Many women in Mongolia experience disrespectful, abusive or neglectful treatment during childbirth in health facilities. Such treatment not only violates the rights of women to respectful care, but can also threaten their rights to life, health, bodily integrity, and freedom from discrimination. This is considered obstetric violence, but this understanding or concept is somewhat “new” for Mongolians. In other words, not many people are aware that this is a form of violation, it is not reflected in the law, and the state has been completely ignorant to this issue.

While disrespectful and abusive treatment of women may occur throughout pregnancy, childbirth and postpartum period, women are particularly vulnerable during childbirth. Such practices may have direct adverse consequences for both the mother and infant.

According to Cara Terreri, community manager of Giving Birth with Confidence Lamaze, obstetric violence is the physical, sexual, or verbal abuse, bullying, coercion, humiliation, or assault that occurs to laboring and birthing people by medical staff, including nurses, doctors, and midwives. Among others, adolescents, unmarried women, women of low socioeconomic status, women from ethnic minorities, migrant women and women living with HIV are particularly likely to experience disrespectful and abusive treatment during labor and childbirth.

Abuse, neglect or disrespect during childbirth can amount to a violation of a woman’s fundamental human rights, as described in internationally adopted human rights standards and principles. In particular, pregnant women have a right to be equal in dignity, be free to seek, receive and impart information, be free from discrimination, and enjoy the highest attainable standard of physical and mental health, including sexual and reproductive health, according to the World Health Organization (WHO).

However, due to the lack of legal framework and policies to ensure the rights of pregnant women in Mongolia, there are still cases of loss of health and life. Nationwide, the average maternal mortality rate per 100,000 live births between 2016 and 2019 was 24, according to the National Statistics Office. In 2019, infant mortality accounted for 62.2 percent of neonatal mortality, which is 1.5 percentage points higher from the average of the last 10 years. As of 2019, 1,041 cases of infant mortality were registered, of which 841 cases or 80.8 percent were hospital deaths.

In the last 10 years, infant mortality has been primarily caused by neonatal miscarriage, cerebral ischemia, and neonatal-specific infections. In 2019, 16.6 percent of infant deaths were caused by congenital malformations or chromosomal abnormalities, 10.5 percent by respiratory diseases, 6.5 percent by other external injuries, and 2.5 percent by infectious and parasitic diseases.

On average for the past decade, 190 cases or 16.4 percent of infant deaths occurred at home without medical care. In 2019, 176 cases of home deaths were registered, accounting for 16.9 percent of infant deaths. An average of 0.7 percent of all births in the last 10 years are reportedly stillbirths.

Only women who have given birth know what lies behind the door to the delivery room. They would agree that these figures do not paint the whole picture and that terrible things can occur in hospitals. Every year, 60,000 to 80,000 women give birth nationwide. Unfortunately, there are many cases of abuse in pregnant women. In Mongolia, reports of disrespectful and abusive treatment during childbirth in facilities have included outright physical abuse, profound humiliation and verbal abuse, coercive or unconsented medical procedures (including sterilization), lack of confidentiality, failure to get fully informed consent, refusal to give pain medication, gross violations of privacy, refusal of admission to health facilities, neglecting women during childbirth to suffer life-threatening and avoidable complications, and detention of women and their newborns in facilities after childbirth due to their inability to pay.

Some mothers commented on the real situation of maternity hospitals on the Facebook group “For Maternal and Child Health”. For instance, one woman wrote, “I gave birth last week. I was not examined by a doctor on Friday, Saturday or Sunday. I was not in pain but on Friday, my roommate began to bleed after a vaginal exam. The doctor and nurse ignored it. It turned out that she had lost her baby while bleeding out. But she did not complain. Pregnant women are often scolded by doctors during birthing. Even when doctors make mistakes, they scold us instead and take advantage of our lack of medical knowledge.”

“One night there was no doctor in the hospital. One woman’s family demanded hospital staff to call a doctor. But the woman was ‘ousted’ from the hospital only eight hours after giving birth. Even in my case, a nurse delivered my baby,” another member of the group commented.

