Exclusive: openDemocracy investigation reveals ‘traumatic’ incidents defying WHO guidelines in 45 countries – as experts warn of ‘tens of thousands’ of extra maternal deaths.
Top doctors and lawyers from around the world have condemned the “shocking and disturbing” treatment of women giving birth during the COVID-19 pandemic, a new openDemocracy investigation reveals today.
Since March, openDemocracy has identified cases of “traumatic” experiences in at least 45 countries that contravene World Health Organization (WHO) guidance, and some national laws. In at least six countries, pregnant women have also died after COVID-19 restrictions reportedly prevented or delayed access to emergency services.
Dozens of women across Europe, Latin America and Africa have also described to openDemocracy their own first-hand experiences of:
- birth companions banned from hospitals – in some cases even after other lockdown restrictions have been lifted;
- forcible separation from newborns and being prevented from breastfeeding – despite no evidence that breast milk can transmit coronavirus;
- pain medication withheld because hospital resources including anaesthesiologists were diverted to the COVID-19 response;
- procedures performed without their consent, including caesarean sections, induced labour and episiotomies, to speed up labour.
Maternal health advocates say that while incidents like these occurred in many countries before COVID-19, responses to the pandemic have made these problems worse.
The findings come as experts warn that COVID-19 restrictions could cause “tens of thousands” of additional maternal deaths around the world.
Across Latin America, which already had the world’s highest C-section rate, doctors and maternal health advocates have warned that the number of these procedures has also increased because of “misguided policies” and “fear of overloading hospitals”.
In many cases, these procedures have been performed against women’s wishes and without the medical justification that the WHO guidelines and national laws require.
In Uganda, a doctor at one hospital told openDemocracy she knows of at least three women who died after they couldn’t reach the hospital due to transport restrictions.
Other women in labour and distress reported being turned away from health centres or shunned by medical staff, because they appeared to have coronavirus symptoms or didn’t have masks, or because maternity facilities were rededicated to the COVID-19 response.
Experts have raised concerns of many more cases like this in countries where health infrastructure was already fragile before the outbreak.
Some hospitals have reversed restrictions affecting women giving birth, following local media coverage and campaigns. In countries including Armenia and Ukraine, however, bans on birth companions have remained even after lockdowns have eased.
“My husband and I are ready to handcuff ourselves together if doctors won’t allow him in,” said one woman in Ukraine who recently launched an online petition to be allowed to give birth with her partner in the room.
“It seems we’ve slipped through a gap,” says Zaynab Iman from the UK, who described feeling “abandoned” in March with the “heartbreaking” cries of other women at one London hospital that had temporarily banned companions.
A woman in Ecuador also told openDemocracy she felt “abandoned” when she gave birth in late March at a health centre without medical assistance. “They left me alone with my husband in the delivery room, with no one to advise us or tell us anything.”
“There is no reason that women should be denied respectful care”
Health experts told openDemocracy that these restrictions on women giving birth were “unnecessary” and lawyers said there could be legal consequences for governments whose pandemic responses failed to protect women’s rights.
“openDemocracy’s research clearly reveals how unnecessary restrictions constitute an alarming pattern of women’s health and rights being deprioritised during the crisis,” said Belgian MEP Petra De Sutter, who is also a gynaecologist and president of the European Parliamentary Forum for Sexual and Reproductive Rights (EPF).
“There is no reason… that women should be denied respectful care,” said Quazi Monirul Islam, a medical doctor involved in drafting WHO’s 2005 childbirth guidelines. The global health body has emphasised that these guidelines still apply under COVID-19.
Islam partly blamed an “initial panic” by hospitals faced with the pandemic. He compared it to his time working in Botswana in the 1980s when, he says, hospitals misunderstanding HIV research had also separated women and children at birth.
But Melissa Upreti, a lawyer and member of a working group on discrimination against women at the UN human rights office OHCHR, warned that around the world “the risk of contagion has been used as a pretext to deny proper care.”
“It’s really shocking and disturbing,” she said, calling the denial of services that women need “discrimination from a legal standpoint. We do have a very strong case to make… that governments are violating their own laws and policies.”
