Obstetric violence in Yemen's hospitals the muffled cry

1 in 5 women in Yemen experienced violence during childbirth

Samia Abdullah, 33, from Harf Sufyan, Amran Governorate (north of Sanaa), sums up her painful experience during her last birth and the amount of violence and abuse she was subjected to, by saying, "She does not think about becoming pregnant again."

In addition to the psychological damage caused by insults, insults and undermining her dignity, the circumstances of the violent birth of Samia (pseudonym) - such as pushing the abdomen forcefully, tying it to the bed, gagging it and then incorrectly dilating the course of delivery - caused complications in the uterus that necessitated two surgeries to close the obstetric-urinary fistula.

Samia's life - a mother of 3 children - changed upside down after the last birth. She fell into severe depression and a desire to isolate from everyone, and the complications of childbirth cost her family a lot of money, which necessitated selling her property and borrowing in order to complete her treatment.

Her husband preferred to remain silent, while her father asserted that he did not file a case against the health center in which the birth took place, for fear of unnecessary problems, and decided to bear her psychological and health condition and treatment costs.

The questionnaire prepared as part of this investigation proves that Samia is among one in five women who have experienced some form of obstetric violence, and 83% of these cases occurred in Yemeni hospitals under the authority of the Ministry of Public Health and Population, while those with the observed cases avoid filing claims for rights recovery.

In turn, Dr. Khaled Al-Sanhani, consultant urology and venereal diseases, confirms that Samia's medical condition is a result of unjustified violence and a medical error in the birth process, which led to poor perfusion of the uterus and bladder due to the pressure process, which caused the uterus to prolapse and the bladder to prolapse.

According to Dr. Al-Sanhani, her case required a caesarean section because the uterus did not open and prepared for the birth process, noting that it is medically wrong to push, restrict and gulp during childbirth, or to expand the birth course in the way that took place for the patient.

He adds that many of the cases he received resulted from violence or an unjustified medical procedure during the birth process, or a failure in diagnosing the case's need for cesarean or natural delivery.

This investigation documents the stories of dozens of Yemeni women who have been subjected to violence during childbirth, which is an aggravating phenomenon in government and private hospitals, without legal protection or deterrent measures that preserve the lives of women and their children, and is also included in the silence for social and legal reasons.

Common phenomenon

In an electronic questionnaire prepared for the investigation, which included 18 out of 22 governorates - during the period from October 2020 to August 2021 - the phenomenon of obstetric violence, its forms and effects, was monitored and data collected from women who had previously given birth.

It is also clear that there is so-called obstetric violence in most government hospitals, and that nurses, midwives and doctors working in the field of obstetrics carry out behaviors that classify some of them as physical assault.

Through the questionnaire, it was found that 79% of all women were exposed to at least one form of obstetric violence, verbal and physical, and 5% of them confirmed that their children were exposed to complications resulting from the birth process, and 2% visited a psychiatrist several times due to the harsh conditions of the birth process. That 23% of the observed samples thought not to repeat the experience of giving birth a second time.

It was also clear that 71% of the samples believed that what happened was normal and not considered a violation of their rights.

The questionnaire monitored more than 11 forms of verbal and physical obstetric violence, 83% of which took place in government hospitals and health centers, and 17% during childbirth in private hospitals or homes. The questionnaire also demonstrated that the rate of exposure to obstetric violence increases in cities compared to rural areas.

A dead body

Samia says that the doctor cut the perineum without her consent or the consent of a member of her family, and the operation was not preceded by any medical examinations, and she was tied to both ends of the delivery bed in a strong and painful way, verbal insults were directed at her by the nurses and gagged to muffle her screams of pain, and they repeated the saying “What is the limit? Tell you to marry and come to us, shout."

Samia later visited many doctors because of the severe pain that resulted from the birth process, and the violence of the experience made her not think about pregnancy again, as she says, "These are not angels of mercy, these are angels of torment."

Samia's case is one of 50 women interviewed by the investigators within 6 months, who spoke of being subjected to obstetric violence in government and private hospitals and others affiliated with international organizations, and by female doctors, nurses, and midwives who practice obstetric operations.

