Released in Johannesburg yesterday (Monday) the 66-page report Stop Making Excuses: Accountability for Maternal Health Care in South Africa shares horror reports of women being physically and verbally abused, turned away from clinics without examination while in labour, ignored by nurses when they call for help, and forced to wait hours and days for care.

The women spoke of abuse at the hands of health workers including pinching, slapping and rough handling during labour.

Several women also claimed that they were ordered to make their own beds, walk and carry their newborns despite being in pain and weak, forced by cleaners to clean up after giving birth, left unattended for hours after giving birth and not given any information critical to their well-being.

Refugee women experienced specific abuse such as delayed and denied care, active discrimination and being seen last despite arriving early.

HRW warned that ill treatment drove women away from seeking care with a greater cost to the health system.

South Africa’€™s maternal mortality rate has more than quadrupled in the last decade, increasing from 150 to 625 deaths per 100 000 live births between 1998 and 2007 (Government data).

The United Nations estimates that 4 500 women die each year in South Africa due to preventable and treatable pregnancy- and child-related causes.

Experts have attributed the increase in deaths to increased reporting and actual deaths, especially among women living with HIV.

HRW identified the underlying problems as shortcomings in accountability and oversight mechanisms that authorities use to monitor healthcare system performance, identify failings and needs, and make timely interventions.

The HRW findings were based on among others interviews with 157 women who received maternal health services or accompanied other women seeking such services in Eastern Cape health facilities over the past five years. HRW also visited 16 health facilities in OR Tambo, Amatole and Nelson Mandela Municipality districts. These districts had the highest maternal mortality ratios in the province in 2008 and 2009. Ironically, the national health department has listed Amatole and OR Tambo as priority districts.

Thirty nurses, mostly working in maternity units, were interviewed, as well as emergency medical services staff, quality assurance officials, facility managers and managers in maternity units.

The report does acknowledge that some government initiatives had borne fruit ‘€“ 92 percent of women attend antenatal care, almost 87 percent deliver in health facilities and South Africa is one of the few countries where maternity care is free, abortion is legal and there is a system of confidential inquiries to assess levels, causes of and contributors to maternal deaths.

However, the information is not used to ensure problems are taken care of or systemic problems not repeated with the result that very little has changed for South Africa’€™s women who continue to die due to the same health system shortcomings.

HRW made an urgent appeal for the health department to ensure that current accountability mechanisms were operating properly if it hoped to make any impact on maternal mortality.

‘€œThe point of the complaint system is to show that South Africa cares enough about women’€™s lives to fix the problems,’€ HRW women’€™s researcher Agnes Odhiambo said.

‘€œWhen 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.’€

Patient Stories

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 days.

On the day of the procedure, she was weak and experiencing blurred vision. ‘€œThe nurses swore at me and insulted me,’€ she said. ‘€œNow 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 ‘€œbe treated like a queen,’€ and she was ordered to clean up her ‘€œmess’€ 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, ‘€œI know, and what do you want me to do?’€ Abeba said the nurse continued ‘€œplaying 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 ‘€œquarrel 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, ‘€œThe 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.

‘€œI was unhappy about the way I was treated; being told that I was lying about being in labor pain, and being delayed,’€ she said. ‘€œWhat is still paining me most is that I don’€™t know what killed my baby.’€

‘€œI did not complain to the hospital,’€ she said. ‘€œThey 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 ask.’€