“I have practiced medicine for 20 years and this is the first meeting I have attended that made me want to go back to work and apologize to all the women I have yelled at.”
This thoughtful comment, from a doctor attending a national stakeholders meeting on respectful maternity care (RMC) in Rwanda, was echoed by others in attendance. “We are teaching midwives to do good vaginal exams, but not to be kind!” said another participant.
These vibrant exchanges were part of a larger discussion on common types and causes of mistreatment during maternity care. During the November 2015 meeting—convened by the Rwandan Ministry of Health, Rwanda Gender Monitoring Office, USAID’s flagship Maternal and Child Survival Program (MCSP), and USAID/Rwanda—participants agreed that more work is needed to achieve high-quality care that is both safe and respectful.
In a second break-out session, participants discussed locally appropriate solutions for combating mistreatment and promoting RMC, acknowledging that multiple stakeholders, including representatives of government, civil society, facilities and professional associations, need to work together to ensure that women receive dignified care during childbirth.
And these issues are not unique to Rwanda.
A rights based approach to RMC may seem to be an obvious standard embraced by all stakeholders. However, in many countries, mistreatment is an all-too familiar experience for women who give birth in facilities.
The effects of mistreatment may ripple far beyond the individual woman who experiences verbal or physical abuse, neglect, humiliation or discrimination. One woman’s negative experience may be enough to dissuade her family, neighbors or friends from giving birth in a facility.
RMC is sometimes framed as a ‘soft issue’ without the same urgency as emergency obstetric services, but the consequences of mistreatment can be serious and far-reaching.
In many settings, fear of mistreatment has proved to be an important deterrent to seeking childbirth care in facilities. In many parts of the world, the percentage of women who give birth in facilities remains low, with mistreatment a known, important contributing factor. This includes Tanzania, where the rate of facility childbirth has stagnated at or below 51% for more than 20 years.
The global maternal mortality ratio has decreased 45% since 1990. Yet, it remains too high: about 830 women die every day from complications due to pregnancy and childbirth, most of which are preventable.
The newly launched Sustainable Development Goals call for a reduction in maternal deaths to less than 70 per 100,000 live births by 2030. To meet this target, there is growing momentum—led by organizations such as the World Health Organization (WHO)—to frame RMC as a universal right of all women and an essential component of quality care.
The WHO believes that “every woman has the right to the highest attainable standard of health, which includes the right to dignified, respectful health care.”
By including women’s experience of care in key international documents and strategies, the WHO is bringing mistreatment of women and RMC to the forefront as an urgent priority in global health care strategies. For example, their Quality of Care framework includes three domains relevant to women’s experience of care: effective and responsive communication; care provided with respect and dignity; and emotional support. Similarly, the WHO’s Ending Preventable Maternal Mortality (EPMM) strategy promotes a holistic, human rights-based approach to reproductive and maternal health.
It is within this global context that MCSP is collaborating with many global and country stakeholders to promote RMC as an essential component of high-quality, safe and person-centered maternal and newborn health care.
There is no one-size-fits-all approach when it comes to ensuring respectful childbirth care. MCSP works with country partners to identify and test solutions for preventing mistreatment and promoting RMC tailored to each country’s context. In Burma and Tanzania, for example, the Program is working with local partners to integrate RMC as a key component of in-service and pre-service education.
If students leave school into service delivery without witnessing first-hand the modeling of RMC, we know there will be little change.
However, when RMC and mistreatment are addressed throughout pre-service and in-service training, health care workers are more likely to value and adopt professional, caring behaviors, and to obtain the skills and knowledge to practice RMC.
As we approach International Day of Maternal Health and Rights on April 11th, consider that women’s health and rights are inextricably linked. With this recognition, we can accelerate progress toward eliminating preventable maternal deaths and upholding every woman’s right to dignity and respect during childbirth.