“You can be sure, cases are going to be filed,” says Nelly Weraga, a lawyer with the Women’s Link Worldwide NGO in Kenya. She said African governments could face lawsuits if their lockdown rules led to the death or injury of pregnant women.
“We expect more from our governments in times of crisis,” added Austrian MP Petra Bayr, chair of the Council of Europe parliamentary assembly’s equality committee and EPF vice-president. “They must be held accountable for the mistreatment documented by openDemocracy and put in place systems to make sure this doesn’t happen again.”
World Health Organization (WHO) guidance on childbirth during the pandemic, published in March, reiterates its long-standing advice that women giving birth should be treated with dignity and respect and given clear communication and appropriate pain relief.
This guidance adds that women should be accompanied by a person of their choice while giving birth, and they should be supported to breastfeed and have skin-to-skin contact with newborns, even if they are COVID-19 positive. Procedures including C-sections should only be performed when they are medically necessary or have the woman’s consent.
Many countries have national policies that echo these principles and in Latin America several countries have in recent years passed laws against “obstetric violence”.
However, openDemocracy has identified cases in at least 45 countries of women who were reportedly treated in ways that defy this guidance during the pandemic.
These cases include bans on birth companions at some hospitals in at least 35 countries; forcible separations of women and newborns in at least fifteen countries; and cases of women who said they were not supported to breastfeed in at least seven countries (despite no evidence that the virus can be transmitted via breast milk).
In eleven countries, women reported that they didn’t consent to the C-sections, induction and episiotomies (the cutting of a woman’s vagina) that were performed on them, or said that they did not believe these procedures were medically justified.
In at least 20 countries, COVID-19 restrictions including curfews and transport bans have blocked women’s access to critical health care before, during or after birth. In at least thirteen cases in six countries, this led to deaths of the women or their babies.
Large global firms that make baby formula have separately been accused of ‘exploiting’ the pandemic by taking advantage of mothers’ fears of transmitting coronavirus through breastfeeding to aggressively promote their products.
WHO’s director of sexual and reproductive health, Ian Askew, says its guidelines are “based on the best scientific evidence available”. They exist to ensure respectful care, and should be followed everywhere, both during the pandemic and beyond, he added.
“Many of us are receiving anecdotal reports of women not receiving respectful, dignified or high-quality care before, during and following childbirth,” says Askew, who is also a medical doctor, calling this an “alarming” trend.
A spokesperson for the Office of the UN High Commissioner for Human Rights, Michelle Bachelet, said it has also received reports of abuses during COVID-19 childbirths. “Documenting these incidents is a critical first step to exposing the problem”, they said.
“Governments need to act now,” says Enid Muthoni from the Center for Reproductive Rights in Brussels, adding that “it is entirely possible for European health systems to follow WHO’s guidelines while responding to the pandemic.”
Disrespected and endangered
Across several African countries there have been reports of women who couldn’t reach hospital in time during emergencies due to COVID-19-related transport restrictions. Some of these women reportedly died as a result, while others delivered their babies by the roadside or in other unsanitary public places.
The imposition of coronavirus curfews and transport restrictions in Latin America has also led to women missing antenatal check-ups, walking long distances to reach hospital, or being forced to have unplanned and risky home births.
Responding to openDemocracy’s findings, maternal health advocates acknowledge that COVID-19 has made things worse for women in childbirth. However, they emphasise that, even before the pandemic, too many women have felt disrespected or endangered while giving birth.
In recent years, this has been increasingly well documented including by the WHO which led a study published in the Lancet last year which found that 42% of women interviewed by researchers in Ghana, Guinea, Myanmar and Nigeria said they experienced physical or verbal abuse, stigma or discrimination during childbirth in health facilities.
In Latin America over the last decade, several countries have specifically outlawed “dehumanising treatment and/or abusive medicalisation” of women giving birth, defining “obstetric violence” as a specific type of criminalised gender violence.
But, says Mercedes Muñoz, head of the NGO Venezuelan Association for an Alternative Sex Education, despite the law in her country, obstetric violence “is so normalised by authorities and medical staff”.
“Women feel they risk being unassisted or neglected if they demand their rights, and this usually makes them keep quiet,” she says. “What pregnant women have to go through in Venezuela is absolutely Dantesque.”