“No Ubuntu in the maternity ward”: An autobiographical analysis of obstetric violence in a public hospital’s maternity ward ^[1]

By Pfarelo Matsila

Obstetric violence-source: https://www.youngfeminist.eu/wp-content/uploads/2019/10/Cover-image.jpg

Introduction

On 12 November 2021, I gave birth to my first child. Having done enough reading and having spoken to my mother and other women in my family regarding what to expect and how to deal with it, I was convinced that I would have this baby my way. I was advised to be a “good patient”[1] and surrender my body to the nurses and doctors for a smooth delivery. However, as submissive as I was, I can truthfully say that I was violated, disempowered and alienated from my body. This labour experience still haunts me today. Soon after being discharged and communicating with other women, I learned that the experience of being violated during childbirth is pervasive and normalised in our society where childbirth remains highly medicalised and exclusively controlled by medical practitioners influenced by capitalist and patriarchal values.

In response to the call “to keep the scourge of obstetric violence in the spotlight” (Chadwick, 2021) for reproductive justice to prevail, I give an autobiographical account of my violent birthing experience, to which countless women have fallen and continue to fall victim. This paper shows (1) how obstetric violence as a form of reproductive governance is an infringement of basic ethical principles, and (2) the lack of Ubuntu [2]in the maternity wards and wider society. It is envisioned that this reflection piece highlights the need for health care practitioners to embody the principles of Ubuntu as they engage with birthing bodies who are in their most vulnerable state during labour, and that the state needs to deal with structural and ideological issues within the health care facilities and health systems that fracture the provision of equitable and humane care.

I begin by describing obstetric violence, its specific character and how it serves as a form of reproductive governance. The conceptualisation of obstetric violence as reproductive governance [3]is most useful to explain and account for the feelings of embodied oppression and denial of bodily autonomy I experienced, as commonly reported by many “victims” of obstetric violence. Lastly, I engage with obstetric violence as an infringement of nursing ethics and argue for the potential impact of Ubuntu in redressing maternity care, achieving reproductive justice and Implementing care ethics rooted in maternal experiences.

Obstetric violence as reproductive governance

For some women, their encounter with the maternal health system is characterised by neglect, physical abuse, lack of privacy during child birth, and misrepresentation of risks (Pickles, 2015; Vacaflor, 2016), while other women and birthing bodies are forced to become mothers and denied abortion procedures through “coercive anti-abortion counselling” (Mavuso, 2021). Some have their birthing plans altered through unnecessary medical interventions such as caesarean sections, which are predominant in private hospitals (Chadwick, 2016). These experiences are conceptualised as obstetric violence, which refers to degrading, dehumanising and disrespectful care that birthing bodies are subjected to in obstetric health care settings and facilities (Chadwick, 2016). Further examples of obstetric violence include: non-consented care, non-confidential care, non-dignified care, discrimination, abandonment of care, and detention of women and their newborns in facilities after childbirth due to an inability to pay (Bowser & Hill, 2010).

In addition, Morales, Chaves and Delgado (2018) posit that obstetric violence is an expression of violence during the provision of health care, which occurs in a social environment favouring the development of power relationships between patients and health care practitioners. The power relationship is disproportionate, with patients being expected to surrender to medical authority. In all its forms, obstetric violence violates the human rights of women “to the highest attainable standard of health, which includes the right to dignified, respectful health care” (World Health Organization, 2015).

According to Morales et al. (2018) obstetric violence’s origin lies in a health care system where political and economic foundations encourage inequality based on patients’ buying power. As such, those with more buying power may receive better care than their counterparts with less buying power; therefore, obstetric violence should be understood and addressed as a key driver of inequitable maternal and child health outcomes (Castro & Savage, 2019:123).

As a tool of reproductive governance used by health practitioners, obstetric violence creates fault lines “along which fault moral regimes are produced” (Morgan & Roberts cited in Castro & Savage, 2019:124):

On the safer side of the fault are wealthy female “consumers “, who can choose among private health facilities and who receive the best care available in the country, whereas on the other side of the crack, and in the crack itself, are poor female “charity beneficiaries” who have the single option of seeking health care in state-operated facilities, where health professionals and other staff may treat them as “favour beggars” devoid of any right”.

