A doctor examined her three hours later,
but it was too late. She delivered a stillborn baby. Neither the doctor nor
the nurse explained what may have caused the stillbirth.

“I was unhappy about the way I was treated; being told that I was lying
about being in labor pain, and being delayed,” she said. “What is still
paining me most is that I don’t know what killed my baby.”

“I did not complain to the hospital,” she said. “They say the patient has
rights but when you are there [in the hospital] you don’t feel it. People
don’t know their rights. You don’t know what questions to ask, or who to

Michael Balter
Contributing Correspondent, Science
Adjunct Professor of Journalism,
New York University

Email:  [log in to unmask]

“Faced with the choice between changing one’s mind and proving that there is
no need to do so, almost everyone gets busy on the proof."
                                                  --John Kenneth Galbraith