Obstetric violence, according to Lamaze International, is defined as any physical, sexual or verbal abuse, bullying, coercion, humiliation and abuse that occurs to women during the delivery process by medical staff, including nurses, doctors and midwives, and includes exposure of a woman during childbirth. Labor or delivery for abuse and lack of respect for her rights, including being forced to take action against her will at the hands of medical personnel.

In the cases documented by the investigation, obstetric violence resulted in severe health and psychological damage that amounted to surgical intervention and harm to the fetus, in violation of Law No. 28 of 2000, which provided for the establishment of the Yemeni Medical Council for the purpose of protecting patients’ rights, promoting medical professions and monitoring the performance of medical professionals.

The law also stipulates in Article 24 of it that the Yemeni Medical Council has the right to take one of the disciplinary penalties that amount to withdrawing licenses to practice the profession or a financial fine and imprisonment for those against whom it is proven that patients have been harmed as a result of negligence and unjustified medical errors and failure to preserve the rights of patients to receive care Integrated health, but this comes in light of a lack of supervision by the Ministry of Public Health and Population and the Yemeni Medical Council.

Psychological effects

For her part, Consultant Obstetrics and Gynecology, Dr. Zainab Al-Khazan, says that obstetric violence is a widespread phenomenon, and that many resulting cases are received almost daily.

Al-Khazan indicates that urinary tract infections, obstetric fistula of both types, uterine prolapse and bladder fall are among the most common diseases resulting from wrong behavior during childbirth, including violence and payment without medical justification and subjecting the patient to operations without the need for it or vice versa, as well as completing the birth process by inappropriate means and unqualified places .

She added that physical abuse, such as beating and restraint, or verbal abuse, such as insults and scolding, increases the difficulty of childbirth, contrary to what is expected, and that the psychological state is important to facilitate childbirth, and its negative impact can continue in the long run, and in cases where a woman may suffer from postpartum depression, and this can constitute a psychological barrier for the patient. He continues with her for years, during which she refuses to experience childbirth again.

According to Al-Khazan, obstetric violence is widespread and has many forms, some of which are related to the psychological aspect and the other to medical errors that occur during childbirth. There are also forms of violence related to privacy and the physical aspect.

Compound violence

In the capital, Sanaa, Naglaa Muhammad, 27, was subjected to several forms of obstetric violence during her first and third births.

She says, "In my first birth in mid-2017 at Palestine Hospital (formerly Zayed), I was in the operating room waiting for the doctor. The nurse told me to wait until the doctor got up so that she could deliver you."

Najlaa had been screaming from labor pains for more than two hours without any intervention from the nurses to relieve her.

Najla was also beaten, tied and pushed hard on the abdomen, and the matter was repeated in her third birth in the Safe Maternity Hospital in the capital, Sana’a.

Najlaa says that she became very afraid of childbirth, and she kept watching with fear the possibility of pregnancy again, and she was unable to talk to her husband and family about the incident of violence that happened to her for fear of problems and a negative view.

Psychology defines the state of fear of childbirth, known scientifically as “Tokophobia” as the psychological state that a woman experiences during labor or childbirth, and she seeks to avoid pregnancy, a condition that affects about 22% of women, but this percentage increases if the woman is exposed to an experience Painful during childbirth, especially obstetric violence.

In turn, the specialist in reproductive health programs at the United Nations Population Fund, Dr. Afrah Al-Adimi, confirms that the phenomenon of obstetric violence is prevalent in Yemeni health centers and is often practiced due to poor awareness of what these behaviors are, due to the failure to address the seriousness of this phenomenon and awareness of it and considering it a silent one.

According to Dr. Al-Adimi, there are many forms of violence, such as the lack of separation between beds in the delivery rooms, respect for privacy, conducting operations without the need, and physical and verbal violence.

She added that many medical staff and women believe that some of these behaviors are normal and do not categorize physical or verbal violence, and there is sometimes confusion between practices aimed at protecting women from hyperactivity and preserving the health of the fetus during childbirth and obstetric violence.

