“I have been suffering from hospital phobia for six years, and I do not like to talk about what happened to me, and I pray to God that I never have children again.” This is how the young woman, “Maryam Omar”, who is not more than twenty years old, expresses the suffering of her birth and her story with the debilitating obstetric violence she suffered and caused her psychological and physical crisis and painful material losses 6 years ago.
Maryam is one of the female victims of obstetric violence in Hadramout governorate in eastern Yemen, which many Yemeni women suffer from due to the deterioration of health services, weak oversight over health workers and facilities, and weak implementation of laws that end this behavior that women are exposed to during childbirth. Lamaze International defines obstetric violence as any physical, sexual or verbal abuse, bullying, coercion, humiliation or abuse that occurs to women during the delivery process by medical staff, including nurses, doctors and midwives, and includes exposure of a woman during labor or delivery for abuse and lack of respect for her rights, including being forced to take action against her will at the hands of medical personnel.

“Four out of five women have been subjected to obstetric violence. The results of the electronic questionnaire that was filled out indicate that 4 out of 5 women were subjected to obstetric violence in Hadramout governorate the coast, the valley and the eastern regions.”

Double Pain
Maryam Omar (a pseudonym), who is 27 years old, relates that since the fifth month, the doctor supervising her condition told her that the fetus was breech (the position of the feet below and the head on top) and that her birth required a caesarean section. Maryam says: “In February 2015, I entered a government hospital, when I was 21 years old. The midwife told me I am able to give a normal delivery and no need for a caesarean. Six hours passed and I was trying to push for a natural birth with all my might, but this effort was in vain. It was the longest six hours of my life, God’s kindness was present.”

Deadly Predicament!
Maryam continues her painful story: “They cut the perineum, without informing me, and it didn’t help. Only the toes appeared from my fetus, at that time the situation was like a fatal predicament. A long time passed and my strength fell and my soul was exhausted. I could see the confusion and fear on their faces. The midwife called the doctor who tried for a long time to no avail! She decided for me a caesarean section screaming, “the fetus will die”. I was quickly transferred, and I refused to be transferred by a wheelchair to the second floor of the operating room, and I was walking with a fetal toes hanging from me. I was afraid of losing him and losing my life. My father and husband carried me on their shoulders, and when I was in difficult labor, I would pass out repeatedly and fall to the ground.
After giving birth, I suffered from urinary retention for 21 whole days. I used to suffer double pain from the suturing wounds caused by cutting the perineum area, suturing the caesarean section, and urinary retention pain. I was recommending my family and my husband for my child. I went back to the doctor who gave birth to me to find answers. She did not sympathize with me, and said angrily, “Urine retention! Take her to a urologist. Do not bring her to me”, and I left with sever pains that only God knows. The urologist told me that the urinary retention was caused by a piece of medical gauze that was forgotten inside me”

Exhausted Childhood
Maryam continues, “My baby also went through prolonged labor and forced labor. He lacked oxygen and swallowed polluted water from my womb. His leg hanging from me was bluish-black. He underwent long sessions of physiotherapy and massage.” Maryam added, “My husband filed a complaint with the hospital director, but he told him that this doctor is excellent and that I am the first case of this kind and that he cannot do without her in the department, and he used to say, “Your child and wife are fine, so thank God they are both alive”.
Dr. Hana Bakour, a specialist in obstetrics and gynecology in the city of Mukalla, stresses that a breech child has certain conditions to allow natural childbirth, and it must be carried out by an experienced doctor. This must be decided by a specialized doctor, not a midwife. The mother is supposed to be transferred to the operating room immediately, even without going to the obstetric emergency. Dr. Hana adds, “Always in the case of a breech fetus, cesarean delivery remains safe to preserve the mother and her fetus.”

Endless Suffering
“I still suffer from the consequences of urethral obstruction, kidney health problems and urinary tract infections. My husband lost nearly 5 million Yemeni riyals,” says Maryam. About the psychological impact on her from this experience, she says, “I could not bear to carry my child. I hated him so much. It was severe depression, and I did not feel myself, and I always got sick with or without a reason. Until now I still suffer from phobia of hospitals and needles, and I have panic attacks, and I suffered from problems in sexual relationship from rejection of the relationship to vaginal spasms, which caused me an emotional separation between me and my husband, and I hate the idea of pregnancy and childbirth.”
This state of fear is called tokophobia among psychologists, and it leads women to avoid pregnancy by all means.

