A recent discussion among legal and human rights experts has exposed the alarming scale of obstetric violence in Africa, a crisis that contributes to the continent’s disproportionately high maternal mortality rates. The findings, shared during a virtual panel, underscore the urgent need for systemic reforms in maternal healthcare. This dispatch was co-authored by Divyabharthi Baradhan (JURIST Staff, Malaysia) and Lana Osei (JURIST Staff, Ghana).

On January 28, Lana and Divya had the privilege of attending a webinar organized by Human Rights Watch (HRW) focusing on obstetric violence in African countries. The webinar shed light on the inhumane and violent treatment faced by vulnerable women in maternal healthcare, a crisis that demands urgent attention and systemic change.

The panel consisted of Achieng Orero, a Kenyan lawyer who leads the Initiative for Strategic Litigation in Africa (ISLA); Melinda Mugambi, a member of KELIN’s strategic litigation team; and Skye Wheeler, a senior researcher at HRW.

Obstetric Violence (OV) is characterized as the mistreatment of women during childbirth, including physical abuse, verbal abuse, humiliation, coercive or unconsented medical procedures, refusal to provide pain medication, neglect during childbirth, and detention of women and newborns in the event of unpaid medical fees.

According to the World Health Organization (WHO), respectful maternal care is defined as “person-centred care organized for, and provided to and with, all women, gender-diverse people, newborns, parents and families throughout the antenatal, childbirth and postnatal periods. It prioritizes dignity, protects against harm and mistreatment, and ensures freedom to make informed choices.” The various forms of OV fall far below this standard.

Wheeler presented HRW’s recent report, “No Money, No Care,” focusing on OV in Sierra Leone. The report was based on 140 interviews and concluded that there is a pattern of “widespread, dangerous” abandonment, neglect, and verbal abuse mostly linked to informal payments. Due to a lack of public funding, informal cash payments are often solicited in government facilities for services, drugs, and other commodities, including in an obstetric emergency.

Rights groups such as Transparency International Global Health consider informal payments as bribes “if they are made prior to any medical procedure, if the health care provider proactively asks for them, or if they involve cash or expensive items.”

Emma, who delivered her son at Sierra Leone’s Princess Christian Maternity Hospital (PCMH) in 2023, shared her harrowing experience: “[The hospital] only focused on the ones who had money, and because I lacked money, I had to suffer.” She was abandoned for two hours while in labor, as her husband tried to collect funds from their community. Despite delivering the baby, she said, “I heard the baby, but then it died.” She attributes her baby’s death to the poor treatment she received at PCMH. Emma’s story is a tragic example of how poverty and systemic neglect can have fatal consequences.

Mugambi emphasized that Africa has the world’s highest maternal mortality rate, accounting for approximately 70 percent of global maternal deaths, with a regional average of 442 deaths per 100,000 live births in 2023. While this marks a decline from 727 deaths per 100,000 live births in 2000, it remains five times higher than the Sustainable Development Goals (SDG) target of 70. Mugambi also noted that other forms of OV, while non-fatal, are equally damaging and often underreported.

Although Africa accounts for the highest maternal mortality rate, similar cruelty is encountered by women in other countries, such as Malaysia, Indonesia, and India. A study in Indonesia has linked OV to a region’s cultural characteristics. For instance, in the Indonesian context, in some local cultures, such as the Gayo tribe, pregnant women are forced to work in the fields and carry out heavy tasks, due to the tribe’s belief that hard work eases childbirth. 

Despite various solutions to address the problem in Africa, such as the adoption of the Convention on Ending Violence Against Women and Girls by the African Union, and ACHPR Resolution 625 by the African Commission on Human and Peoples’ Rights, to develop guidelines on the elimination of obstetric violence and promotion of maternal healthcare in Africa, the record-high maternal mortality rate is deeply concerning.

According to Achieng, courts in Kenya often avoid the term obstetric violence. Instead, the language used is “respectful maternal healthcare, mistreatment, and negligence,” which she says undermines the scale, severity, and gendered dynamics of abuse experienced by women and girls during pregnancy, birth, and postpartum. This means that the courts will only partially address the issue of obstetric violence on a case-by-case basis, substantially diluting the effectiveness of seeking legal remedies.

JURIST staff also posed a question to the panel: How does strategic litigation work in the context of ongoing conflicts in various African countries, such as Sudan and the Democratic Republic of Congo (DRC)? What challenges have you faced in this work?

Addressing the question, Achieng said that litigation, in general, in conflict areas is quite difficult due to the complete breakdown of judicial systems and the government that implements court decisions once they are issued. She added that there are organizations on the ground documenting the instances of violence that are being witnessed as the conflict rages on. Litigation at regional mechanisms may also provide solutions that domestic courts are unable to. She also noted that a potential area of exploration is litigation in the regional courts to seek some type of relief in the instance of ongoing conflicts.

Additionally, JURIST staff interviewed a midwife in Ghana’s northern region, who requested anonymity, about her experience witnessing obstetric violence in her workplace. With over seven years of practice, she recounted witnessing a pregnant woman being beaten and verbally abused by a colleague, purportedly due to the woman’s perceived lack of cooperation. The baby died after delivery.

According to the midwife, maternal care in her hospital has since seen some progress after management “cautioned” staff about physical and verbal abuse of patients. However, no legal action was taken against the midwife involved in the incident.

She agreed that such treatment has become normalized in Ghana’s healthcare settings. She urged the Ghanaian government to prioritize training and retraining healthcare providers on obstetric violence and respectful maternal care. She also emphasized the need to hire more staff, noting that overworked nurses may displace their frustration onto pregnant women, and called for patient-centered policies and greater awareness of obstetric violence.

Interestingly, in 2020, a study conducted in Ghana revealed that the midwives, who were interviewed, had “demonstrated some awareness of respectful maternal care, [but] their support for disrespectful and abusive practices such as hitting, pinching, and implicitly blaming childbearing women for mistreatment suggests a disconnect between awareness and practice of [respectful maternal care].”

The midwife’s recommendation aligns with a proven model in Tanzania, which has successfully reduced maternal mortality by 80 percent in 7 years, from 556 deaths per 100,000 live births in 2016 to 104 per 100,000 in 2022. Tanzania’s success—achieved through expanded Emergency Obstetric and Newborn Care (EmONC) facilities, more healthcare workers, and a stronger referral network—serves as a model for other African countries.

Obstetric violence is a violation of human rights and a public health crisis. Without strong local governance, accountability, and systemic change, women and babies will continue to suffer. Africa and the world must prioritize respectful, dignified maternal care to end this cycle of abuse.