Another woman said that while she was in the maternity hospital, a lady lost her baby. She had apparently begged for a caesarean section, but the doctors ignored her request and couldn’t let the baby draw its first birth.

In 2015, a 38-year-old woman who was pregnant started bleeding and went to the Urgoo Maternity Hospital. However, the hospital staff did not accept her, saying, “Residents of Sukhbaatar District must go to the Khuree Maternity Hospital.” The hospital could have taken immediate action and avoided a miscarriage, but they did not. When she arrived the Khuree hospital, she was told, “Since you had a miscarriage, you should come on Monday to get an outpatient examination.”

The WHO recommends emergency surgery after a miscarriage to save a mother’s life. But the doctors of this maternity hospital appear not to have known that.

In 2013, a nurse of Bayankhongor Province’s General Hospital burned a newborn baby in boiling hot water, according to reports. Later, at the Third Maternity Hospital, doctors left a bandage about two meters long in a mother’s womb during caesarean section. In Sukhbaatar Province, a mother who was taken to the hospital to give birth was reported unable to walk again due to medical malpractice.

In November 2015, a mother who went to the Urguu Maternity Hospital to give birth died with her infant. The doctors had apparently told to her, “There is no bed, it’s not time to give birth,” before sending her back. After a forensic examination confirmed that the doctors were at fault, the hospital’s management simply apologized to the family of the deceased.

GREATER SUPPORT IS NEEDED FROM GOVERNMENT

UN special rapporteur on violence against women, its causes and consequences Reem Alsalem, who visited Mongolia earlier this month, revealed these gaps in identifying gender-differentiated impacts of gaps in the health sector. She discovered that there are no laws or regulations that allow for the response to obstetric violence in Mongolia.

In fact, the procedure for care during pregnancy, childbirth and postpartum was updated last year based on the National Maternal, Child and Reproductive Health Program. However, it does not address the issue of obstetric violence. In other words, in Mongolia, women who experienced obstetric violence cannot take any action against medical staff by law. It’s not possible for mothers to be compensated for the financial and emotional damage.

The WHO addressed this gap in a 2014 statement on mistreatment during childbirth and its associated human rights violations, calling for greater action, dialogue, research, and advocacy on this global problem. Accordingly, many governments, professional societies, researchers, international organizations, civil society groups and communities worldwide have already highlighted the need to address this problem and have begun to take action against obstetric violence.

For instance, in the US, there are rights specific to pregnant and birthing people in a document called, “The Rights of Childbearing Women,” which details 20 specific rights, including the right to accept or refuse procedures, drugs, tests, and treatments, and have those choices honored. When these rights in childbirth are ignored or forcibly denied, it is considered as obstetric violence and illegal in the country. In addition to seeking justice for mistreatment in birth, those who have experienced obstetric violence can be compensated for healing the trauma from their birth. Victims can demand monetary compensation for the harm done.

Mongolian authorities believe that only increasing salaries can contribute to improved attitudes of medical staff and elimination of ethical violations. Therefore, last year, a regulation was introduced to raise salaries of medical workers who did not commit any ethical violation. However, the current situation and international examples show that Mongolia needs tougher measures and policies to address this issue.

In fact, even local offices and authorities didn’t know what obstetric violence was when we asked them to comment and share insights into the matter. This calls for greater action to raise awareness of this form of human rights violation and support for changes in provider behavior, clinical environments and health systems to ensure that all women have access to respectful, competent and caring maternity health care services. Moreover, greater support from the government and development partners is needed for further research on defining and measuring disrespect and abuse in public and private facilities worldwide, and better understand its impact on women’s health experiences and choices.

Health systems must be accountable for the treatment of women during childbirth, ensuring clear policies on rights and ethical standards are developed and implemented. Health-care providers at all levels should require support and training to ensure that childbearing women are treated with compassion and dignity, as recommended by experts.

To achieve a high standard of respectful care during childbirth, health systems must be organized and managed in a manner that ensures respect for women’s sexual and reproductive health and human rights. Ensuring access to safe, acceptable, good quality sexual and reproductive health care, particularly contraceptive access and maternal health care, can dramatically reduce rates of maternal morbidity and mortality.