From Rights-Based Advocacy to Maternal Health Outcomes
The health system is responsible for poor maternity care
Women’s health is affected by how they are treated during pregnancy, childbirth and after. South African women, for example, have described verbal abuse, including being ridiculed while pleading for assistance or pain relief, and being berated for “messing up” when they bled on the floor during labour. Many are later forced to clean up their own blood, the report states. “It’s become so normal some nurses don’t understand why it’s a problem to slap or shout at women in labour,” says Odhiambo. “Some say it’s necessary to get patients to follow directions, and it’s for their own good.” Health providers, especially midwives, nurses and obstetricians are held responsible for this situation, but in fact, it is the whole health system that allows the abuse and lack of care to take place.
It is up to leaders, managers and communities to work together to improve quality of care and bring respect into maternity care.
Health providers and women need knowledge and their rights protected
Both health providers and women need to understand and recognise risk factors during pregnancy and childbirth, and there has to be a functioning health system in existence so that women can reach the right care at the right time. This means that health care providers must listen to women, be respectful of their opinions about their own bodies, and have the skills and knowledge to diagnose effectively. They also need to be connected with other parts of the health service.
Women and their families have a role to play. In low resource settings, women’s lives can be saved if they know about maternal dangers signs, have the power to make decisions about their health, and can communicate with health providers.
Community engagement is an important part of developing respectful maternity care
A DFID-funded programme in Northern Nigeria has shown that maternal and newborn mortality can be reduced by combining improvements in the health facility, including the training of health providers, with volunteer-led community engagement. This consists of volunteers leading dialogue with the whole community to increase the level of knowledge of reproductive health, maternal dangers signs, nutrition and immunisation among other maternal and child health issues.
This Community Engagement (CE) programme includes a volunteer-led emergency transport scheme (ETS); a blood donor group; an emergency savings scheme; a facility health committee; and young women’s support groups, which promote experience sharing and learning. Improved communication with health providers has transformed overall relationships between the health facility and the community – and women are now reporting that they are treated well by health providers. As one ETS driver in Katsina mentioned “It was because of the sudden change by the health workers in terms of their attitude and behaviour. They are no longer shouting at our women, when they discovered that women need some kind of advice, they sit them down and give them the necessary advice they require.”
A man interviewed in another community emphasised the success of new relationships: “Before the commencement of CE activities there was no functional health facility committee but with presence of health committee and their hard work, the attitude, the behaviour and the general conduct of the health workers has changed. People in the community are now participating in the services rendered by the health facility.”
Midwives and women health providers need more support
Many women still choose to deliver at home because there is a lack skilled female birth attendants at the health facility. Lack of female midwives in Northern Nigeria is a longstanding problem. Another DFID programme, Women for Health, has been addressing this issue by improving and accrediting midwifery training colleges and encouraging girls to choose midwifery as a health career. Lack of personnel in busy health facilities increases the stress of health workers and their likelihood of mistreating or neglecting women who are giving birth. Female health workers are often mistreated themselves within the health system and the gender norms of a country are played out at every level – often leaving women in the least powerful positions.
Health system policies, such as birthing position, can also increase women’s reluctance to deliver in the health facility. Health providers should encourage women to give birth in the way they find most comfortable – and they need support within the health system and from supervisors for this to happen. Sexual and reproductive health services are essential for saving women’s lives In relation to sexual and reproductive health – it is a reality that women all over the world would like to use contraception but can’t due to lack of supplies, no trained providers or inadequate methods. Global unmet need for contraception is about 12%, and as high as 50% in some countries.
Midwives and health providers in primary health facilities have a key role in counselling and providing family planning or child spacing services – and this also is a way of protecting and supporting women’s rights. Adolescents are particularly stigmatised for using family planning services and are often treated badly at health facilities, which puts them off using the service. Unintended pregnancy and unsafe abortion can therefore result, causing further risks to young women’s lives. Sexual and reproductive health services are an essential part of saving women’s lives.
Respectful maternity care can be achieved if the whole health service and communities are involved in the transformation.
Women and men need knowledge and need to be empowered to provide feedback to health services and hold them to account. Midwives and primary healthcare providers can’t make the transformation on their own. Not only do they need the skills and resources and status within the system to provide good quality and respectful services; but they also need sexual and reproductive health knowledge and supplies, especially contraceptives, to fully protect and enhance women’s rights. To make a difference, women and health providers need to have maternal health knowledge, the power to make decisions, and systems that protect their rights.
This post was originally posted by the White Ribbon Alliance.
To promote the WHO’s consensus statement, ”Prevention and elimination of disrespect and abuse during childbirth”, follow #EndDisrespect and contact Natalie Ramm at nramm@hsph.harvard.edu for a copy of our social media toolkit.