INTRODUCTION

A fundamental component of quality maternal and newborn care is access to care that is safe, inclusive and respectful, and enables women to have dignity and control.¹ Women and their families also need to feel included and engaged in order to optimize access to, and use of, available health services and facilities. However, this is not always what women experience – a lack of respectful maternity care is a key reason why many women do not choose to access health facilities for care during childbirth.^2,3

Respectful and inclusive maternity care is a human right, reflected in the Human Rights Council’s 2012 Technical guidance on the application of a human-rights-based approach to the implementation of policies and programs to reduce preventable maternal morbidity and mortality⁴ and the Universal Rights of Childbearing Women Charter from the White Ribbon Alliance.⁵ These documents highlight the need for an effective and functional health system in order to ensure equitable and dignified health care for all women. It is essential that health systems meet the needs of women equitably, and enable women to participate in decisions that affect their reproductive health and the health of their babies. The importance of valuing and supporting the health workforce is also recognized as a critical element to achieving these goals.

This chapter begins by describing what is meant by disrespectful care and outlines the key evidence to illustrate the magnitude of the problem. The importance of health systems and clinicians providing respectful maternity care is explained, followed by a list of strategic and practical actions. The World Health Organization (WHO) has recently released a recommendation on respectful maternity care during labor and childbirth⁶ and this is referenced throughout the chapter.

A 2014 systematic review of qualitative studies (qualitative evidence synthesis showed that a number of aspects of care that could be seen as disrespectful, abusive or neglectful impacted on women’s experiences and decisions.³ These included a lack of privacy in a facility, lack of supportive attendance during birth and being subjected an excessive number of intrusive vaginal examinations, which were described by women as uncomfortable and dehumanizing. A fear of being cut (either an episiotomy or cesarean section) were also barriers to women attending a facility for birth and contributed to women’s poor experiences of care. Women have described being shouted at, insulted and even physically abused during labor and birth, resulting in women avoiding health facilities (or advising others to avoid facilities) and giving birth at home or in their communities. Across a number of studies, women described healthcare providers who were rude, bossy, disrespectful, insulting, easily angered, having poor attitudes, and lacking compassion. Other women described situations where they were left alone during labor, gave birth in a facility without the presence of a healthcare provider, and denied any communication or information. The review highlighted the importance of addressing low-quality or disrespectful care at facilities, not just to reduce barriers to facility birth, but also to improve the overall experience of care for women and families.³

What is disrespectful care?

A landscape analysis undertaken in 2010 defined seven key areas of disrespect and abuse in childbirth as being: physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination based on specific patient attributes, abandonment of care, and detention in facilities.² Some instances of disrespect and abuse overlapped and fell into more than one area.

Subsequently, a 2015 mixed-methods systematic review of qualitative and quantitative evidence was conducted.⁷ This review included 65 studies from 34 countries on the experiences and perspectives of women and healthcare providers related to mistreatment during childbirth in facilities. From these studies, a comprehensive typology of the mistreatment of women during childbirth was developed (Table 1). The authors explain that “the first-order themes are identification criteria describing specific events or instances of mistreatment. The second- and third-order themes further classify these first-order themes into meaningful groups based on common attributes. The third-order themes are ordered from the level of interpersonal relations through the level of the health system.⁷

The terminology used to describe mistreatment of women during facility-based childbirth varies between settings, cultures and studies, including terms such as ‘disrespect and abuse’, ‘obstetric violence’ and ‘dehumanized care’ – terms that are to a large extent overlapping. Regardless of definitional differences, other country-specific studies have shown similar findings. For example, a 2017 review of quantitative and qualitative studies from Nigeria reported that poor and unfriendly staff attitudes were very common and contributed to women not accessing health facilities.⁸ Disrespectful behaviors were influenced by low socioeconomic status and lack of education of the women, limited training and supervision of the health workforce, dis-empowerment of women, weak health systems, lack of accountability and limited legal redress mechanisms. In Ethiopia, studies have shown approximately 20% of women experience some form of disrespect and abuse during facility-based childbirth.^9,10 However, variations in definitions and methods used to measure its occurrence complicate meaningful comparisons across settings.¹¹

In practice, disrespect and abuse may range from overt examples of physical abuse to more covert (and perhaps unintentional) acts. For example, more overt actions may include women being slapped by a healthcare provider during labor, or being forcibly detained in hospital because of unpaid fees. More subtle actions may include being left alone during labor, being reprimanded, experiencing interventions without the provision of information, consent or shared decision-making and a lack of privacy.⁷ Research has shown that in some cases, providers may use physical abuse (the ‘obstetric slap’) with the intention of helping the woman, or to encourage her to push.¹² However, there are no known benefits of this approach.

Many health workers have described witnessing or performing disrespectful behaviors in their clinical practice. For example, one study from Ethiopia showed that at least half of staff reported not gaining consent before procedures, one-quarter had witnessed physical abuse of women while in labor in their health facility (e.g. using physical force, slapping or hitting), one-third reported privacy violations and almost one-fifth had detained women against their will.¹³ Interestingly, despite recognizing these elements of disrespect and abuse, the majority of health staff believed that a lack of respectful care discouraged women from coming to a health facility to give birth. A high workload and poor working environment probably contributed to the low-quality and disrespectful care.¹³ It is also known that social, cultural, economic and professional barriers can limit the ability of midwives to provide quality care in low- and middle-income countries,¹⁴ and likely contributes to the occurrence of disrespectful care.