The above moral regimes set the stage for the worthiness that society assigns to women and the reproductive processes (Castro, Khawja & Gonzalez-Nunez, 2007; Suh, 2018). Castro and Savage (2019) developed six typologies representing forms of reproductive governance that lead women to lose control of their own reproductive processes. The typologies are: “verbal abuse, such as harsh and disrespectful language, patient blaming, public humiliation, scolding, and name-calling; poor rapport with women, such as miscommunication of procedures and processes, and language and communication barriers; sociocultural discrimination based on socioeconomic position, cultural insensitivity, and lack of intercultural care; physical abuse, such as performance of unconsented or unnecessary examinations and procedures, hitting, slapping, or touching women in painful or uncomfortable ways, refusal to administer pain medication, and sexual abuse; failure to meet professional standards of care, such as delays and purposeful neglect, denial of medical attention for both minor and life-threatening health concerns, lack of accountability to patients, lack of supportive care, and breaches of confidentiality; and health system conditions, such as failure to ensure privacy, assigning multiple patients to a single hospital bed, lack of resources to provide more comfort to women, and refusal to allow visitors or family members present” (Ibid, 2019:125–126).

In her study analysing “marginalised” and low-income South African women’s public hospital birthing narratives, Chadwick (2017) finds that obstetric violence and the threat of violence function as modes of discipline that shape women’s actions and subjectivities during labour. The threat and abuse serve as a productive force that results in certain kinds of embodied performances from birthing women, for example, “women were aware of the importance of performing the role of the ‘good patient’ in order to receive adequate care and avoid violence” (Chadwick, 2017:497). Even under severe labour pains, women were concerned with the successful performance of a “good patient” script in order to avoid trouble or hostility (Ibid, 2017). As Shabot (2016:246) posits, the threat of hostility and violence in relation to medical ideals of the good, docile patient engenders a situation in which some women adopt a “hesitant, docile, silent body” as a way to avoid obstetric violence. While compliance, obedience, and docility serve as means to enact the “good patient” script and avoid violence, such actions are not productive for wider reproductive justice. Instead, not challenging the violent power dynamics in maternity wards normalises the violence, hence its perpetuation.

Analysing both obstetric violence as a form of reproductive governance that produces moral regimes built for people who live in poverty and women’s perceptions as a form of adaptive preference helps to explain why most women in public hospitals resiliently expect and accept the poor quality of care that they receive. At surface level, compliance and docility can be likened to passivity; however, Tanassi (cited in Chadwick, 2017:498) argues that compliance should be recognised as “material strategy” and a form of “ambiguous agency” formed in response to hierarchical obstetric power relations, norms and ideals. Simply put, “[p]erforming passivity and docility serves as a response to threat of violence and thus is a form of constrained or ‘ambiguous agency’” (Chadwick, 2017:499).

Autobiographical narrative of my experience of obstetric violence

Three months later and I still remember it like it happened yesterday. Everything I was afraid of regarding childbirth in a public hospital came true. Two student nurses(?) walked in and asked me to open my legs. Before I could understand that they were checking for dilation, one of the students had already violently shoved her fingers inside of me and left me confused on the bed. I asked if I was dilating and she said it was not for me to worry about and she left. While I was still trying to come to terms with what had happened, a senior nurse came in and closed the curtains yet again. She shoved not two but four fingers inside me. She then hooked me up to a monitoring machine and left.

The machine was beeping away, and my pains were getting stronger and more unbearable with each beep. I did not know that once hooked up to this machine, I was not supposed to move. I felt a sharp pain and remembered that my mother had told me to breathe and find a comfortable position to get through each wave of pain. I went on my hands and knees and began to huff and puff. When the pain was gone, I went back to the original position, still hooked up to the machine. The senior nurse came back and looked at the long piece of paper that the machine had produced.

