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Abeba M., an Ethiopian refugee living in Port Elizabeth, a small coastal town of South Africa’s Eastern Cape Province, developed severe high blood pressure during her pregnancy. She went to a district hospital for treatment of this dangerous condition, but left because “the nurses and doctors did not treat me well,” she told me. She had to return when her condition worsened, though, and was admitted. Instead of getting the help she needed, she experienced treatment delays, abuse, and negligence.

A vital scan to check if her baby was alright, a precondition for further treatment, was delayed for 10 days because “the doctor kept saying he had forgotten.” When she complained about severe pain one night, a nurse who Abeba said “was playing a gospel song on her cell phone and dancing” retorted: “I know, and what do you want me to do?” She did not help Abeba and instead “continued whistling and dancing.” Abeba was ordered to clean up her “mess” when she bled on the floor.

Abeba’s daughter was born prematurely in an emergency caesarean section. Although she was able to take her baby home two weeks later, her wound from the surgery became septic and did not heal for three months. ”"It was the worst time of my life,” She told me about her treatment at the hospital.

Sadly, Abeba’s case is not uncommon in South Africa. She was one of the 157 largely poor, rural and refugee women I interviewed between November 2010 and April 2011 in Eastern Cape about their experiences with maternity care in government facilities. Women and other witnesses described chilling scenes of humiliation, neglect, and verbal and physical abuse by health workers.

Every woman has a right to safe maternity care, but every year about 358,000 women die worldwide from preventable and treatable causes during pregnancy, childbirth and in the six weeks after giving birth. The Every Woman Every Child (EWEC) initiative, introduced in September 2010 by the UN secretary-general during the Millennium Development summit, has galvanized unprecedented attention to and resources for improving maternal health through the Global Strategy for Women’s and Children’s Health.

In 2010, governments, intergovernmental agencies, and private groups made major commitments to tackle maternal mortality, resulting in pledges of approximately $40 billion in resources over five years. The recent announcement by the UN secretary-general of 100 additional pledges signals significant global commitment to ensuring that all women go through pregnancy and childbirth safely.

As Abeba’s story shows, though, poor quality maternity care, abuse by health workers, and health systems that are unaccountable to pregnant women and mothers all can subvert efforts brimming over with resources and political will.

South Africa, for example, has per capita health spending of $748, the highest in sub-Saharan Africa. Ninety two percent of women in South Africa get prenatal care, and almost 87 percent deliver in health facilities. 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.

Yet, by the government’s own count, the maternal mortality ratio has increased from 150 deaths per 100,000 live births to 625 between 1998 and 2007. Recent analysis of global levels and trends in child mortality by the UN shows that South Africa also had not reduced that rate between 1990 and 2010.

So what is wrong here? Our research indicated that the South African health care system is largely unresponsive to the needs of pregnant women and mothers despite the financial and human resources at its disposal. Experiences such as Abeba’s constitute both a human rights concern and an important quality of care problem. Abuses drive women away from seeking care in health institutions and lead to delays in diagnosis and treatment. This in turn contributes to increased illness and the risk of death for women and their newborns, and is costly to families and the health care system.

Unfortunately, abuse of women during pregnancy and delivery and afterward, often accompanied with substandard care, is not unique to South Africa. A study by the United States Agency for International Development (USAID) shows that many resource-poor countries in Africa and beyond are struggling with this problem.

But there is hope. South Africa has developed norms and standards for maternity care and plans to establish an office of standards compliance to address the gaps in its quality of care. Some health facilities also have complaint mechanisms, although they don’t function well. Some funding agencies are also paying attention. USAID has provided funding to develop and evaluate programs to address the disrespect and abuse women face during childbirth in Kenya and Tanzania.

Nonetheless, national governments, donors, and other funding agencies need to pay much more attention to the abuses pregnant women face in health facilities if the Global Strategy is going to work. Governments and funders should strengthen health systems, including management of health facilities. The systems need to be more accountable for all women, including poor, rural, and illiterate women, as well as marginalized women such as refugees. The effort to improve care will only work when everyone involved with health care systems, from the planners and funders to the health care providers at the ground level realize that every woman and child counts. 

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