The Power of the Pregnancy and Substance Use Toolkit in Ending Obstetric Violence

As a lecturer at the Division of Clinical Associates at the University of Witwatersrand, I am reminded daily that the heart of nursing is advocacy—advocacy for science, for public health, and, most crucially, for the lived experiences and dignity of those we serve. This responsibility is nowhere more urgent than in maternity care for women on the margins.  

Their encounters with the healthcare system are shaped not just by clinical need but by social stigma, discrimination, and, far too often, profound harm. I support the use of the Pregnancy and Substance Use Toolkit as an integral part of nurse education, because this is more than a matter of professional development—it is a moral and public health necessity influencing real outcomes for mothers and their children.
 
In November 2022, Obstetric violence was formally acknowledged at the Presidential Summit on Gender-Based Violence and Femicide as a distinct form of gender-based violence. Obstetric violence manifests as neglect, verbal and physical abuse, non-consensual procedures, and overt discrimination. The Commission for Gender Equality’s 2022 report, which exposed the forced or coerced sterilisation of nearly fifty women living with HIV and AIDS in public healthcare, made this reality impossible to ignore. These cases are not only assaults on bodies but ongoing violations of dignity.
 
Why does obstetric violence continue? The reasons are complex but rooted in the system. Many clinics are understaffed. Professionals are overburdened. Most importantly, there is a lack of training in trauma-informed and addiction-informed care. Cultural norms sometimes redefine abusive behaviour as “discipline” or “motivation.” Nurses, when insufficiently educated on these nuances, are not equipped to challenge the blaming, shaming, or dehumanising narratives—especially when aimed at women already stigmatised by poverty, substance use, or exclusion.
 
For women, the impact is devastating. The emotional trauma can trigger anxiety and postnatal depression. Many survivors of abuse or indignity during childbirth delay future antenatal care, raising the risk of complications. This dynamic erodes already fragile trust in the health system, particularly for vulnerable groups, making every clinical encounter a source of apprehension. For newborns, the damage often results in low birth weight, preterm delivery, and poor mother-infant bonding. These are not inevitable outcomes; they reflect failures to truly centre women’s experiences, as well as the absence of adequate training—both of which we have the power to address.

Rebecca Coetzee is a Registered nurse and lecturer in the Division of Clinical Associates at Wits University

​It is in this context that the Pregnancy and Substance Use Toolkit stands out as an effective resource for eradicating the effects of obstetric violence. This toolkit results from direct collaboration with pregnant women who use substances and invested healthcare professionals. Developed under the stewardship of Julie Mac Donnell and validated by bodies like the National Harm Reduction Coalition and the Academy of Perinatal Harm Reduction, this toolkit responds to real-world needs. It is rooted in evidence and frames care around empathy, patient rights, and harm reduction—an approach vital for areas lacking sufficient substance use supports.
 
The toolkit’s design is particularly worth noting. It contains six integrated sections: Know Your Rights, Harm Reduction and Substance Use, Navigating the Healthcare and Legal Systems, Prenatal Care, Labour and Childbirth, and Postpartum Care. Each section closely follows the route to motherhood faced by pregnant people who use substances. The first sections empower mothers with knowledge of their human rights and legal protections, ensuring they have the tools to advocate for themselves. The next sections offer evidence-based medical guidance on the effects of substance use, clarify associated risks, and support informed choices. Practical strategies for prenatal care are provided, guiding access to services and preparation for labour and childbirth in ways that prioritise dignity and autonomy. Postpartum Care not only deals with newborn immunisations but critically addresses postpartum depression, recognising the psychological needs of new mothers. Together, these components provide a holistic roadmap, nurturing agency and respect at every stage.
 
Significantly, nurses are the most consistent point of contact during maternity care. Their attitude and expertise often shape whether a woman’s birth experience is one of empowerment or trauma. Investing in nurse education is key. It enables early recognition of risks, builds trust, and—most importantly—disrupts cycles of silence, violence, and mistrust. Nurses equipped with the Pregnancy and Substance Use Toolkit are empowered to see addiction through a clinical lens, not as a moral failing. They become champions for safety and dignity for both mother and baby.
 
Treating women with dignity in childbirth is not just about delivering babies—it is about delivering justice. Every encounter between a nurse and a patient is an opportunity to restore what harm has stolen: safety, trust, and self-worth. The introduction of the Pregnancy and Substance Use Toolkit gives us a concrete means to make this restoration possible, offering nurses the training, perspective, and practical resources necessary to support and empower even the most marginalized mothers.