Then she said, “You moved. Why did you move? Now you have disturbed the record.” ……  I responded, “I did not know that I was not supposed to move once hooked up to the machine, no one told me. Sister, it is my first time giving birth, and while I have read to prepare, I am begging you to kindly direct me on how to get through this night”. She said, “Suit yourself, I am going to keep you hooked up for another one and a half hours”. With a sigh of defeat, I just said, “Wow” and then she left. It became apparent at that moment that there was no way that I was going to positively collaborate with the nurses to safely usher my child into this world.

I was once again left to go through the pain alone, with no pillow, and no one to explain what I should anticipate. I could not move. The only thing I could hear was the beeping machine and the screaming coming from the other room. Every scenario played out in a loop. I was rescued from my thoughts by a lady that brought tea and bread. I told her I could not eat but asked for a pillow, which she took from another empty bed and gave me.

The senior nurse came back at around 12am. She took me off the machine, shoved what felt like a whole hand inside me and told me she would be back at 2am to check on me. I waited and waited. She was nowhere to be found. The pain intensified, I started experiencing involuntary muscle spasms, my legs were shaking, and my body felt cold. I could not continue with the breathing routine my mom had taught me. I spoke to my mom over the phone and told her what was going on. She told me to look for someone to help me as the baby might be coming. After all, I was feeling the urge to push but my water had not broken yet.

At 2.45am, as I was getting up to go look for help, the nurse came in and said she was moving me. I asked her where we were going, and she said not to question how she did her job. She told me to carry my bags and follow her to the room next door. As I walked out of the room, I prayed for the other ladies that theirs would be a bearable process. I could not feel my legs anymore; my body was tired and weak. I got onto the bed in the other room, and she took a long tool and put it inside me. I guess it was to break my water. How would I know? My body was a toy on the table, everything felt like an out-of-body experience, it all happened to me without me. Then she said, “Your baby has already pooped inside you. This is a critical situation. If you do not cooperate you will go home with your bags and empty hands”. Scared, I asked her, “What do you need me to do? I can’t feel any pressure to push anymore, I am not in pain anymore”. “Well,” she said, “that is because your baby is tired and if we don’t move, you will lose this child”. I prayed to God for strength. I did not want to go home empty-handed. This was not how this journey was supposed to end. She had already concluded that whatever happened from this point onwards would be my fault. How do I live if I kill my own baby? I did everything I had been asked to do; she was the one that had not come back at 2am as promised.

The students walked in with their university supervisor and the senior nurse told me to open my legs and push with each contraction. I told her I felt nothing anymore but continued to push. She said, “You are playing, you think we are here to play, your child is dying, and it is your fault, you will go home empty-handed”. I said, “Teach me how to push better, I have never done this before. At least have someone help me lift my head or tilt the bed for me so that I can push better, help me please”. She said, “My job is to help you give birth, not to baby you”. And then she said, “Let’s just cut her, she is wasting my time”. I had not even been there for 10 minutes but she had concluded that I was not going to do this. The student nurse injected me and cut me. I could feel my skin tear, the scissors snipping away my flesh and my body getting colder and weaker. But still I had a fighting spirit. I called on God… and the nurse said, “What did God do, you are making noise”. Yet this was me drawing strength from the only source I regarded reliable at that moment.

Snip… Snip… Snip. I was told to push again. I gave it my all and I could feel my baby’s head. Then he was out. At 3am I was reborn, my child quietly graced us, and I was so out of touch with reality. He only cried once, softly, and they put him on my chest. Still connected by the cord, I held my future. A promise for a better society, my chance to lovingly guide someone through life. I was in the room, but I still felt out of touch. I thanked them for the baby’s delivery, they took him to check him and clean him up. They put their hands in me, “reaching for clots”; they injected me and started sewing away. The injections did nothing for me, I screamed as the needle weaved through my fragile flesh. This went on and on and they kept shouting at me to open my legs, to stop making noise, to sit still.

I was not going home empty-handed! Once in the recovery room, I begged him to latch, I begged him to get stronger, I begged him to let me love and protect him and take him home with me. One more nurse came and told me to put my baby down and open my legs, she violently shoved her fingers inside of me again without any lubricant. My fragile, sore, and sewed up body was re-traumatised. I screamed and they laughed at me calling me a coward. They were “checking for clots” they said. What felt like hours finally came to an end. I decided not to sleep but to stay awake and feed my baby. I called my mom and told her to go to sleep.