According to Dr. Al-Adimi, there is no statistics with the United Nations Population Fund or its local partners on this phenomenon, due to the absence of studies or projects seeking to raise awareness of its risks, in addition to the failure of the vast majority of women to submit complaints to the competent authorities and organizations working in the field of women and reproductive health.

Excesses of necessity

During the research process, the investigator interviewed 7 midwives and nurses who practice obstetrics in health centers or at home, and it became clear that 5 out of 7 of them consider some behaviors that classify obstetric violence as necessary for the success of the birth process, and they all do not know any previous information about what is called obstetric violence.

The midwife, "Um Muhammad Al-Najdi," 41, has been working in the field of obstetrics for 17 years in health centers in Ibb Governorate (central Yemen), and says that she has to handcuff women, and in many cases she puts a piece of cloth to muzzle their mouths because of their screaming during childbirth. .

For her part, the midwife, "Umm Muhammad", does not rule out that she sometimes utters outlandish words, justifying this by the psychological pressure that occurs during the birth process, and pushing on the abdomen, restraining or gagging, and even cutting the perineum and others are all - according to her - procedures that help facilitate the completion of the process Birth.

On the other hand, Dr. Maryam (a pseudonym) - a gynecologist and obstetrician working in the Safe Motherhood Center in the capital, Sana’a, and other government hospitals - says that sometimes there may be an exaggerated hold, for fear of hyperactivity that may harm the fetus and the birth process, but there may also be abuses. The process of childbirth, such as hair-pulling, hitting and slapping in the face, neglect and deliberate abandonment during labour, lack of barriers in delivery rooms or violation of privacy in the corridors of health centers.

She points out that these abuses took place in Amanat Al Asimah hospitals and health centers in Sana'a and other governorates, and were monitored by Yemeni nurses and doctors of other nationalities, and that the problem of lack of awareness among women undergoing childbirth and among nurses and doctors is the danger of this to women and children - which may amount to death Mother or Child - Pretty much present.

Legal and regulatory negligence

In turn, lawyer Abdul Raqib Al-Najjar, who specializes in medical errors cases, confirms that many cases have been received by the Yemeni Medical Council and are related to unjustified medical errors resulting from obstetric violence.

Al-Najjar added that there is a severe shortcoming in deciding these issues and holding accountable and monitoring the performance of obstetric nurses, in addition to the low societal awareness of the need for women to obtain the necessary health care during childbirth, and that any transgression or error in their right calls for the perpetrator to be held accountable.

Al-Najjar also points to the existence of supervisory and executive negligence with regard to those responsible for these errors by the Medical Council, which is an authorized body - as he put it - and has the power to form investigation committees in the cases brought to it, as well as oversight committees on the performance of hospitals and practitioners, in a way that ensures that patients receive their rights.

Regarding the legal classification of obstetric violence, he says that if this violence amounts to a medical error, it is subject to Article 24 of Law No. 28 of 2000 and the internal disciplinary regulations of the Medical Council, and if otherwise, it is subject to the evaluation of the Medical Council committees, and as a result, the appropriate disciplinary action is determined.

The investigation team continued with some female doctors and heads of obstetric departments in the hospitals that were mentioned as part of the research process as having practiced obstetric violence, and contacted the Yemeni Medical Council to respond about the monitoring mechanism over hospitals and medical professionals associated with childbirth, and if there were cases filed and a process of monitoring the phenomenon of obstetric violence, and actions taken, without receiving any response in this regard until the investigation is prepared for publication.

In the absence of deterrent laws, strict control, and the tyranny of the culture of secrecy, many Yemeni women suffer from their harsh experiences during childbirth in silence, while the phenomenon of obstetric violence is spreading shockingly - as the numbers have proven - as one of the disturbing medical and social phenomena in Yemeni society.(AL JAZEERA)

This report was produced within the framework of the project to develop the capabilities of Yemeni women journalists in investigative journalism, which is implemented by the Yemeni Center for Media Support in partnership with the Investigative Support Fund "Nawa".

Supervision: Aseel Sariyah