Disrespect and Abuse During Maternity Care Keep Women From Seeking Facility Births
This post is part of the Maternal and Newborn Integration Blog Series, which shares themes of and reactions to the “Integration of Maternal and Newborn Health: In Pursuit of Quality” technical meeting.
Forward: In the following post, Dr. Agarwal speaks of an unfortunately common problem between health workers and mothers: disrespect and abuse. This problem and its solution—respectful maternity care—play a role not only in health outcomes for the mother, but for the baby as well. At the Integration of Maternal and Newborn Health technical meeting, Rima Jolivet and Jeff Smith reviewed research that showed emotional support during labor significantly decreases:
- The need for pain medication during labor
- The rate of prolonged labor, labor complications, episiotomies, caesarean sections, low apgar scores, lack of exclusive breastfeeding, and severe postpartum depression
- The risk of newborn sepsis
In addition, global experts identified key areas to address when implementing integration to improve health outcomes for both the mother and newborn. The themes included strengthening service delivery points, preventing “content-free contact,” and understanding context and health systems in order to implement integration.
Recognizing and addressing disrespect and abuse are essential for evaluating context and strengthening service delivery points to improve maternal health outcomes. Lastly, disrespect and abuse may prevent a woman from seeking skilled care, which means she and her newborn are both exposed to unskilled care, or no care at all.
Increasingly, worldwide, more women are delivering in facilities, where they have safer births with trained providers. And while this is good news, statistics on respectful maternity care (RMC) reveal that the care women receive at the facility is one of the biggest drivers—or obstacles—to the type of treatment they’ll choose.
According to Diana Bowser and Kathleen Hill, “examples of disrespect and abuse (D&A) include subtle humiliation of women, discrimination against certain sub-groups of women, overt humiliation, abandonment of care and physical and verbal abuse during childbirth.” The causes of D&A during maternity care can vary – beginning at the community level with a lack of engagement or financial barriers, and extending to individual providers, who may lack training or have personal biases. But the result is often tragically the same: too many women deliver at home and with untrained providers because they fear the D&A that may accompany a facility birth.
In some cases, policy makers, program managers, and care providers are unaware of the D&A that is experienced in their own settings or the settings for which they are responsible. In other cases, people entrusted with the care of women and their newborns may recognize a need for RMC, but may feel ill-equipped to address it.
In response to these needs, USAID’s flagship Maternal and Child Health Integrated Program (MCHIP) launched a Respectful Maternity Care Toolkit in 2013 to provide the necessary tools to these actors to begin implementing RMC in their area of work or influence. With these combined tools, users can help to change and develop attitudes within themselves and among their colleagues and other stakeholders in the care of women and their newborns – and, ultimately, reduce this underutilization of skilled birth care.
For providers, improving RMC can be as simple as addressing patients by name, using understandable language, and conducting examinations privately. It involves sympathy: looking for signs of anger, stress, fatigue and pain. To a fearful patient, it is critical to explain any actions being taken, and to provide reassurance.
But to truly remove D&A from all care, we must gain acceptance at the highest levels: among policymakers and program managers, clinicians, and other groups and institutions who affect the work done every day by providers on the ground. These stakeholders must hold providers accountable by establishing processes for registering complaints and effectively enforcing policies.
As Bowser and Hill point out, “A central factor at the core of addressing disrespectful care at birth is the unequal relationship between the skilled provider and the woman giving birth.” To even this playing field, medical personnel must be held responsible for D&A and even the most marginalized women—those who are illiterate or of an ethnic minority—must be able to assert their complaints without fear of redress.
As we continue marking the final days to the Millennium Development Goals, we know that MDG 5—improving maternal health—can only be met if more women choose safer, facility-based births. RMC is not a checklist, an intervention, or a dialogue that is spoken: it is an attitude that permeates each word, action, thought, and non-verbal communication involved in the care of women during pregnancy, childbirth, and the postnatal period. Let us ensure women receive this basic human dignity during one of the most vulnerable times in their lives.