I am a first-time mother, a scared mother, a traumatised mother. I am a mother and I am going to leave with a healthy baby boy, not empty-handed!

Being assertive and inquisitive while asking for gentle care is punished in the narrative above. The nurses respond to my requests by threatening me, insinuating that I want to leave the hospital with a dead baby. My questioning is viewed as a challenge to their medical knowledge and skills, as a threat to the established power dynamics. When I insisted on requesting information, I was disciplined, silenced, and forced to become docile. I was thingified, and was expected to remain a thing – a thing with no voice, with no brain, with no feelings, with no power and with no choices, but always obedient to the “masters’” instructions and “performing” as the thing they had made me to their expectations. Reflecting on my experiences, I realise they also expected me to come into their space “trained” and with the whole package of how to be their “thing” during the entire process, hence the punishment whenever I went beyond being their “thing”. Obstetric violence becomes visible here as a disciplinary and reproductive process “involving a flow of unspoken norms, affects, and regulations embedded in class, race, and gender dynamics” (Chadwick, 2017:499) with implication for my subjectivities during labour.

As a working class, black, public sector patient, and “unknowledgeable” of the space I was in, I was expected to be undemanding and passive in order to fulfil the normative expectations of the “good patient”. My defiance of the accepted norms was treated as gaining agentive power (which was regarded an abnormality within the space), and was met with violence, which resulted in the subjective diminishment and loss of agency. As a result, my ability to enjoy a dignified and positive birth experience was reduced. According to Shabot (2016:232), obstetric violence is experienced by women as “a diminishment of their embodied selves: a reduction, repression, and objectification.” As explained in my narrative above, “My body was a toy on the table”, they used me for the students’ practical session. The senior nurse was hostile, trying to teach her students, showing them that she was in control. My life and my son’s life were in her hands. The senior nurse was reproducing the students to be like her, so that they perform and reproduce her in future, making this hospital situation of powerful and knowledgeable bodies versus helpless and thingified bodies normative. In addition to my body and spirit being violated, I was also an object in reproducing the violation of future bodies within hospital spaces.

The threat of violence namely, “I am going to keep you hooked up for another one and a half hours”, was enough to constrain, reduce and diminish me during birth. As the night progressed, it became apparent that I was expected to surrender my body to the health practitioners and not ask questions. Being inquisitive marked me not only as a “bad mother” who would kill her child, but also a “bad patient”. My punishment took the form of psychological abuse, physical abuse, and degrading comments. From the first time I was given a bed, my loud and agentic body instantly became vulnerable to punishment. My narrative account highlights how medicalised childbirth undermines birthing bodies’ sense of self and core being; they are turned into moral objects rather than subjects. As Wolf (2013) argues, the medicalised birth experience cancels women’s epistemic authority, embodied capabilities and sense of being a particular individual in labour.

African philosophy of Ubuntu and nursing ethics

Caring is the essence of health care practice. The meaning of this concept differs according to the theoretical and cultural perspectives in which it is situated. As Watson and Smith (2002) posit, caring looks different depending on the ontological and ethical perspective in which the approaches to and categories of care are located. The majority of caring theories and models have been developed by American and European theorists and may be incompatible with cultural and other considerations in other countries. As such, to deliver efficient and patient-centered type of care, health care practitioners need a context-specific conceptualisation of care (Walker & Avant, 2011). According to the South African Nursing Council (SANC), all nursing practitioners have the responsibility towards individuals, families, groups and communities to protect, promote and restore health, prevent illness, preserve life and alleviate suffering. This responsibility ought to be carried out with the required respect for human rights, which include “cultural rights, the right to life, choice and dignity without consideration of age, colour, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status” (SANC, n.d.). It is envisaged that when these responsibilities are adhered to, the persons in the care of every nursing practitioner must be able to trust such nursing practitioner with their health and wellbeing (SANC, n.d.).

