October 16, 2015

Pulling back the curtain on disrespect and abuse

Written by Mary Beth Hasting, Consultant, White Ribbon Alliance


This blog is an excerpt from the recently published White Ribbon Policy Brief. Visit the Respectful Maternity Care page for more information and materials on this subject.

The global drive to improve maternal health has made striking progress in recent decades, vastly expanding women’s access to skilled providers during childbirth 
in most countries around the world. However, evidence about widespread disrespect and abuse of women and girls by health care workers during labor and childbirth lays bare the yawning gaps that persist between the stark realities many women and girls experience daily, and articulated human rights ideals and maternal health standards of care. To close these gaps, a rapidly-growing, multisectoral movement of providers, maternal health implementers, global institutions, and human rights advocates has advanced policy and programmatic support for respectful maternity care (RMC).

The movement for RMC has advanced rapidly in 
the past five years, culminating in significant recent successes. In 2014, the leading authority on global health standards – the World Health Organization (WHO) – has called for increased action at the global and national level to stem abuses of women in maternity care.That same year, the Lancet called for a “shift in perspective” to assess maternal health services based on “what women need and want in pregnancy and childbirth.”Perhaps most notably given the importance of ownership by and engagement of medical professionals, the International Federation of Gynecology and Obstetrics (FIGO) in July 2014 approved guidelines for “mother-baby friendly birthing facilities.” These guidelines affirm women’s “right to be treated with dignity and respect,” and call for protections from “unnecessary interventions, practices, and procedures that are not evidence-based, and any practices that are not respectful of their culture, bodily integrity, and dignity.”

Transecting human rights, gender equality, gender-based violence, quality of care, and reproductive, maternal, newborn, and child health (RMNCH), the RMC movement has captured the attention of key and diverse stakeholders at the global, national, and local levels. As a result, the movement has facilitated common understanding of disrespect and abuse in childbirth, set global targets for respectful care, and developed appropriate interventions to address the individual and structural drivers of disrespect and abuse.

As global leaders look more critically at how to simultaneously advance women’s health and rights, particularly in light of the Sustainable Development Goals, it is important to examine where the momentum for respectful maternity care has led thus far, lessons learned in the process, and essential components that must be prioritized moving forward. The following policy recommendations for advancing maternity care that places women at the center 
are informed by program documents, global and national policies, and interviews with key stakeholders who have worked for years to advance attention to this issue.

Program Recommendations

Disrespect and abuse (D&A) must be addressed at multiple levels because responsibility for D&A is broadly shared. D&A is generated by power dynamics between provider and patient, under-resourcing of the health sector, gender inequality, discrimination, and poor training. Successful responses must cross sectors, including legal cases, social accountability, provider values clarification training, health systems strengthening, and grassroots education to empower women as rights bearers.

Approaches to reducing D&A must be contextual and involve women. In developing responses to D&A, it is critical to keep women in the center. Women should be involved in the definition of their needs and preferences in maternity care, as well as in setting up systems to facilitate their ongoing feedback and participation. Interventions must be specific to their location, and elements that are transferable can only be adapted from one place to another with women’s active involvement.

Process is important. The visibility of RMC has increased interest in rapidly developing and implementing responses. However, it is important to ensure that the process builds participation of and support from all stakeholders, including providers, health officials, community leaders, and women themselves. Project designers should examine their assumptions and be quite careful that projects do not inadvertently cause harm. Because RMC is a fresh field, poorly implemented projects risk not only localized setbacks, but can cause a loss of political or donor interest in other RMC interventions.

RMC needs better definition and indicators. RMC 
is not simply the absence of D&A, yet its definition remains elusive. Program implementers should seek to define indicators that pinpoint what successful RMC interventions look like.

Isolated trainings are not the solution. As discussed above, the sources of D&A are at multiple levels.

Interventions should address as many levels as possible, avoiding quick fixes that lack sustainability.

Policy Recommendations

RMC should be a global maternal health priority.
The universality of the Sustainable Development
 Goals (SDGs) meshes well with the universality of RMC principles, posing an important opportunity
to consolidate global progress on RMC. Global and national leaders should ensure that commitments
to RMC are woven into their health strategies to achieve the SDGs, building on evidence of RMC’s contributions to maternal health and human rights. Civil society organizations also have an opportunity with the SDGs to insist on integrating RMC into public and private sector approaches to maternal health.

RMC is a legitimate and important aspect of quality maternal health care. The WHO vision of quality care affirms RMC’s legitimacy as an essential aspect of quality of care. Global and national leaders should incorporate this broader definition of quality of care into health policies, and ensure their measurement of success incorporates respect, protection, and fulfillment of human rights in the health care setting.

RMC is at a critical juncture; needs increased investment to ensure implementation. As a relatively new intervention area, RMC requires adequate resources to test approaches and expand its scope. Policy commitments are not sufficient without support for policy implementation, participatory accountability systems, and programming. Donors and national governments should commit sufficient funds to make RMC an integral part of maternal health programs.

Ongoing advocacy is critical to sustainability, but cannot happen without funding. Donors interested in maternal health, sexual and reproductive rights, and quality of care should invest in global and grassroots advocacy, as well as implementation, to ensure RMC’s success. Advocacy isn’t only important for creating policy change. It is important for monitoring, sustaining, and deepening progress.

Women’s voices must be central to policies that advance respectful care. Policies to promote respectful care – and the advocacy movements that advance these policies
– must be guided by women and grassroots women’s organizations to ensure legitimacy and effectiveness. Women do not have one set of ideas and preferences for childbirth, yet meaningful consultation with a range of groups, particularly those representing marginalized women, is essential to shaping policies that recognize and respect a diversity of views and needs. The RMC advocacy movement must continue to develop ownership of the movement by women themselves to ensure that their needs and preferences are prioritized.

Integration with other global health movements can feed success. D&A is strongly linked to human rights and quality of care failures within other health sectors. For example, young, unmarried, or otherwise marginalized women are more likely to experience D&A, particularly from providers of sexual and reproductive health services. The RMC movement is strong enough to position itself within a continuum of care model with an understanding of the intersectionality of discrimination, helping shape a positive and fully inclusive vision of respectful care throughout the lifecycle. By linking with gender-based violence, HIV, sexual and reproductive health, and adolescent health movements, RMC advocates can improve their understanding of the drivers of D&A, use this understanding to improve RMC outcomes, and incorporate a more powerful analysis of rights-based health.

Photo: “Changing lives: Ante and post natal care for mums and babies in Orissa” © 2011 Pippa Ranger/Department for International Development, used under a Creative Commons Attribution license: http://creativecommons.org/licenses/by/2.0/