The Power of Listening, Not Just Counting

By: Kate Ramsey, Columbia University AMDD

Last week, a report of a horrifying incident in a maternity ward appeared in my email inbox. A woman was beaten by a health provider as she died on the floor while delivering in a health facility. When it happened was anyone listening? Did anyone hear her crying out? We are listening now and most likely a response is being planned, but for this woman it is too late. Her cries have been silenced. She is only one woman, but one is too many.

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For the last five years I have been working closely with colleagues in Tanzania at Ifakara Health Institute and in Korogwe District to measure, explore and respond to disrespect and abuse experienced by women delivering in health facilities. In our research, we have found that women do want to be heard. Some women may not be ready or may not want to demand a voice at the highest platform, but they do want maternity providers to listen in their one-on-one interactions. They want them to listen and hear what is happening in their lives and consider their knowledge of their bodies credible and legitimate. They want to feel that their words have power and their experience matters. And through listening, care can gradually transform to better meet their expectations. Woman can begin to feel that they are being treated as a human rather than an aggregate collective.

But maternity providers also resoundingly expressed a desire to be heard, for health system managers to listen to their expectations and experiences. They want them to understand that daily, they face women’s disappointment and sometimes untimely death due to health system dysfunctions. They are the people who must manage women’s expectations when practice does not and cannot yet meet policy promises. They also want the community to hear what is in their power to change and what are the health system constraints that they also need to cope with daily.

How can we make sure we’re listening to women and providers – their fears, expectations, needs and experiences? The new maternal and newborn health quality of care framework from WHO squarely places women’s experience of care as equally important to the clinical provision of care. In addition, the growing movement for respectful maternity care has acknowledged the need to care for both women and maternity providers. These provide important opportunities to listen to women and providers about what quality means to them. And while we pursue measures that will enable us to quantify women’s experience at population level, we need to listen carefully. Listening will ensure that we can develop measures that are meaningful to women and providers.

In public health, there is no doubt that counting matters for planning at systems level, for understanding whether we’re making progress at the population level, and for identifying which groups are being left behind. But sometimes we need to stop and listen in our programs and our evaluations. Giving voice is not just about hearing and responding, it’s also about giving people power over the services and programs that affect their daily lives.