Return of Depression and the Recurrence of the Experience of Obstetric Violence Again
Maryam continues to recount her suffering and her second exposure to another obstetric violence, “Three years later, I got pregnant for the second time. Depression returned to me, and the idea of suicide came to me a lot. I used to call my mother daily to consult her about an abortion and go into a fit of hysterical crying,” Maryam adds, “I became literally insane, six years passed and nothing ever erased this pain. In my second pregnancy, I also experienced obstetric violence, this time from a nurse. I gave birth to my second child by caesarean section in a government hospital as well. I went back to check after the caesarean section. The nurse pulled the operation string. I told her it’s only been four days since I had my caesarean section. The nurse was surprised. After that, I called my doctor who delivered me by caesarean section, and she went crazy, “who allowed the nurse to pull the thread” she categorically refuses to deal with that hospital because they are neglectful, but out of respect for my financial conditions, she performed the operation there.” Maryam continues, “The doctor told me that I must lay on my back for two whole months and never moved, even my baby I was breastfeeding him on my back. I didn’t even go to the bathroom, I was using elderly diapers. I was bedridden and had sad, dreary days. I hope I never get pregnant again, this doctor complained against the nurse. The hospital director pledged to dismiss her, and I do not know whether she was dismissed or not.”
Midwife Azhar Mohsen, 30, who has been working in midwifery for 13 years, stresses: “There is more obstetric violence practiced by female doctors and nurses than by the midwife herself.”
The result of the electronic questionnaire that was published indicates that 34.2% of women who filled out the questionnaire were subjected to obstetric violence at the hands of a nurse, while 31.6% were exposed to obstetric violence at the hands of a midwife at hospital, and 32.9% were subjected to obstetric violence at the hands of a female doctor, while 1, 3% were subjected to obstetric violence at the hands of a midwife at home.

The Forgotten Gauze Script
Sarah Mohsen, 25, from the Mukalla city, recounts her tragedy, saying: “In January 2015, I entered a government hospital in Mukalla for my third birth after I was discharged from the hospital. I had a bad smell and interrupted urine. I felt something would come out of me. I found that it was the tip of a piece of medical gauze that started to rot inside. I pulled it out and I thought it was the only one. Then it took me a while until I found three pieces of medical gauze.” She adds, “This contaminated thing has been in my body for whole days and has started to decompose, and thank God I did not have more complications.” She asserts that she did not file any complaint about what happened to her at all, saying, “I do not want to cause any problems for others”

Absence of Complaint
During my preparation for this investigation and through listening to a large number of cases, I found that a large percentage of women who have been exposed to obstetric violence and its complications believe that what they have been subjected to is destiny. They do not want to create problems and complaints, and often they are ignorant that they have the right to file a complaint, while the biggest problem is that they don’t know where to complain.
Ms. Alia Al-Hamid, director of legal affairs at the Yemeni Women’s Union, Hadramout branch, which was established by a decision of the Prime Minister and concerned with women and their defense, indicates that they do not have any statistics on obstetric violence and that women and their families believe that they are not able to file a complaint.
The results of the survey indicate that 88.9% of those who have experienced obstetric violence did not file a complaint despite their suffering.

Non-Recognition of Obstetric Violence!
In this investigation, we met the midwife Maram Hassan (pseudonym), who works in the obstetrics department in a government hospital and a private one in the city of Mukalla. She states that she has been working for 15 years and that there is no so-called “obstetric violence,” and that the matter is exaggerated. She added that what happens in the delivery rooms is nothing but help and encouragement for the mother to make the correct delivery, as the mother often wastes time screaming and crying hysterically, and the child is in a dangerous stage, and the mother enters the stage of surrender and waste of time talking and arguing with the medical staff. She sees this reprimand and screaming for the benefit of the mother and her fetus.
Samiha confirms that her newborn’s navel remained swollen in a very worrying way. He was constantly in pain, and his tests indicated that there was bacteria that moved to his stomach. She said that the doctor when she did the tests and checked her condition, she deplored the situation and almost lost her temper, and began to wonder nervously, “What is this neglect?” We asked her about the problem, and she told us that a non-sterile instrument had been used in the process of cutting the umbilical cord, and she began to blame and reprimand, thinking that I had given birth at home. Samiha added, “My mother told her that the birth took place in the same hospital.” The doctor then said, ” you and your child ok!” Regarding the effects, Samiha says, “My son still suffers from the consequences of this matter to this day, and I still cry heartily every time I remember what happened.” Samiha refused to continue the remaining dialogue, and closed the topic by saying: “I never want to talk about it!”
The percentage of women who have been subjected to obstetric violence is higher in the city of Mukalla than in other regions; it reached 6.67% of the total questionnaires because the city is the center of three governorates, Shabwa, Al-Mahra and Hadramout, where there are two of the largest governmental maternity and childhood hospitals. The number of births in one government hospital only during the past year alone amounted to approximately 4,645 natural births and 1,667 caesarean births.
The results of the electronic questionnaire that was published say that about 48 out of 60 women who filled out the questionnaire were subjected to verbal violence, neglect and being left to struggle with labor pains alone. Midwife Maram points out that the lack of staff in the delivery room makes mothers feel neglected and abandoned. It is difficult to have three midwives who can cover 15 deliveries in the delivery room, and she points out that the hospital administration also practices other violence on the midwife, so the latter transfers this violence to the delivery room.
Most of the midwives whom I interviewed in preparing this investigation stress that it is not necessary to ask the permission of the mother regarding perineal cutting, and she does not have the right to refuse because this procedure is in her best interest and that they give her notice only, and this does not always happen.

