“If men were giving birth, things would not happen in the same way ” – Rethinking the treatment of obstetric violence in the Maghreb
Written by Marion Luc et Noumidia Bendali Ahcene
Translated by Julie Penverne
Countries of the Maghreb have recently experienced a reassessment of their health systems, following the denunciation of gynaecological and obstetrical violence suffered by patients. Doctors, patients and activists have joined together to point out the lack of political will to change these oppressive patriarchal behaviours, and to organise new ways of looking at health care.
As discussed in the first article on the politicisation of the issue of gynaecological and obstetric violence in France, this subject is complex as it requires the consideration of several types of key actors in society in order to be addressed. Indeed, the patriarchal foundations of most modern societies have created fertile ground for the perpetuation of such violence, and amending these entrenched norms takes a long time. In this article, we will focus on the geographical area of the Maghreb, where the process of denouncing violence against women has also been set in motion.
Due to the relative lack of academic research available in English or French on this subject, it has been difficult to find objective figures or data. Instead, the testimonies of patients and parturients, as well as of doctors, provide us with material to study this issue. This article will focus on Morocco and Tunisia, countries in which a process of re-appropriation of gynaecological and obstetrical practices has begun to be carried out by patients and doctors. This dynamic was driven by a part of the medical staff involved as well as by women’s rights activists.
Introducing the issue on the political and activist agenda : a difficult undertaking
The year 2019 saw an increase in the number of gynaecological and obstetric violence reports. In this article, we will focus mainly on obstetric violence , as it is the most denounced of the two. In order to create a favourable framework for changing gynaecological and obstetrical norms and practices, several types of actors need to be involved. The adoption of legislation denouncing violence against women is a first step towards sustainable behavioural change. This observation is recalled in a report published in 2019 by UN Women on the transformations of family life around the world . It explains that “laws enacted and enforced have an impact on gender equality in families“. It is important to mention family units as they are the source of many obstacles to the recognition of violence against women.
Thus, in Morocco, on 14 February 2018, Law No. 103-13 to combat violence against women was adopted by the House of Representatives. It defines violence against women as: “any act based on gender discrimination that is likely to cause physical, psychological, sexual or economic harm to a woman“. This first rights-based approach makes it possible to provide a legislative framework for denouncing violence, particularly that suffered in the context of gynaecological or obstetrical consultations. However, as Human Rights Watch regrets, this law does not clearly designate the institutions competent to deal with these requests. An opaque or insufficient judicial system therefore does not allow all victims of these types of violence to have access to justice. In addition, the enactment of a law must be accompanied by wide dissemination and popular education so that everyone can be informed and enjoy these rights. Without access to legal information, the law cannot be properly applied and produce the expected emancipatory effects.
Fatma Safi, President of the Tunisian Association for Prenatal Education, regrets that “women do not know their rights and that social pressure prevails!” . She explains that in Tunisia, the overly medicalized environment prevents women from expressing their views on the violence they may suffer during childbirth. When patients have little knowledge of their rights, the voice of the medical profession can be perceived as all-powerful, and is difficult to challenge. In the long term, this delays the collective awareness of the experience of violence, making it more difficult to think of violence as a system.
A lack of political will and a failing public service
As an explanation for the continuation of this system of violence, doctors and activists agree that the lack of public resources in health centres is to blame. Fatma Safi testifies: “This is institutional violence. The large health centres are overwhelmed, lack resources and the caretakers are under a lot of pressure. I’ve seen some really violent scenes and it’s still traumatic for me to talk about it.” This lack of means can be explained in part by the geography of these territories, which has very remote rural areas that are difficult to access, but this cannot be the only explanation, since hospitals in the cities experience similar conditions. This is what obstetrician Zouhair Lahna  denounces. After having practiced in war zones, such as Syria or Bangladesh with Médecins sans Frontières, he returned to practice in Morocco, his country of birth. There, he deplores a largely failing health system, which is unable to meet the needs of its patients. In one of his blog posts, he denounces: “Childbirths take place with the help of the cleaning lady because there are no nurses or childcare assistants in public maternity wards .”
The lack of trained birth attendants not only affects the physical health of those who give birth and their babies, but also has serious psychological consequences. Lack of time and resources can lead to situations of psychological or physical violence that can have serious after-effects. According to Dr. Lahna, this situation in Morocco stems solely from a lack of political will. Recent figures show a form of shortage in the supply of care in Morocco in the public sector. In 2018, the country had 471 gynaecologists for a population of 36 million, including 17.67 million women, or one gynaecologist for every 37,516 women.
Resilience and behaviour change
Faced with these observations, several actors have mobilized to remedy the situation. This is notably the case of Dr. Lahna in Morocco, who has trained midwives, maieuticians, and obstetrician-gynaecologists. However, this militant will is not enough if the public authorities do not make available the necessary equipment and personnel to detect and deal with the various complications that may arise during childbirth. There is an urgent need for more aggressive advocacy with governments, both from civil society and medical associations, to move the issue forward on the political agenda.
