Health system accountability in South Africa

Violence against women during childbirth and obstetric malpractice are common globally. A central factor in these injustices is gender discrimination, which results in inequalities in power. This is ‘obstetric structural violence’ and there are three key factors that generate and sustain this: social norms, political-economic arrangements , and health systems and their policies . This chapter investigates health system accountability in South Africa, and draws from primary and secondary data on the distribution and functioning of health governance, obstetric malpractice case law, settlements, and a legislative response. The analysis evidences a relationship between obstetric violence, maternal mortality, and neo-natal disability. Further, despite legislated community oversight, power remains concentrated within an institutional hierarchy. The structure of health systems undermines the authority of healthcare professionals and enforces complacency, tolerance, and the normalisation of violence against women. Obstetric-related negligence case law shows that such law suits have little bearing on accountability and have little impact on improvements to the quality of care. Rather, direct acts are invisibilised by the way they feature as evidence in the litigation. Thus, the main conclusion is the functioning of health system accountability mechanisms, legal claims, and several examples of Ministerial leadership encourages the tolerance of direct and structural obstetric violence in several overlapping and reinforcing ways.