Domestic Obstetric Violence
Alia Saleh (pseudonym) (26 years old), from the city of Ash Shihr, is also telling us her story while being subjected to obstetric violence. She says: “In the ninth month, the doctor told me that the size of my fetus is very large, which means giving birth in the hospital and under medical care, so that intervention can be made in the event of an emergency. Economic conditions forced me to give birth at home, and I could not afford to give birth in a hospital. In October 2018, the fetus’s water (amniotic fluid) started coming out, so they brought me a midwife at home who was old and sick. It was my first delivery, so I was ignorant and naive. The payment did not work due to the large size of the fetus. She forced me to try again and again but to no avail. She decided on her own to sit on my chest with her face on my stomach and then repeatedly and forcefully pushed her hands on my stomach in an attempt to push the fetus out. I was ruptured internally due to the strong push, and also the size of the fetus needed surgical intervention. My son came out and did not make any sound or movement. The midwife hid it from me thinking he was dead. After which I could not sit, stand or walk for days on end. My mom told me that all women feel this way after giving birth. When I insisted it wasn’t normal and the pain didn’t go away with time, they called the same midwife again. She did not advise me to go to the hospital. She told me hesitantly and in a low voice so no one could hear her, “you were ruptured”. Then I decided to visit a gynecologist and she told me that I had severe internal ruptured. She told me that she could not do anything now; and that if I attended the first days, it might work. Currently, I suffer from the consequences of this in my sexual relationship with my husband, and sometimes he tells me that I need genital reconstructive surgery.” In her speech, Alia mentions that society needs to raise awareness, and that traditional or home-based midwives need more qualification and training.
Many of the women I interviewed in the process of producing this investigation say that they were subjected to excessive pressure on the abdomen using the forearms or using (the elbows) during childbirth.
Obstetrician and gynecologist Hana Bakour mentions that these are wrong practices, and they have not been scientifically proven. They are habits inherited from generation to another, and have nothing to do with obstetrics. Doctor Bakour adds, “the complications of this matter are many and dangerous, and whoever performs this procedure will be punished.”
In the electronic questionnaire that was published in connection with the production of this investigation, a sample of 60 women was filled out. The percentage of those who were exposed to obstetric violence in hospitals and health centers of the Ministry of Health and Population was 90%, and the percentage of those who were exposed to obstetric violence in private hospitals, private health centers and at home was 10%.

Torn Womb!
During the investigation, we met Nada Talib, a 31-year-old , from Daw’an in the valley of Hadramout, in the other half of the governorate. She tells what happened to her saying: “In my third childbirth, September 2010, I had entered to government hospital in one of the villages of the villages of Dawn. The fetus was very large which impossible with natural birth. The doctor revealed and told me that it was normal and I could normal birth. Three hours passed and I as trying to push in vain. ”
Nada adds: “The doctor cut the perineum without returning to me. After birth, the area was stitched quickly and randomly. Few minutes have passed until I suffered from a terrifying bleeding, very large blood pieces. I was lying on my back and the bleeding reached to my back and neck, it dripped on both sides of the bed. She asked me, “are these large pieces of blood coming from your?”. Then she inserted her hand and tore off all the stitches she had made in the perineum area. I was crying and shouting, it was a terrifying situation. She said, “Enough! No problem! I will take out your womb and sew it then return it to its place! Just shut up! ” The doctor was of a foreign nationality, and she was alone with me in the delivery room without an assistant or midwife or surgeon. Nada continues, “When she was stitching up the wound, my stomach swollen very much, and the bleeding did not stop. She repaired the uterus and left the perineum suture scattered open. She asked me to get off the bed and the bleeding was still going on. Then another doctor came in, when he saw what I am, he reprimanded her and stated that what happened was a disaster.” Nada continued, “a doctor put big ice cubes on my stomach. I lost consciousness and no longer felt anything around me. After about two hours, I opened my eyes, the ice still on my stomach. I went home and when I arrived a large piece of blood came out of me. I didn’t know if blood froze from the snow or something else. It had been two months since I couldn’t sit or stand. I was suffering from dizziness and loss of consciousness for a long time. My body was swollen for nearly two months, I still suffer from ulcers of the uterus and I suffer repeatedly from infections and prolapse of the uterus.” Nada continues, saying “I did not think about the complaint, and I did not know that I had the right to do so.”
Doctor Amira Abdullah (pseudonym) said, “This situation occurs when the fetus is violently pulled by the doctor or midwife, causing uterine outflow or explosion, or causes the weakness of muscles to control the urination process. Whoever commits it will be judged, because there is no room for more than a medical opinion ”
Obstetric violence in the valley of Hadramout is repeated by the other seal of Hadramout because of the ignorance of people there, because of the lack of cadres and poor health system. It’s also because of the proliferation of early marriage and low education, as well as women do not favor talking about what happened to them and tend to say it’s just destiny, in addition to the culture of the shame. During the preparation of this investigation, I contacted a number of women who had been subjected to obstetric violence in any hospital of the valley, but the majority did not approve the participation even though under aliases.
According to the electronic questionnaire, the proportion of the obstetric violence in the Valley of Hadramout was approximately 20% of the total questionnaires.

