During her visit to Mongolia last December, UN special rapporteur on violence against women, its causes and consequences Reem Alsalem revealed that there are no laws or regulations that allow for the identification and response to obstetric violence in the country. Obstetric violence occurs during pregnancy, childbirth and the immediate postpartum period. Hence, it is violence that directly affects women. In reality, many Mongolian women experience disrespectful, abusive or neglectful treatment during childbirth in health facilities. Unfortunately, relevant officials, governmental and non-governmental organizations, especially in the health sector, have turned a blind eye to this issue.
Founder and consultant of the Princess Center for the Protection of the Rights of Girls and Young Women Ch.Undrakh gave an interview about the situation of maternity hospitals in Mongolia and the attitudes of medical staff toward patients.
You say that teenage mothers appear particularly vulnerable to obstetric violence. Does your center conduct research works on this?
Founded in 2003, our center has been operating for 19 years and is the only organization that works with teenage mothers. Adolescent mothers who contact us participate in the annual service quality survey. The majority of respondents raised the issue of attitudes of medical staff. Especially adolescent mothers answer that they were discriminated against and harassed by doctors and medical staff during pregnancy or childbirth. Our teenage clients reported that when they visited the Family Group Practice for regular monitoring of pregnancy, they were often insulted, abused, and scolded for getting pregnant at a young age. They described their most poignant experiences of verbal or emotional violence perpetrated by obstetric care providers. Because of this issue, teenage mothers are either afraid or anxious to go to the hospital and some do not receive prenatal care before delivery.
Can you share the results of last year’s survey of adolescent mothers?
Due to financial and human resources issues, we are mainly based in Ulaanbaatar. Unfortunately, we are not able to work in every province. Therefore, we pay more attention to training local social workers who work with adolescent mothers and provide professional assistance. Our center runs a one-year program to empower 50 to 60 teenage mothers each year. The youngest mother who is involved in this program this year is 14 years old.
Last year, more than 50 mothers from Ulaanbaatar and Darkhan-Uul and Khentii provinces were surveyed. When asked if they had any problems receiving antenatal care, 45 percent responded “yes”. Moreover, 7.8 percent of them said that they gave birth without any prenatal care. The study also found that only half of the respondents were monitored during the first trimester of pregnancy. This is a very low figure. In addition, 17 percent of the mothers surveyed said that healthcare workers had treated them badly. It should be noted that the scope of our study is limited and does not reflect the national level. However, I think the results of this study reveal that women are mistreated while receiving care during pregnancy, childbirth and the immediate postpartum period.
Does this mean that half of the young mothers are unable to get antenatal care on time due to unethical attitudes of doctors?
Adolescent mothers are psychologically more vulnerable than adult women. About 80 percent of teenage pregnancies are unwanted. In some cases, young pregnant women were sexually abused. They may have some kind of family, emotional, and personal problems as well. However, if doctors and medical staff discriminate against them when they are most sensitive, they become afraid to go to them for antenatal care.
Discrimination is one of the most common forms of violence against pregnant women in Mongolia. Many mothers who contact us say that when they went to receive antenatal care, doctors and medical staff discriminated against them. For instance, a woman who has given birth to many children may be asked, “Are you pregnant again?” In addition to teenage mothers, poorer women experience more violence than those with relevantly better social connections or economic standing. Therefore, I think it is necessary to study such issues in more detail.
Instructions, counseling, and psychological support are crucial for all pregnant women. However, local health facilities do not provide this service at all, right?
Yes. In addition, mothers should be psychologically prepared for safe child labor. Internationally, mothers receive training on childbirth such as overcoming fear and pushing their baby down properly during delivery, as well as training on postpartum care and breastfeeding. However, our country does not have prenatal training at all, and mothers themselves find information from various sources and social networks. Unfortunately, many women give birth without any knowledge or understanding of this process. In fact, the maternity hospital conditions and attitudes of doctors and medical staff are not very good.
Our center has produced a documentary about teenage mothers. One of the participants said, “Even though the baby’s head was sticking out, the doctor scolded me and told me to walk on my own.” Therefore, we have started implementing the Baby Box Mongolia Program. In this context, a series of trainings is being conducted to provide pregnant women with much-needed knowledge, information and advice on how to overcome fears about childbirth, eat properly during pregnancy and prevent postpartum depression. We are trying to give mothers the services and support that public hospitals cannot provide. Although people have to pay a fee to get this training, target groups or adolescent mothers are involved free of charge.
What do you think we need to change in order for mothers to give birth in a peaceful and non-violent environment?
Doctors and medical staff need to radically change their attitudes, be more proactive and have human rights-based approaches. In the emergency department of Mongolian maternity hospitals, women who are about to give birth, whose fetus has not grown, and who are about to have an abortion are placed in the same waiting room. In fact, a woman whose fetus has not grown may need to deliver her baby early and is often anxious and stressed out so she should not be exposed to more stress or heartache by being kept in the same room as pregnant women. Physicians and health care providers need to understand this. Unfortunately, they do not pay attention to such issues or understand that they must act on the basis of human rights.
In developed countries, hospitals follow this simple principle very well. In specific, some countries have special guidelines for providing health care to adolescent mothers. According to the guidelines, teenage mothers are not screened with adult women. This is because they must be asked why they are pregnant. If she had been exposed to any criminal offense, the police are notified. Furthermore, maternity hospitals are required to provide much more monitoring and information to adolescent mothers. When I was studying in the US, I found that some hospitals have a special day for young mothers to come and get checkups. However, most Mongolian doctors and medical staff do not know that adolescent mothers suffer a lot and some of them do not even want to understand them. They really need to understand that teenage mothers have a lot of fear and anxiety.
Doctors themselves claimed that scolding pregnant women is not violence. What is your position on this?
Violence is most commonly classified as emotional or physical. Scolding or insulting a pregnant woman can be emotionally damaging. In reality, it not only causes emotional damage but also makes them afraid to see a doctor again. If it causes emotional damage, it is violence.
Many people attribute this issue to the high workload and low salaries of doctors. What do you think?
Of course, the workload of medical staff is high. Public hospital doctors defend themselves as low-paid and overworked. Does that mean they interact with people according to their salary? On the contrary, will they be able to treat patients better if they get paid more? It is a misconception that low wages and heavy workloads can lead to unethical behavior. It’s just a matter of one’s attitude. Also, there is a big reason behind this issue. More specifically, medical students are not taught human rights. That’s why doctors and medical staff don’t seem to understand human rights or realize that they mustn’t scold or insult a client. Conversely, it can be said that the common culture of Mongolians also influences this. We usually communicate with each other in the form of scolding. For example, even when we go to the store, the seller scolds us. It is safe to say that such unhealthy relationships have become a part of our social culture. Therefore, in order to change it, we need to at least understand that we cannot scold people.
Caesarean section or episiotomy without the client’s consent is internationally considered obstetric violence. Were there any young mothers in your center who faced this issue?
In Mongolia, obstetricians and gynecologists do not explain this at all. Because of this, we once received a girl who understood that an episiotomy is done to every mother. In principle, any problem related to pregnancy or labor needs to be explained to the client. In specific, doctors should ask in advance, “If you cannot give birth, we will do an episiotomy. Do you agree?” However, public hospital doctors do not tell them anything in advance. People are afraid to talk about such issues related to the maternity hospital. Many are reluctant to speak out because they fear that they will not receive good health care in the future. It is unfortunate that such problems exist everywhere nowadays.