Disrespect and Abuse of Women in Facility Childbirth Services: Deeply Political and Deeply Personal

By: Kathleen Hill, M.D., Senior QI Advisor, USAID Health Care Improvement and TRAction Projects, University Research Co., LLC

My first visit to the world of childbirth--apart from my own delivery by a midwife in Nigeria--came over 20 years ago when as a young adult I worked for 2 years with midwives in a district hospital and rural health center in Niger. I immediately understood the numbing vulnerability of childbearing women and their providers in a setting without reliable electricity, transportation or basic elements for safe childbirth. I worked alongside deeply respectful and attentive providers and also providers who regularly humiliated and occasionally neglected laboring women, sometimes even as they were dying. The faces of many of these women stay with me today.

Five years later as a medical student and resident I witnessed the same reality in U.S. hospitals (minus the heart-wrenching lack of basic health system capacity). I worked alongside kind and gentle midwives and obstetricians and also unkind and sometimes abusive providers who bullied and trampled on the tender needs of their laboring patients for reassurance, control and dignity. Later as my professional responsibility for patients increased, I recognized in my most honest moments that my own capacity for kindness went up and down in relation to the shifting manageability of my workload. During long shifts when I was unable to eat, sit down or sleep, I was far less kind than on days when I was rested, not hungry and knew, gratefully, that I could rise to the challenge of being the kind and competent provider I wanted to be for every patient.

Twenty years later when I was asked to co-author a review of the evidence on disrespect and abuse in facility-based child-birth as a staff member on the USAID-funded Translating Research into Action (TRAction) project managed by University Research Co., LLC., I approached the task with some uneasiness. I knew first-hand from my years working on global maternal health and part-time as a practicing family physician, that this was a complex topic without quick and easy solutions.

The literature review presents evidence from over 32 countries across five regions. It describes a range of disrespect and abuse that we organize into seven categories: physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination, abandonment, and detention in facilities. These categories line up with the essential human rights upheld in the charter of the Universal Rights of Childbearing Women.

In addition to the literature review, our interviews and discussions with many stakeholders showed us this is a topic that resonates deeply and on many levels with maternal health stakeholders across the globe. From my perspective those of us who are concerned about non-dignified maternal care must answer two central questions: why does disrespect and abuse happen so frequently in childbirth across the globe, and what can we do to break the cycle?

The results of the literature review offer some possible answers. Power imbalances, rooted in larger societal inequities, which permit staff to abuse the powerful positions they hold in relation to women at the vulnerable moment of childbirth are probably central to non-dignified maternity care in most settings. Also probably important are: health system shortages that burn out providers (especially in low-resource settings); provider training that shapes disrespectful behavior; lack of community entitlement, engagement and oversight of health care; and lack of political commitment to putting in place mechanisms that hold staff accountable to respecting patient dignity and rights 100% of the time. It is likely that the specific kinds of disrespect and abuse and the main drivers vary depending on the context.

Some promising strategies for tackling disrespect and abuse are covered in the evidence review, but few have been formally tested. In a world of limited resources, finding solutions that are effective and can be reliably repeated requires commitment to continued research. We need more studies that show us what kinds of disrespect and abuse are happening, how frequently, and what drives them and we must be willing to test and evaluate effectiveness of a range of creative and sometimes bold interventions.

Some encouraging initiatives to promote respectful maternal care include:

The Humanization of Childbirth Movement in Latin America that has spurred huge public attention raised awareness, and brought advocacy and innovative service delivery approaches.
The Respectful Maternal Care Charter developed collaboratively with multi-sector partners convened by the WRA that lays out clearly and unequivocally the minimum universal rights for every woman who gives birth
Ongoing implementation research that measures key manifestations of disrespect and abuse in facility-based childbirth in two local settings and tests and evaluates interventions to reduce the problem
The International Initiative on Maternal Mortality and Human Rights
The efforts of local champions worldwide, including patients, providers, managers, lawyers, human rights activists and politicians.
The many partner and country initiatives to tackle this problem via research, policy, legal, accountability, human rights, health system strengthening, quality improvement, behavior change, and community engagement approaches.