Screams and bloodied floors: Childbirth violence in Syrian hospitals

Rowaida al-Khalid (pseudonym), 28-year-old a displaced woman from Aleppo governorate, sums up the extent of suffering she experienced during her recent childbirth at one of the free hospitals in northern Idlib, which is supported by a non-governmental humanitarian organization. The experience was so distressing and traumatizing that she decided to refrain from getting pregnant again due to the psychological and physical pressures she endured during childbirth.

Rowaida, a mother of two, tells Raseef22, "Three days after the end of the ninth month, I didn't feel any contractions as I did in my previous delivery, but I would always feel a general weakness and fatigue. I decided to go to the hospital with my mother and sister to monitor the pregnancy, and upon our arrival, the medical staff allowed only one person to accompany me, so my sister had to stay outside at the hospital entrance."

"When I entered the labor ward located in the basement, I heard nothing but intense screaming, pleading and praying of women. I saw delivery rooms with three beds separated by a curtain and blood flowing on the floor between them, and I felt genuine fear"

"I will never forget those moments as long as I live," says Rowaida, waving her hand. "When I entered the labor ward located in the basement, I heard nothing but the intense screaming, pleading and praying of women. I only saw delivery rooms with three beds separated by a blue curtain and blood flowing on the floor between them. As I held my mother's hand tightly and asked her to stay by my side, that's when I felt genuine fear."

Rowaida adds, "A nurse greeted us, and I don't even know what she was chewing in her mouth. She asked, 'When did you have your first contraction? What month are you in?' My mother answered her, and the nurse led us to a bed surrounded by streaks of blood. I still remember the sight of the trash bin next to me, which was full and looked horrifying, and the screams of the young girl whom I could see through the curtain giving birth in the bed next to mine, and the woman giving birth to her yelling at her mother, saying, 'You want to marry off your daughters.. Here you go, this is what happens'."

Obstetric or childbirth violence is defined as any verbal, physical, or emotional abuse, bullying, coercion, humiliation, or assault that occurs to women during childbirth

Rowaida continues, saying that a midwife named Umm Ahmed entered her room and said, "What are you waiting for? You haven't taken off your clothes yet. Hurry up, are you the only one here?" She adds, "I was afraid of her, and she examined me, saying, 'You're giving birth today, don't go anywhere'... She started repeating her examinations every 30 minutes, and then she asked me to walk around in the maternity corridor or the group "labor" room and drink castor oil, which helps facilitate delivery. That's when the contractions intensified, and I started crying and begging my mother to relieve me from this pain."

She goes on to say, "My mother yelled at the midwife, Umm Ahmed, to pay attention to me, and the latter responded angrily, 'Take her to her bed so I can examine her.' The midwife came and asked me to open my legs. I was very afraid, so she hit me and continued to do so repeatedly with great force, saying, 'Those who are shy don't give birth. No one told you to get married and come here to scream at us.' Then she continued examining me with a great amount of violence, as if I were a lifeless body without soul or feeling."

The normalization of violence

Obstetric or childbirth violence is defined as any verbal, physical, or emotional abuse, bullying, coercion, humiliation, or assault that occurs to women during the process of childbirth at the hands of the medical staff, including nurses, doctors, and midwives, according to the international organization Lamaze. It includes mistreatment and the violation of women's rights during labor or delivery, including being forced into procedures against their will by healthcare professionals and medical personnel.

The nurse led us to a bed surrounded by streaks of blood. I still remember the horrifying sight, the screams of the girl giving birth in the bed next to mine, and the midwife yelling, 'You want to marry off your daughters. Here you go, this is the result'

Rowaida goes into detail about what happened to her, "The pain from the intensity of the contractions went on until dawn, and then I felt extreme cold despite it being summer. At one point, my mother suddenly screamed and I looked at the spot she was pointing at to find blood flowing as if it were the blood of a sacrificial lamb. I started screaming and asking her while crying hysterically, 'Tell me what happened?' But the midwife only came and said, 'It's your turn.' Another nurse, whom I cannot accurately describe, began pressing hard on my abdomen while I was bleeding, and then they asked my mother to leave. The sound of my screams of pain reached my mother as she was crying outside, as she later told me. During those moments, the nurse slapped me across the face, and I thought she did it to prevent me from losing consciousness, but in reality, she wanted to silence me because I was bothering her."

Rowaida looks into her son's eyes to make sure he's asleep, then moves him from her embrace to the bed, and continues her story, "When I felt the baby's head starting to emerge, the nurse started pressing hard on my abdomen, and the midwife began hitting my legs with all her might, asking another nurse to hold them so I wouldn't close them, amidst her screams, 'Damn you, why are you so strong? Yalla, hurry up and finish'."

Justifications for the violence

Midwife Fidaa al-Sami (pseudonym), who works at a hospital in the city of Sarmada, northern Idlib, spoke to Raseef22 about how in some cases of childbirth, midwives are forced to shout at the patient and raise their voices, especially when the baby's head begins to crown. This stage is considered one of the most difficult and sensitive stages, and requires strength and determination from the woman to push.

"The pain went on until dawn. A nurse began pressing hard on my abdomen while I was bleeding heavily, then slapped me. I thought it was to prevent me from losing consciousness, but she actually wanted to silence my screams of pain because I was bothering her"

She says, "Many women in northern Syria do not cooperate with the midwife who supervises them during childbirth due to the intensity of the pain and their young age. Sometimes this forces the midwife to apply great pressure on the uterus, which is a painful procedure. Sometimes the woman closes her legs on the baby's head, which can make the midwife react strongly and seek assistance from those who are present to force open the woman's legs until the delivery is successfully completed. All these procedures are carried out due to the midwife's concern for the baby's safety from potential risks and dangers."

