Beyond human rights and ethics

Rima Jolivet, Maternal Health Technical Director, Maternal Health Task Force, noted that disrespect and abuse (D&A) of women during facility-based childbirth has different manifestations and drivers; thus, context-specific measurement and intervention are crucial. According to Jolivet, “The absence of disrespect and abuse is not the same thing as respectful maternity care.” Jolivet explained that the effects of D&A extend beyond human rights and ethics:

“Disrespect and abuse of women during childbirth is important fundamentally as a human rights issue and an ethical issue—but also, concretely, in terms of implications for maternal health outcomes, women who experience disrespect and abuse during childbirth are less likely to deliver in a facility in a subsequent pregnancy or to seek facility-based care in the future.”

The concept of RMC encompasses women’s experiences along the continuum of care, including antenatal care, previous birth experiences and any stigma or discrimination faced along the way.

The importance of clear communication

Rose Molina, obstetrician/gynecologist at Beth Israel Deaconess Center and research fellow at Ariadne Labs, explained how her team adapted the World Health Organization Safe Childbirth Checklist to include principles of RMC in Chiapas, Mexico. Calling attention to communication and women-centered care, the team modified the checklist to allow women to choose their position during delivery and have a companion of choice. Molina shed light on the importance of clear communication among health providers and women regarding the process and plan of care:

“Many women reported that they did not understand what happened during their delivery because it was never explained to them…Many women were unsure whether they required an episiotomy or whether they had a laceration during delivery. This is an important distinction as we work to reduce the number of non-indicated episiotomies and alleviate the fear women have of requiring an episiotomy after their first delivery.”

Addressing fear

Saraswathi Vedam, Principal Investigator, Birth Place Lab, and Associate Professor, Division of Midwifery, Faculty of Medicine, University of British Columbia, discussed the process of developing patient-centered measures of RMC. Approximately 95% of respondents involved in the participatory research for the Mother’s Autonomy in Decision-Making scale (MADM) said that it was very important or important that they lead the decision about pregnancy, birth and newborn care. Vedam noted disparities in autonomy based on race and socioeconomic status. She stressed the importance of expanding respectful communication and shared decision-making into health professional education programs to allay fears and improve outcomes:

“Fear of neglect, fear of being alone or abandoned, fear of the unknown, fear of trauma—all of those things actually lead to failure to seek or accept care.”

Improving knowledge of rights and attitudes among both providers and clients

David Sando, PhD Student in Global Health and Population Science at the Harvard T.H. Chan School of Public Health, explored the issues of D&A and RMC in Tanzania, stating that “Numerous studies have shown that disrespect and abuse is a major contributor to low facility delivery and poor pregnancy outcomes.”

According to Sando’s baseline research in Tanzania, during interviews conducted three to six hours after delivery, 15% of women reported experiencing at least one occurrence of D&A. During community follow-up interviews held four to six weeks later, however, more than 70% of women reported an instance of D&A. To address limited knowledge of rights among both providers and clients, the research team conducted two interventions, an RMC workshop and Open Birth Days program, which contributed to fewer reports of disrespect and abuse at endline. Sando emphasized that making progress towards RMC is possible—even in low-resource settings:

“Even in constrained health systems, results show that changing attitudes and behaviors can effect significant change, but all disrespect and abuse cannot be addressed without structural and systemic changes.”

Respecting women and their choices

Katherine Semrau, BetterBirth Program Director, Ariadne Labs, summarized key takeaways from the webinar, including:

“Implementing respectful maternity care practices requires recognizing individual needs and desires of women and what their choices are around the time of labor and delivery.”

This blog was cross-posted from the MHTF blog.