Achieving Inclusive and Respectful Maternity Care | Article

This chapter should be cited as follows:
Homer CS, Bohren MA, et al, Glob. libr. women's med.,
ISSN: 1756-2228; DOI 10.3843/GLOWM.411763

The Continuous Textbook of Women’s Medicine Series – Obstetrics Module

Volume 3

Elements of professional care and support before, during and after pregnancy

Volume Editor: Professor Vicki Flenady, The University of Queensland, Australia

Chapter

Achieving Inclusive and Respectful Maternity Care

First published: February 2021

AUTHORS

Caroline SE Homer, RM, PhD

Co-Program Director, Maternal and Child Health, Burnet Institute, Melbourne, Australia

Meghan A Bohren, PhD, MSPH

Lecturer, Gender and Women’s Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Australia

Alyce Wilson, MD, MPH

Public Health Registrar, Global Maternal and Newborn Health, Burnet Institute, Melbourne, Australia

Joshua P Vogel, MBBS, PhD

Co-Working Group Head, Global Maternal and Newborn Health, Burnet Institute, Melbourne, Australia

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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

Typology of the mistreatment of women during childbirth.⁷

Third-order themes	Second-order themes	First-order themes
Physical abuse	Use of force Physical restraint	Women beaten, slapped, kicked, or pinched during labor and birth Women physically restrained to the bed or gagged during labor and birth
Sexual abuse	Sexual abuse	Sexual abuse or rape
Verbal abuse	Harsh language Threats and blaming	Harsh or rude language Judgmental or accusatory comments Threats of withholding treatment or poor outcomes Blaming for poor outcomes
Stigma and discrimination	Discrimination based on sociodemographic characteristics Discrimination based on medical conditions	Discrimination based on ethnicity, race or religion Discrimination based on age Discrimination based on socioeconomic status Discrimination based on HIV status
Failure to meet professional standards of care	Lack of informed consent and confidentiality Physical examinations and procedures Neglect and abandonment	Lack of informed consent process Breaches of confidentiality Painful vaginal exams Refusal to provide pain relief Performance of unconsented surgical operations Neglect, abandonment, or long delays Skilled attendant absent at time of labor and birth
Poor rapport between women and providers	Ineffective communication Lack of supportive care Loss of autonomy	Poor communication Dismissal of women’s concerns Language and interpretation issues Poor staff attitudes Lack of supportive care from health workers Denial or lack of birth companions Women treated as passive participants during childbirth Denial of food, fluids, or mobility Lack of respect for women’s preferred birth positions Denial of safe traditional practices Objectification of women Detainment in facilities
Health system conditions and constraints	Lack of resources Lack of policies Facility culture	Physical condition of facilities Staffing constraints Staffing shortages Supply constraints Lack of privacy Lack of redress Bribery and extortion Unclear fee structures Unreasonable requests of women by health workers

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).

Box 1 Twelve domains of respectful maternity care¹⁹

Being free from harm and mistreatment
Maintaining privacy and confidentiality
Preserving women’s dignity
Prospective provision of information and seeking informed consent
Ensuring continuous access to family and community support
Enhancing quality of physical environment and resources
Providing equitable maternity care
Engaging with effective communication
Respecting women’s choices that strengthens their capabilities to give birth
Availability of competent and motivated human resources
Provision of efficient and effective care
Continuity of care

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).

Box 2 Actions to prevent and eliminate disrespect and abuse during facility-based childbirth²¹

In order to prevent and eliminate disrespect and abuse during facility-based childbirth globally, the following actions should be taken:

Greater support from governments and development partners for research and action on disrespect and abuse
Initiate, support and sustain programs designed to improve the quality of maternal health care, with a strong focus on respectful care as an essential component of quality care
Emphasizing the rights of women to dignified, respectful health care throughout pregnancy and childbirth
Generating data related to respectful and disrespectful care practices, systems of accountability and meaningful professional support are required
Involve all stakeholders, including women, in efforts to improve quality of care and eliminate disrespectful and abusive practices

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.