According to a survey conducted by Raseef22 with 13 women in northern Syria (in opposition-held areas) who gave birth in free clinics, it was found that maternity clinics are distributed in most medical facilities scattered in the Idlib and Aleppo countryside. Midwives and nurses supervise women's deliveries, while the role of the attending doctor is limited to providing medical consultation in difficult cases or cesarean births, and do not intervene in normal deliveries.

The surveyed women stated that a significant number of those who go to free maternity clinics end up giving birth in labor room corridors due to the rapid and intense contractions and the midwives' lack of accurate timing for the delivery. The role of midwives often focuses on cleaning the uterus after childbirth, and the role of nurses is limited to stitching wounds without even the use of local anesthesia.

For her part, civil society activist Faten (who preferred to not mention her full name) criticized the state of indifference with regard to the lives of women in hospitals and the absence of real oversight over medical staff. She affirmed that "as a civil society, our work is limited to raising awareness among women about their rights and how they can be influential.

She refers to a personal experience she had, "A few months ago, I accompanied my sister to the Women and Children's Hospital in the city of al-Dana, north of Idlib (35 km), to monitor her pregnancy in her ninth month due to the pain she was experiencing. As a piece of advice, one of the patients in the first waiting area asked me to go outside the hospital and have an examination at our own expense in private hospitals, due to the frequent mistreatment and neglect this woman experienced during the birth of her daughter."

While conducting this report, Raseef22 attempted to contact an administrator in the organizations responsible for these hospitals, but they refused to provide any statement or clarification, citing a ban by the organization on media statements. They contented themselves with denying any issues or problems faced by the organization-supported hospitals and criticized "the role of the media for shedding light on this matter."

"My screams of pain reached my mother as she was crying outside. When I felt the baby's head begin to emerge, the midwife began hitting my legs, telling a nurse to forcefully hold them open while screaming at me, 'Damn you, hurry up, we don't have all day'."

Reasons for the lack of care

According to an administrative official working in the Al Sham Humanitarian Foundation, named Salah (declined to provide his full name), the lack of financial allocations provided by the foundation to maternity clinics or free hospitals in the region is one of the main reasons for the indifference and lack of care. Midwives only get paid $350, while nurses receive $300, at a time when most free hospitals witness daily overcrowding due to the high population density in northern Syria.

He points to "the absence of alternatives that could help this sector avoid this issue, which is one of the most important issues affecting citizens. The salaries of doctors do not match the foundation's budget for operating a medical facility, especially obstetric specialists. Therefore, midwives and nurses are employed and entrusted with this issue, taking into account that there is only one doctor on duty during specific hours of the day to intervene only in emergency cases."

The doctor receives a monthly salary of $950 for a work schedule of 56 hours per week at the medical facility where he works.

A population of approximately 4.3 million people live in northern Syria, specifically in the Idlib region, most of whom were internally displaced from Syrian cities, amidst harsh living conditions.

According to the Idlib Health Directorate, the area needs about 100 maternity and birthing centers, given that every 50,000 people require at least one center. However, in reality, there are only 22 centers in the Idlib region specializing in natural childbirth. The monthly birth rate in these centers ranges between 3,000 and 3,500 cases. As for specialized maternity hospitals, there are only eight, with a total number of births ranging between 5,000 and 6,500 per month, including both natural and cesarean deliveries.

Raseef22 tried to contact an administrator in the organizations responsible for these hospitals, but they refused to provide any statement or clarification

Psychological effects

Today, Rowaida is suffering from fears of becoming pregnant once again and having to enter the hospital for delivery. She says, "I won't get pregnant until things get better and we can give birth in a private hospital."

While conducting this report, we spoke to the information department at Issa Hospital, a private hospital located in the city of al-Dana, and we asked them to provide us with their child delivery fees. They confirmed that the cost of a natural birth is $90, while for a cesarean section, it is $150, excluding the special medications required for both procedures, which cost around $15.

During the survey we conducted in northern Syria, Manal Q. told us the story of Rowaida, confirming that she experienced the same experience during her third pregnancy in one of the hospitals in Idlib. But, according to Manal, "I learned a lesson I will never forget, and for this reason, I gave birth to my fourth child, Zain (3 months old), in a private hospital."

Does the law hold those guilty accountable?

In his interview with Rasayel22, lawyer Hudaifa al-Hajji believes that it is difficult to curb this phenomenon in free hospitals in the region without serious and genuine legal action against the abusive medical personnel, especially within the delivery rooms. It is inhumane for a woman to be abused during the most important moment in her life (the moment of giving birth to her child).

Today, Rowaida is suffering from fears of becoming pregnant once again and having to enter the hospital for delivery. She says, "I won't get pregnant until things get better and we can give birth in a private hospital."

Women who experience childbirth violence are urged to go to the legal office in hospitals and file an official complaint when such incidents occur, using those who were accompanying them as witnesses or through documenting the abuse through audio recordings to prove the inhumane practices they have endured, so that the abused woman can file a legal complaint.

Most of the women we spoke to in northern Syria confirm that the most prominent violations against women in free hospitals are not related to the procedures themselves but rather to the attitude of nurses and midwives towards the patients and the way they treat them, along with the disregard for their lives.

International laws indicate that women have many rights in the delivery room, including being informed by the doctor about the medical procedure that will be taken and ensuring that the woman fully understands the procedure. The standards also state that a woman has the right to refuse to be treated by a specific doctor or nurse and request a replacement. Additionally, a woman has the right to communicate with the hospital administration to report any violations she has experienced in the delivery room.

It is worthy of note that some of the interviewed women assured us that not all midwives and nurses are as bad as described above, and some midwives treat women with kindness. Some even calm the woman's nerves and alleviate her pain during childbirth with gentle words that reassure her about her and her baby's well-being.