Disrespectful and non-inclusive care is not confined to low- and middle-income countries. There are documented examples of these negative care experiences in high-income countries, though they are possibly less overt. Women in countries such as Australia have reported feeling coerced and threatened into complying with procedures, especially with fears or threats related to the well-being of the baby.¹⁵ A small study from Denmark showed that some women experienced abuse that could be classified as neglect or verbal abuse and left them feeling de-humanized.¹⁶

Why is respectful maternity care important?

Respectful and inclusive care is a key element of the provision of quality maternity care.¹⁷ Women who feel safe, supported, respected and able to participate in shared decision-making are likely to have more positive childbirth experiences.

It is important to note that respectful maternity care is not merely the absence of mistreatment.¹⁸ Women value being provided with care that is respectful, inclusive and of good quality. A 2018 qualitative evidence synthesis (that included 67 studies from 32 countries) showed that women appreciate care that respects their culture, values and beliefs. Healthcare providers also recognize that respectful care is an important part of the provision of safe, good-quality care, even if they were not always able to provide it owing to resource or workload constraints. What women value as the most important aspects of good-quality, respectful care may vary across settings – for example, women in high-income countries seem to place a high value on shared decision-making and being an active participant in care.¹⁹

How can maternity care be inclusive and respectful?

The qualitative evidence synthesis described above identified 12 key domains of respectful maternity care.¹⁹ These domains show that the institution, as well as the individuals providing care, play a significant role in meeting women’s expectations of respectful and inclusive care (Box 1).

Maternity care must be inclusive, respectful and provide the care that women want and need. A 2018 systematic review on what matters to women in intrapartum care identified five studies (all conducted in Africa) suggesting that the use of policies to promote respectful maternity care in hospitals meant women were more likely to report their care as being of good quality, be satisfied with their care and less likely to experience incidents of mistreatment, abusive or non-dignified care.²⁰ These respectful maternity care (RMC) interventions included: staff training in values and attitude transformation; training in interpersonal communication skills; setting up quality improvement teams; monitoring of disrespect and abuse; staff mentorship; improving privacy in wards (providing curtains or partitions between beds); improving staff conditions (e.g. providing tea for those on shift); maternity open days; community workshops; mediation/alternative dispute resolution; counseling of community members who have experienced disrespect and abuse; providing a method for submitting complaints; educating women on their rights; and companionship during labor and childbirth.²⁰

Recommendations and actions

World Health Organization recent recommendations on intrapartum care for a positive childbirth experience have a specific recommendation on the provision of respectful care. The recommendation states that:

Respectful maternity care – which refers to care organized for and provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labor and childbirth – is recommended.⁶

Over 90 global organizations, including the International Federation of Gynecology and Obstetrics (FIGO) and the International Confederation of Midwives (ICM), have endorsed a statement from WHO calling on governments, healthcare institutions and healthcare providers to prevent and eliminate disrespect and abuse during facility-based childbirth. The vision is to ensure that 'every woman has the right to the highest attainable standard of health, which includes the right to dignified, respectful health care'.²¹ A series of actions to achieve this vision have been articulated in the WHO statement (Box 2).

One of the additional challenges towards achieving respectful and inclusive maternity care is when mistreatment of women during childbirth may have become the norm. For example, studies have now shown that some healthcare staff see mistreatment during labor and birth as being acceptable, usual and necessary to gain compliance from the woman and result in a healthy baby¹² and, for some women, mistreatment is just a reality of giving birth in a health facility.²² Therefore, a process of change that labels, challenges and makes such behaviors unacceptable is critical, and must be acceptable to women, their families, healthcare providers and researchers.²³ This will develop or enhance the enabling environment that is needed to enable healthcare providers to bring about change.

It is also important to care for the caregivers, including midwives, nurses, doctors and other healthcare workers. Addressing the need for quality education, training and regulation, having a supportive environment with appropriate supervision, ensuring workers have fair and reasonable remuneration and working hours, reducing social isolation and low status are all important.¹⁴ Health workers need to be respected and valued by the health system and colleagues for the work they do. If health workers feel undervalued, underpaid, overworked and unsupported, they will not be able to provide kind, respectful, inclusive and quality care.¹⁸ The promotion of gender and health equity are fundamental to efforts to provide respectful and inclusive maternity care.

The WHO recommendation on respectful care during labor and birth highlights the importance of local adaptation and implementation through a participatory, consensus-based approach. It is important that local adaptation is influenced by global norms and standards so that the adaptation process does not normalize existing abusive behavior because it is “the way things are done here”. Adaptation should be best approached as part of broader efforts or initiatives to measure and improve the quality of maternal and newborn care.¹⁷ Effective implementation needs to include considerations at health policy, organizational and systems levels; as well as community engagement and sensitization. These activities also target changing the social or institutional norms about disrespect and reframing quality health care as essential for all women to receive. Box 3 reproduces these considerations.

CONCLUSION

Quality maternal and newborn care requires more than just access to interventions, drugs and commodities.²⁴ A fundamental component of quality care is respectful and inclusive care – care that is clinically safe but, importantly, feels emotionally and psychologically safe to the woman and her family. This means that care must include respect, community knowledge and values, be tailored to womens’needs; and importantly must be provided by health workers who can combine clinical knowledge and skills with interpersonal and cultural competence.¹ Respecful maternity care encompasses all these elements and more and needs to be a fundamental element of all maternity care provision in every country.

PRACTICE RECOMMENDATIONS