At the same time, in response to requests for better psychological care for patients during childbirth, associations have begun to set up pre-natal preparation activities. This is notably the case of the association La Bulle des Mamans, founded by Dora Ladjimi in Tunisia, which is the “first structure in Tunisia to offer physical and psychological preparation workshops around maternity“. These actions allow people who are about to give birth to be better prepared and accompanied during their pregnancies in order to approach childbirth more serenely.
However, this type of structure raises an important question, that of the State’s responsibility in accompanying pregnant people through their care journey. Delegating this care to associations, whether national or international, does not necessarily lead to a lasting change in standards.
Sources Dr Kaouther Dimassi, very active member of the Birth and Parenthood Preparation Unit of the Mongi Slim Public Hospital (La Marsa, Tunisia)  We will use the definition provided by Marie-Hélène Lahaye in her book Accouchechement, les femmes méritent mieux, (2018): “the addition of two types of violence: institutional violence and gen
der-based violence”, characterized by “any behaviour, act, omission or abstention committed by health personnel, which is not medically justified and/or which is carried out without the free and informed consent of the pregnant woman or parturient”.  UN Women, Le progrès des femmes dans le monde 2019-2020 : les familles dans un monde en changement, 2019, available at : https://www.unwomen.org/-/media/headquarters/attachments/sections/library/publications/2019/progress-of-the-worlds-women-2019-2020-fr.pdf?la=fr&vs=2759  Human Rights Watch, « Maroc : Une nouvelle loi contre les violences faites aux femmes », 2018, available at: https://www.hrw.org/fr/news/2018/02/26/maroc-une-nouvelle-loi-contre-les-violences-faites-aux-femmes#  Ibid.  ROY Geneviève, « En lutte contre les violences obstétricales », Breizh Femmes, 2018, available at : http://breizhfemmes.fr/index.php/en-lutte-contre-les-violences-obstetricales  Ibid.  Obstetrician at the Bouskoura clinic in Morocco, and author of the blog “Chronique du Dr. Lahna”.  LAHNA Zouhair, « Chronique du Dr Lahna: Les violences obstétricales au Maroc », Yabiladi, 2019, available at : https://www.yabiladi.com/articles/details/76023/chronique-lahna-violences-obstetricales-maroc.html  Op cit.  ZERROUR Leila, « Carte sanitaire: les chiffres de la honte », Aujourd’hui le Maroc, 2018, available at: https://aujourdhui.ma/societe/carte-sanitaire-les-chiffres-de-la-honte  LesEco.ma, « HCP : Les femmes représentent plus de la moitié de la population en 2018 », 8 March 2019, available at : https://leseco.ma/hcp-les-femmes-representent-plus-de-la-moitie-de-la-population-en-2018/  LAKHOUA Emna, « Les super mamans tunisiennes: Dora Ladjimi, fondatrice de La Bulle des Mamans », Femmes de Tunisie, 2018, Available at: https://femmesdetunisie.com/les-super-mamans-tunisiennes-4-dorra-ladjimi-fondatrice-de-la-bulle-des-mamans/
LAHNA Zouhair, «Chronique du Dr Lahna: Les violences obstétricales au Maroc », Yabiladi, 2019, available at: https://www.yabiladi.com/articles/details/76023/chronique-lahna-violences-obstetricales-maroc.html
LAHAYE Marie-Hélène, Accouchement, les femmes méritent mieux, 2018, Ed. Michalon, p.187
LAKHOUA Emna, « Les super mamans tunisiennes: Dora Ladjimi, fondatrice de La Bulle des Mamans », Femmes de Tunisie, 2018, Available at: https://femmesdetunisie.com/les-super-mamans-tunisiennes-4-dorra-ladjimi-fondatrice-de-la-bulle-des-mamans/
Human Rights Watch, « Maroc: Une nouvelle loi contre les violences faites aux femmes », 2018, available at: https://www.hrw.org/fr/news/2018/02/26/maroc-une-nouvelle-loi-contre-les-violences-faites-aux-femmes#
UN Women, Le progrès des femmes dans le monde 2019-2020 : les familles dans un monde en changement, 2019, available at: https://www.unwomen.org/-/media/headquarters/attachments/sections/library/publications/2019/progress-of-the-worlds-women-2019-2020-fr.pdf?la=fr&vs=2759
ROY Geneviève, « En lutte contre les violences obstétricales », Breizh Femmes, 2018, available at: http://breizhfemmes.fr/index.php/en-lutte-contre-les-violences-obstetricales
ZERROUR Leila, « Carte sanitaire: les chiffres de la honte », Aujourd’hui le Maroc, 2018, available at: https://aujourdhui.ma/societe/carte-sanitaire-les-chiffres-de-la-honte
To quote this article : Marion LUC et Noumidia BENDALI AHCENE, “”If men were giving birth, things would not happen in the same way ” – Rethinking the treatment of obstetric violence in the Maghreb”, 01.08.2020, Gender in Geopolitics Institute.