Box 3 Implementing respectful care policies and actions – health policy considerations⁶

A firm government commitment to increasing coverage of maternity care for all pregnant women giving birth in healthcare facilities is needed, irrespective of social, economic, ethnic, racial or other factors. National support must be secured for the whole package of recommendations, not just for specific components.
To set the policy agenda, to secure broad anchoring and to ensure progress in policy formulation and decision-making, representatives of training facilities and professional societies should be included in participatory processes at all stages.
To facilitate negotiations and planning, situation-specific information on the expected impact of the new intrapartum care model on service users, providers and costs should be compiled and disseminated.
To be able to adequately ensure access for all women to quality maternity care, in the context of universal health coverage (UHC), strategies for raising public funding for health care will need revision. In low-income countries, donors could play a significant role in scaling up implementation.

Organizational or health-system level considerations

Long-term planning is needed for resource generation and budget allocation to address the shortage of skilled midwives, to improve facility infrastructure and referral pathways, and to strengthen and sustain good-quality maternity services.
Introduction of the model should involve training institutions and professional bodies so that preservice and in-service training curricula can be updated as quickly and smoothly as possible.
Standardized labor monitoring tools, including a revised partograph, will need to be developed to ensure that all healthcare providers (1) understand the key concepts around what constitutes normal and abnormal labor and labor progress, and the appropriate support required, and (2) apply the standardized tools.
The national Essential Medicines Lists will need to be updated (e.g. to include medicines to be available for pain relief during labor).
Development or revision of national guidelines and/or facility-based protocols based on the WHO intrapartum care model is needed. For healthcare facilities without availability of cesarean section, context- or situation-specific guidance will need to be developed (e.g. taking into account travel time to the higher-level facility) to ensure timely and appropriate referral and transfer to a higher level of care if intrapartum complications develop.
Good-quality supervision, communication and transport links between primary and higher-level facilities need to be established to ensure that referral pathways are efficient.
Strategies will need to be devised to improve supply chain management according to local requirements, such as developing protocols for obtaining and maintaining stock of supplies.
Consideration should be given to care provision at alternative maternity care facilities (e.g. on-site midwife-led birthing units) to facilitate the WHO intrapartum care model and reduce exposure of healthy pregnant women to unnecessary interventions prevalent in higher-level facilities.
Behavior change strategies aimed at healthcare providers and other stakeholders could be required in settings where non-evidence-based intrapartum care practices are entrenched.
Successful implementation strategies should be documented and shared as examples of best practice for other implementers.

User-level considerations

Community-level sensitization activities should be undertaken to disseminate information about:

Respectful maternity care (RMC) as a fundamental human right of pregnant women and babies in facilities
Facility-based practices that lead to improvements in women’s childbirth experience (e.g. RMC, labor and birth companionship, effective communication, choice of birth position, choice of pain relief method)
Unnecessary birth practices that are not recommended for healthy pregnant women and that are no longer practised in facilities (e.g. liberal use of episiotomy, fundal pressure, routine amniotomy

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

Every pregnant women deserves consistent access to skilled routine and emergency care in a safe, respectful and affordable manner.
Health facilities must offer women privacy through use of curtains or partitions and allow her to choose her own support person.
All women deserve to receive care before, during and after pregnancy that is free from physical, verbal and sexual abuse and any form of discrimination.
Women have the right to be informed and communicated with regarding the care of themselves and their babies.
Women’s capabilities to give birth are strengthened when they are part of the decision making process and their choices are respected.
Maternity health staff need to be value and respected, and provided with adequate support, mentorship and training, in addition to working conditions which enable them to provide respectful and inclusive care.

CONFLICTS OF INTEREST

Author(s) statement awaited.

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RELEVANT CURRENT AND APPROPRIATE GUIDELINES/STATEMENTS/POLICIES OF PROFESSIONAL ASSOCIATIONS

FIGO’s guidelines on developing mother–baby friendly birthing facilities: https://www.whiteribbonalliance.org/wp-content/uploads/2017/11/MBFBF-guidelines.pdf.
WHO. Prevention and elimination of disrespect and abuse during childbirth. Available at: https://www.who.int/reproductivehealth/topics/maternal_perinatal/statement-childbirth-programs/en/.
International Confederation of Midwives. Position Statement Midwives, Women and Human Rights. Available from: https://www.internationalmidwives.org/assets/files/statement-files/2018/04/eng-midwives-women-and-human-rights1.pdf.
International Confederation of Midwives. Core Document Bill of Rights for Women and Midwives. Available from: https://www.internationalmidwives.org/assets/files/general-files/2019/01/cd2011_002-v2017-eng-bill_of_rights-2.pdf.

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