Respectful Maternity Care: Think Globally, Act Locally.

Think globally, act locally. With momentum building, nowhere is this axiom more relevant than in the context of Respectful Maternity Care (RMC). Recently, USAID, The White Ribbon Alliance, and The Health Policy Project published a brief called “Pulling Back the Curtain on Disrespect and Abuse: The Movement to Ensure Respectful Maternity Care[1]. The brief details the transformation of abuse and disrespect toward women in labor from an insidious, ill-defined problem to an internationally recognized priority among maternal health policy and program experts. Why the change? Poor progress toward the Millennium Development Goals’ skilled birth attendance targets has led to the realization that providers needed to be more than skilled to attract clients – they needed to be respectful. The architects of the RMC campaign made a conscious decision to frame the problem in a positive light and it has paid off: Stakeholders are more focused on creating solutions than being defensive.

warrenprofile
Nicole E. Warren, PhD, MPH, CNM, Assistant Professor, Johns Hopkins University School of Nursing

The fact is, the people who provide care to women are not inherently cruel or spiteful. They are, in most cases, motivated to help women and their newborns’ well-being. They are also often women, many of whom have experienced violence themselves and/or live in a society where that violence is normative. Recent evidence suggests that, globally, 35% of women have experienced either intimate partner violence or non-partner sexual violence[2]. Birth attendants may also be overworked, underpaid or not paid at all, or simply modeling what they learned during training.

My own experience working with rural auxiliary midwives in Mali illustrates how this cycle of violence can co-exist with kindness. To provide context, more than 60% of women surveyed in Mali believe they can be justifiably beaten for refusing sex or arguing with their spouse[3]. This suggests a norm around violence that may make behaviors abhorrent to some, seem normative. In our article, “Nègènègèn: Sweet talk, disrespect, and abuse among rural auxiliary midwives in Mali” [4], we describe how a group of mostly rural women, passionately serve as rural midwives yet describe common abusive and disrespectful practices against women. Our findings were consistent with the categories of abuse and disrespect first published by Bowser & Hill in 2010.

This struggle is possible only because dehumanization,
although a concrete historical fact, is not a given destiny but
the result of an unjust order that engenders violence in the oppressors,
which in turn dehumanizes the oppressed. (Freire, 2013, p. 44)

My life and practice as a midwife is based in the U.S. and has been since the RMC campaign gained steam. While the RMC campaign is rightly focused on where maternal mortality is highest – where not being with a skilled attendant can be the difference between life and death – it provided new language to describe what I had experienced in birth settings in the U.S. The campaign gave voice to what I had seen as a nurse and ultimately motivated me to pursue midwifery as a career. The unique brand of abuse and disrespect against women in labor in the U.S. is more subtle, and in some respects, more menacing. It can be disguised by hotel-like accommodations with flat screen televisions and concierge service. But look deeper: women are not allowed to walk after they have ruptured, and newborns are taken away moments after birth with no medical indication. Sometimes the disrespectful care is out of earshot, but it permeates the care nonetheless. In “The Ethics of Shift Report”[5], Rushton highlights how disrespectful, judgmental, and biased comments made to colleagues during routine shift reports have the power to interfere with quality care. The violence gets worse: women are manipulated into cesarean sections (a luxury our colleagues in low-income settings cannot afford), subjected to instrumental deliveries because of change of shift concerns, and ignored when they cry out in pain during procedures for which they have not been consented. Women with English as a second language are routinely denied access to adequate interpretive services. All of these examples have the potential to result in unnecessarily traumatic births for women.

But almost always, during the initial stage of the struggle, the
oppressed, instead of striving for liberation, tend themselves to become
oppressors, or “sub-oppressors.” (Freire, 2013, p. 45)

In the U.S. context we have managed to conceal just how many choices – choices in provider, birth location, even position of birth – have been taken away. Like some victims of date rape, mothers in this setting know they did not feel right, knew they felt shamed and aggressed, but they question themselves: this was supposed to be a safe context.  But someday when she describes what happened to a friend, her friend will say, “That was not right.” And the mother will straighten up a bit, and feel relieved, and repeat, “No, that was not right.” For some, the trauma has staying power and may impact their relationship with their baby, their body and future births. Stories like this are eloquently documented by “American Childbirth: Exposing the Silence”[6], a project by Cristen Pascucci and Lindsay Askins, who photographed and voiced stories from women who say they had a traumatic birth in cities across the U.S. As a nurse and midwife, their stories are agonizing to read. I think back and consider – was I a witness? Did I turn away because of concerns about hierarchies or a lack of confidence? I know there were times I fought to delay or defer interventions. Sometimes I won. Other times I made a fuss, but proceeded when the obligatory, slightest rationale was dutifully provided. Did I fight hard enough? Often enough?

The momentum is with us now to ensure respect and dignity during maternity care. The brief released this year should be a tool for every clinician, regardless of setting. Think globally, act locally. And ensure that others are held to the same standard. Obstetric providers of all kinds have initiated interventions without evidence and/or consent from women for centuries. Let this be the point where women voice what they want and need. Let this be the point where we finally, finally listen.

An easy place to start is at this website. Start a conversation. The White Ribbon Alliance has materials in English, French, Arabic, and Spanish that you can use with your colleagues today. Post a flyer. Leave a copy of the “Rights of Childbearing Women” in the staff bathroom. But do something.

To surmount the situation of oppression, people must first critically
recognize its causes, so that through transforming action they
can create a new situation, one which makes possible the pursuit of
a fuller humanity. But the struggle to be more fully human has
already begun in the authentic struggle to transform the situation.
Although the situation of oppression is a dehumanized and dehumanizing
totality affecting both the oppressors and those whom they
oppress, it is the latter who must, from their stifled humanity, wage
for both the struggle for a fuller humanity; the oppressor, who is
himself dehumanized because he dehumanizes others, is unable to
lead this struggle. (Freire, 2003, p. 47)

 

References:

Bowser D, Hill K. (2010). Exploring evidence for disrespect and abuse in facility-based childbirth. USAID TRAction Project, Harvard School of Public Health. Retrieved online from: http://www.tractionproject.org/sites/default/files/Respectful_Care_at_Birth_9-20-101_Final.pdf.

Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to MothersSM III: Pregnancy and Birth. New York: Childbirth Connection, May 2013.

[1] “Pulling Back the Curtain on Disrespect and Abuse: The Movement to Ensure Respectful Maternity Care”, (http://whiteribbonalliance.org/wp-content/uploads/2015/10/Pulling-back-the-curtain-on-d-and-a.pdf).

[2] World Health Organization. (2013). Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Retrieved online at http://apps.who.int/iris/bitstream/10665/85239/1/9789241564625_eng.pdf.

[3] United Nations. (2010). Violence against women. In The World’s Women 2010 (chapter 6). Retrieved online from http://www.un.org/esa/socdev/ageing/documents/egm/NeglectAbuseandViolenceofOlderWomen/Violence%20against%20women.pdf.

[4] Nègènègèn: Sweet talk, disrespect, and abuse among rural auxiliary midwives in Mali (http://www.sciencedirect.com/science/article/pii/S0266613815002028)

[5] “The Ethics of Shift Report” (Rushton, 2010; http://www.ncbi.nlm.nih.gov/pubmed/21045577 )

[6] “American Childbirth: Exposing the Silence”, a project by Cristen Pascucci and Lindsay Askins (http://www.exposingthesilenceproject.com/)

[7] Freire, P. (2005). Pedagogy of the Oppressed. 30th Anniversary Edition. (M.R. Ramos, Trans). The Continuum International Publishing Group Inc: New York.

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