Addressing obstetric violence as a relational phenomenon: obligations on the South African state under the right of access to health care services

Thesis

Maternity ‘care’ in South African public healthcare facilities is frequently accompanied by abuse, which is becoming known as ‘obstetric violence’. That abuse may be interpersonal (including physical and verbal abuse) or structural (including harms caused through institutional arrangements or cultural norms and narratives). Notwithstanding a wide range of laws, policies, and ethical guidelines that prohibit many of the practices that harm women and birthing people (‘WBP’) during labour or childbirth, many of those practices have become normalised.

This thesis explores the state’s immediate obligations to address institutionalised obstetric violence. It does so in two parts. First, it conceptualises obstetric violence through a WBP-centric lens, focusing on the relational harms that serve as threads connecting its range of manifestations. The phenomenon may thus be characterised as a breakdown of caring relationships in maternity wards. However, the thesis highlights the role of broader social and institutional structures in facilitating or undermining ‘care’.

Second, the thesis considers the South African state’s constitutional obligations to address institutionalised obstetric violence. It focuses, in particular, on the constitutional right of access to health care services (the ‘Healthcare Right’), read with the constitutional values of dignity, equality, and freedom. Having made the case that those (transformative) values are grounded in relational conceptions of rightsholders, it argues that the Healthcare Right envisages the development of both medical services and networks of care. The former without the latter entails – at best – partial fulfilment of the Right.

Finally, the thesis outlines some minimum, immediately-enforceable obligations encompassed by the Healthcare Right, including duties of non-interference (duties to ‘respect’ human rights), duties to ‘protect’ the exercise of rights, and duties to remedy institutionalised interferences (including through institutional reform). These generate a kind of ‘manner-based’ minimum core of the Right. While the law offers only limited tools to respond to a complex structural crisis, this thesis argues that constitutional litigation offers opportunities for structured dialogue, institutional accountability, and public challenges to normalised crises.

Authors: Speechly, G

• DOI: 10.5287/ora-yqverpz1v
• Type of award: DPhil
• Level of award: Doctoral
• Awarding institution: University of Oxford
• Language: English
• Keywords: South Africa; structural violence; socio-economic rights; reproductive justice; maternity care; health rights; obstetric violence; relational theories of personhood
• Subjects: Philosophy; Medical ethics; Medical laws and legislation; Human rights