Reticence and Absence of Complaint
The lawyer Etab Al-Amoudi, advocate before the courts of the second instance in Mukalla, said “women are just talking in women gatherings about what happened to them, there is no kind of claim; and that secrecy is the biggest reason for the increase in cases. Therefore, women are declining to complete the complaint to the difficulty of proof of what happened when they are in the rooms of the delivery.

Getting Rid of the Rest of Memories!
During our investigation, in all ways have tried to obtain medical documents for each of the cases we have heard, but they have destroyed their papers. Women believe that these medical papers are futile, while the majority of them do so trying to forget what happened.

Administrative Punishment and The Complainant is Free
Mr. Salem Kenid, Director General of the Office of Legal Affairs at the Ministry of Health and Population in Hadramout, said, “The governorate does not have an office for the Yemeni Medical Council. The complainant is free to submit his complaint to the party he wants a public prosecution, the same hospital in which the mistake occurred, or the health office, which in turn forms a specialized committee according to the area in which the mistake occurred and then takes administrative action. The absence of an office for the medical council in the governorate, in addition to three other governorates, Shabwa, Socotra and Al-Mahra, multiplies the negative effects.” He added, “We have not received any complaints related to obstetric violence.”
Lawyer Ahed Al-Kasadi, Director of the Department of Legal Affairs at the Motherhood and Children’s Hospital in Mukalla, said “the majority of problems and mistakes are resolved technically without being referred to the competent authorities. In rare cases, only the administrative penalty is sufficient”
During my preparation for this investigation, I contacted the technical affairs of the largest government hospitals specialized in maternity and childhood to ask about the complaints about obstetric violence, but there was no response.

Legal Legislation
There are legal articles in the Yemeni Constitution and Internal Disciplinary Regulations of the Yemeni Medical Council of the Ministry of Health and Population on Obstetric Violence. Article 24 of Act 28 for 2000 and Internal Disciplinary Regulations of the Medical Council stipulate that if this violence amounts to a medical mistake, it is subject to evaluation by the medical council’s committees, and as a result, the appropriate disciplinary action is determined.
Article 22 of the Regulation of Medical Profession provides that the patient’s approval or guardian shall be obtained prior to medical intervention. Despite the existence of this article, most of the cases we listened to which confirm that the medical intervention took place by cutting the perineum without the consent of them or their guardian’s. Article 36 of the same law also provides on criminal accountability for any perpetrator of an act that considered as a crime and for compensation for those who have suffered harm. The law also stipulates in Article 24 of it that the Yemeni Medical Council has the right to take one of the disciplinary penalties that amount to withdrawing the licenses to practice the profession or a financial fine and imprisonment for those against whom it is proven to harm patients due to negligence and unjustified medical errors and failure to preserve the rights of patients to receive integrated health care.
The majority of cases of obstetric violence mentioned in this investigation were exposed to legal and ethical violations in dealing with women during childbirth, unlike what article 19 of the Medical Organization Act provides. Dealing with the obstetric violence as a normal matter on a continuous basis that leads to the recurrence and doubling of forms of obstetric violence and its danger to the life of the pregnant mother and her fetus. The concerned authorities should perform their supervisory role, correct errors, compensate the affected cases, create a safe environment for childbirth from staff and services, and hold accountable all those responsible for these issues in accordance with the what the law, the constitution, the internal regulations of the Medical Council, the Law Regulating Medical Professions and the Law of Crimes and Penalties have legislated. There also should be recommendations to civil and social bodies concerned with women, children and reproductive health to work on increasing the comprehensive awareness of women and all organizations towards this issue to preserve the mother and her fetus.