Four main principles are part of the nursing code of ethics namely, autonomy, beneficence, (social) justice and non-maleficence[4] (International Council of Nurses, 2021). In addition to these four ethical principles, the SANC also recognise “veracity, fidelity, altruism and caring”[5] as fundamental principles to be upheld at all times by all nursing practitioners in whatever role they fulfil as direct or indirect patient care providers, including, amongst others, educators, administrators, researchers, policy developers and others, in any setting whatsoever.

There are many similarities between caring in nursing and Ubuntu because both emphasise caring and other principles of caring such as respect, dignity, and compassion. The Ubuntu application is pervasive in almost all parts of the African continent. Hence, the Ubuntu philosophy is integrated into all aspects of day-to-day life throughout Africa and is a concept shared by all tribes in southern, central, west, and east Africa amongst people of Buntu origin (Rwelamila, Talukhaba & Ngowi, 1999:338). However, it is important to note that the qualities of Ubuntu are not innate; rather they are acquired through socialisation and, hence, its practices vary across time and space and are dependent on (changing) social, linguistic, economic and political contexts (Kamwangamalu cited in McDonald, 2010:142).

In practice, the philosophy of Ubuntu emphasises one’s responsibility to ensure the wellbeing of others. When applied to the health sector, Ubuntu stands for humane care, and using humane methods to achieve humane goals. In this way health practitioners have a twin responsibility of embracing Ubuntu and using values of Ubuntu to influence their colleagues and patients. The concept of Ubuntu also calls us to consider the context of patient–provider interaction. In South Africa, work conditions are difficult for health care workers in the public sector. These workers are confronted with low remuneration, lack of basic equipment, bullying and shortage of staff amongst other contextual issues (Chadwick, 2021). Obstetric violence stems and flourishes in such conditions; therefore, we cannot reduce it to individual perpetrators but must attribute it to both the actions of medical personnel and structural issues within the health care facilities and health systems that fracture the provision of health care (Bohren, Vogel, Hunter, Lutsiv, Makh, Souza & Aguiar, 2015; Chadwick, 2021).

The silence and lack of action on the issues of obstetric violence, irrespective of its long-lasting occurrence in South African health care facilities since the late 1990s, “denotes a wider social disrespect for women and reproductive matters” (Chadwick, 2021). Against this backdrop, it is evident that our state is not practicing Ubuntu, not looking after the vulnerable, but putting a price on the quality of health care one ought to receive. As MacDonald (2010:146) argues, “the language and practice of contemporary Ubuntu is too compromised by the market ideology and discourse to be revised for a socialist agenda”. Nonetheless, it remains “the state’s responsibility to ensure that the scourge of obstetric violence is recognised, addressed and eradicated” (Chadwick, 2021).

As shown above, the two paradigms, ethics of nursing care and Ubuntu, both emphasise relationships in which respect, compassion, warmth, and understanding are evident, and both value communication, dialogue and negotiation. While nursing ethics have been criticised for not being cognisant of afro-centric factors, which hinders the deliverance of humane care, the use of Ubuntu should be the foundation from which those in power draw when attending to the consciousness of what it means to be a caring human and to be in service and relationship with one another. The concept of Ubuntu is best summarised by Tutu (1999 cited in Nolte & Downing, 2019:16), who said,

We do need other people and their help to form us in a profound way. You know just how you blossom in the presence of someone who believes in you, and who helps you having faith in yourself, who urges you to great thoughts and yet accepts you as who you are, and not for what you have or can achieve, who does not abandon you because you have failed.

Conclusion

From my autobiographical narrative, it is evident that the health practitioners infringed most of the ethical nursing principles. It is possible that they may have been understaffed and tired from working overnight. However, I was in my most vulnerable state, willing to be a “good patient” for a smooth delivery and asking questions about the best way I could make the process easier for all of us. Yet, that was met with inhumane responses in the form of neglect, psychological abuse and physical abuse. In addition, I was denied information regarding the procedures that were imposed on my body. No informed consent had been requested before I was subjected to repetitive excruciating cervical examination, and there was lack of humane care and Ubuntu when I was asked to carry heavy bags to the delivery room while I was in active labour. Furthermore, I was denied bodily autonomy when I had to undergo an episiotomy within 10 minutes of pushing. While the priority was the child who according to the nurses was already in distress, the hours of neglect had contributed to the baby’s distress. I was ready to push hours before, but there was no one to help me and my water had not broken yet.

