Obstetric violence, the abuse of pregnant women by health workers, is shockingly common in the Indian medical system though it is rarely talked about. Recently, three infants died in Uttar Pradesh’s Balia district after their mothers were forced to deliver on the floor even though beds were available at the primary health centre (the attendants reportedly didn’t want to deal with soiled sheets).

Though the violation of reproductive rights is not yet considered a human rights issue in India, in the Balia case, the National Human Rights Commission ( NHRC ) has taken suo motu cognizance and issued notices to the state government and concerned officials. But the fact is that obstetric abuse is not limited to remote villages or distant towns, it happens quite often in big cities as well.

Medical interns will tell you of the horrors they frequently witness during their gynaecology postings. Of pregnant women being asked to deliver on the floor, yelled at for screaming in pain, or being asked to clean up their own ‘mess’ (See box).

Dr Varun Patel, who did his internship in Sassoon Hospital in Pune, kicked up a storm when he wrote in December 2013, “…in an Indian government hospital giving birth to a child is not a unit less than suffering third degree torture in jails. Pregnant women are beaten like anything and, worst of all, the doctors feel it’s justified. …. Unreasonable use of Buscopan and Drotaverine to speed up the labour and unwanted episiotomies (vaginal cutting to prevent tear) with accompanying fundal pressure manoeuvres (which are contraindicated) leave you baffled,” he had blogged.

Recently, nurses in a Delhi government hospital threatened to slap a pregnant woman if she screamed during labour and handed her the unwashed body of her still-born in a polythene bag. The Human Rights Law Network (HRLN) filed a case in the Delhi High Court, which ordered the government to pay Rs 10,000 to the mother as an interim measure and posted it for the next hearing in January 2016.

“Women face varying degrees of obstetric violence in most settings. But the worst is the treatment meted out in government hospitals to the poor and most vulnerable population, people who cannot stake a claim to their rights and who do not know their entitlements. It is made worse by a culture of impunity, where health providers know they will get away with it,” says Dr YK Sandhya of Sahyog, an organization working to promote gender equality and women’s health from a human rights framework.

HRLN, a collective of lawyers and social activists, has filed 150 cases in 14 states regarding violation of reproductive rights. “The health sector has had massive budget cuts at the central level and under-spending at the state level, which has led to a shrinking of the public health sector and perennial shortage of doctors and health personnel. There is also an endemic attitudinal problem towards the poor, but it is wrong to fix the blame at the lower level of health providers such as nurses and ward attendants. People at the top are supposed to be monitoring the services but that monitoring is completely absent,” says Sarita Barpanda, director of HRLN’s Reproductive Rights Unit. Despite progressive judgments in these cases, change on the ground has been slow with few cases of abuse actually coming to light and even fewer resulting in convictions.

Schemes like the Janani Suraksha Yojana, which pays pregnant women to give birth in health facilities and health workers for bringing them in, have pushed up institutional deliveries from 40% to about 80%. However, this surge in institutional deliveries – targeted as a means of reducing maternal mortality – has not seen a proportionate increase in investment in public health facilities. This often means staff shortage and poorly trained personnel.

Abuse by health workers in maternity care is not unique to India. A study published in June this year, which analysed 65 studies from 34 countries about the mistreatment of women during childbirth across income levels, found that such abuse was prevalent globally. The study categorized the abuse into seven domains: physical abuse (e.g slapping or pinching); sexual abuse; verbal abuse such as harsh or rude language; stigma and discrimination based on age, ethnicity, socioe-conomic status, or medical conditions; and loss of autonomy. Little wonder that the World Health Organisation (WHO) found it necessary to issue a statement on preventing and eliminating disrespect and abuse during childbirth.

“Public health personnel need to see the delivery of care as their duty and a patient’s right. In their training, there is no sensitising about gender or imparting of soft skills such as how to engage with patients,” said Dr Sandhya. “The terms of abuse used against pregnant women are shockingly similar across the world. It could be something to do with how we view reproduction and women.”

A senior neonatologist in a large public hospital who’s also practised in the private sector says that there is a distinct class bias in how women in labour rooms are treated. “It has to do with disempowerment. I have seen my professors being saccharine sweet with patients in their private practice, and then proceed to shout and use crude language to abuse their patients in government hospitals,” he says. “So it is not just about socialization. It is also about openly demonstrating their bias against poor patients because they will not be held accountable for their behaviour.”

An indication of just how bad things are is the fact that a judgment from the Madhya Pradesh High Court had to state the obvious – “a woman’s right to survive pregnancy and childbirth is a fundamental right”.