My violent birthing experience and that of many other unnamed women is the reason I think there is no Ubuntu in the labour wards. If our society is serious about eradicating violence, achieving gender equity and reviving the spirit of Ubuntu, then we need to come together as we did during COVID-19 and “transform cultures of obstetric and maternal health care away from violence, hierarchies, punishment, coercion and discrimination and towards establishing relations of care characterised by respect, dignity, inclusivity and autonomy” (Chadwick, 2021). [6]

Reference list

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Footnotes

[1] According to broader South African health literature, good patients are compliant, docile, clean and obedient (Khahil cited in Chadwick, 2017:497).

[2] Ubuntu as an African philosophy of caring is based on “generic life values of justice, responsibility, equality, collectiveness, relatedness, reciprocity, love, respect, helpfulness, community, caring, dependability, sharing, trust, integrity, unselfishness, and social change” (Khoza, 2006:6; Luhabe, 2002:103; Mayaka & Truell, 2021:3; Tutu, 1999:34–35).

[3] Reproductive governance is defined as the mechanism through which different historical configurations of actors – such as state institutions, churches, donor agencies, and non-governmental organisations (NGOs) – use legislative controls, economic inducements, moral injunctions, direct coercion, and ethical incitements to produce, monitor and control reproductive behaviours and practices (Morgan & Roberts cited in Castro & Savage, 2019:124).

[4] (Social) Justice – Nurses are at all times expected to act fairly and equitably where there is competition of interest among parties, groups or individuals. Non-maleficence – This requires a nurse to consciously refrain from doing harm of any nature whatsoever to health care users, individuals, groups and communities. Beneficence – Nurses are required to do good and to choose the “best option” of care under given circumstances and act with kindness at all times. It gives expression to compliance with the “duty to care” as a professional practice imperative. Autonomy – Respect for the autonomy of eligible persons (health care users) to make their own decisions and choices in matters affecting their health.

[5] Veracity – This principle requires the nurse to act with truthfulness and honesty and to ensure that the information provided to and on behalf of the health care user is always in the best interest of the health care user. Fidelity – This entails adherence to factual and truthful accounting and balancing that with respecting, protecting and maintaining confidential information pertaining to the delivery of health care, including health records of health care users. Altruism – Nurses are at all times expected to show concern for the welfare and wellbeing of health care users. The nurses are to be mindful of the fact that wishes and actions of health care users may be in conflict with the values and principles of the code, e.g. where health care users refuse treatment to the detriment of their health and that of others. Caring – Nurses are required to demonstrate the art of nurturing by applying both professional competencies and positive emotions that will benefit both the nurse and the health care user with inner harmony.

[6] Chadwick (2021) calls for a multi-dimensional approach that includes targeted reform of medical and midwifery training (towards a curriculum that emphasise more humane and respectful maternity care); legal interventions (such as recognising obstetric violence as a legal concept); robust and accountable complaint mechanisms, social campaigns to raise public awareness of birthing and reproductive rights, and the eradication of the patriarchal, racist and discriminatory attitudes that are often embedded in obstetric violence.

[1] Please note: This reflection is part of a longer draft paper “Ubuntu: A regenerative philosophy for dismantling obstetric violence in the South African maternity wards” in which I use a unique combination of feminist phenomenology, intersectionality and Foucadian “analytics of power” to analyse my experience of obstetric violence as a first-time mother in a South African public hospital. I critique the normalisation of obstetric violence by engaging with Tronto’s ethics of care lens rooted in the moral characteristics of care, namely attentiveness, responsibility, competence, responsiveness and solidarity. Using the above as a backdrop, I argue that the African philosophy of Ubuntu has the potential to redress maternity care and reproductive justice. The findings of the long draft focus on (1) obstetric violence as a mode of discipline embedded in normative relations of class, gender, race, and medical power, (2) obstetric violence as an infringement of basic ethical care principles, and (3) draws on African indigenous birthing systems and settings as a way of moving towards notion of Ubuntu/care in the ‘medicalised’ health system.