Respectful Care During Childbirth

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Landscape Analysis: Exploring Evidence for Disrespect and Abuse in Facility-Based Childbirth

Introduction

Throughout the world, women are humiliated and abused in subtle and overt ways during childbirth, a time of intense vulnerability. While the world has focused on overcoming financial and geographic obstacles to connecting women with lifesaving childbirth care, little attention has been paid to documenting and tackling the significant barriers posed by disrespect and abuse of women in facilities.

There is increasing evidence for the negative impact of disrespectful care on skilled birth care utilization in a range of countries, including recent qualitative and quantitative studies that suggest disrespectful care may often act as a more powerful deterrent to skilled birth care utilization than other more commonly recognized deterrents such as geographic or financial obstacles.

Disrespectful and abusive maternal care represents distinct points along a continuum that spans dignified, patient-centered care, non-dignified care, and overtly abusive care. Non-dignified maternal care may manifest in a range of ways, including subtle humiliation, discrimination based on specific patient attributes, or overt humiliation. Likewise, abusive maternal care may manifest in a range of ways, including physical or sexual abuse, detention in facilities for failure to pay, or deliberate gross negligence.

Various approaches have been developed to address this problem, including quality improvement, stigma reduction, and accountability measures. Civil society organizations are also promoting human rights efforts and public interest litigation to raise awareness and hold governments accountable.

Background

In March 2010, the TRAction Project, in collaboration with the Center for Reproductive Rights, organized a meeting of stakeholders to review the problem of facility-based disrespect and abuse in childbirth. Participants at the meeting agreed on the importance of the problem and on the need for a review of the evidence around the causes and manifestations of facility-based disrespect and abuse in childbirth, including tested interventions to address the problem.

As a follow-up to the meeting, the TRAction Project commissioned a landscape analysis of the evidence, culminating in a formal landscape analysis titled, Exploring Evidence for Disrespect and Abuse in Facility-Based Childbirth. The report reviews the evidence for this issue and, based on the results, develops a framework that includes a definition of disrespect and abuse and its main contributors, and negative impact on skilled care utilization, a key indicator of Millenium Development Goal 5. Additionally, the report reviews interventions in the literature that might be tailored to ameliorate this problem.

The report defines seven categories of common disrespect and abuse in facility-based childbirth, including:

Physical abuse
Non-dignified care
Non-consented care
Non-confidential care
Discrimination
Abandonment of care
Detention in facilities

The report highlights a range of factors that contribute to disrespect and abuse in childbirth including:

Individuals and communities normalize disrespect and abuse during childbirth.
National laws and policies do not exist or are not enforced.
Leadership and governance for respect and non-abuse are lacking.
Standards of care and mechanisms for accountability are not available.
Providers demonstrate prejudices or are demoralized due to weaknesses in the health system.

In tandem with the landscape analysis, the TRAction Project has supported several activities to promote communication and shared learning around this topic, including an open satellite breakfast meeting at the June 2010 Women Deliver Conference, titled Do No Harm: Building Evidence and Action for Dignified, Non-Abusive Maternal Health, in which preliminary results of the landscape analysis were presented. In October 2010, Mary Ellen Stanton, Senior USAID Maternal Advisor, and Kathleen Hill, Senior Technical Advisor with the TRAction Project, gave a presentation on the topic at USAID's Mini-University at the George Washington University School of Public Health and Health Services.

TRAction Research

RFA Solicitation for Tackling Disrespect and Abuse in Facility-based Childbirth (MCH-2010-004)

An important theme highlighted in the landscape analysis is the relative lack of formal research on the topic and, specifically, the lack of impact studies of interventions implemented to address this problem in high-prevalence settings. Since the release of Exploring Evidence for Disrespect and Abuse in Facility-Based Childbirth, TRAction has awarded implementation research grants to the Population Council and Averting Maternal Death and Disability Program (AMDD), Mailman School of Public Health, Columbia University, to study the problem, including key manifestations and potential drivers, and to develop and implement interventions to reduce disrespect and abuse in facility-based childbirth.

Fact Sheet - Summary of Population Council’s Implementation Research on Tackling Disrespect and Abuse in Facility-based Childbirth in Kenya

Fact Sheet - AMDD, Columbia University’s Research on Tackling Disrespect and Abuse in Facility-based Childbirth in Tanzania

Resources

Reports

No More Needless Deaths: A call to action on human rights and maternal mortality
International Initiative on Maternal Mortality and Human Rights (IIMMHR) (2009)

At Risk: Rights Violations of HIV-positive Women in Kenyan Health Facilities
Center for Reproductive Rights (2008)

Broken Promises: Human Rights, Accountability, and Maternal Death in Nigeria
Center for Reproductive Rights and the Women Advocates Research and Documentation Centre (2008)

Failure to Deliver: Violations of Women's Human Rights in Kenyan Health Facilities
Center for Reproductive Rights (2007)

Testing Approaches for Increasing Skilled Care During Childbirth: Key Findings from Homabay and Migori Districts, Kenya
Family Care International (2007)

Care-Seeking During Pregnancy, Delivery, and the Postpartum Period: A Study in Homabay and Migori Districts, Kenya
Family Care International (2003)

Harmful medical practice and barriers women face when seeking reproductive health care in Ukraine: what we learned from service providers
(2003)

A Behavior Change Approach to Investigating Factors Influencing Women's Use of Skilled Care in Homa Bay District, Kenya
The CHANGE Project, Academy for Educational Development/The Manoff Group (2002)

Health Workers for Change: A Manual to Improve Quality of Care
World Health Organization, an informal publication (1995)

Articles

Facilitators and barriers in the humanization of childbirth practice in Japan
Behruzi: BMC Pregnancy & Childbirth (2010)

Women's Preferences for Place of Delivery in Rural Tanzania: A Population-Based Discrete Choice Experiment
M. E. Kruk, M. Paczkowski, G. Mbaruku, H. de Pinho, and S. Galea: Journal of Public Health (2009)

Safe motherhood and newborn health: FIGO projects and progress
A. Lalonde and A. C. Lee: International Journal of Gynecology & Obstetrics

Ecuador addresses cultural issues for pregnant women
S. C. Vivar: The Lancet (2007)

Using Accountability to Improve Reproductive Health Care
A. George: International Journal of Gynecology & Obstetrics (2003)

Quality of care in institutionalized deliveries: the paradox of the Dominican Republic
S. Miller et al: International Journal of Gynecology & Obstetrics (2003)

Human rights, constructive accountability and maternal mortality in the Dominican Republic: a commentary
L.P. Freedman: International Journal of Gynecology & Obstetrics (2003)

Violence against women in health-care institutions: an emerging problem
A.F.P.L. d'Oliviera et al: The Lancet (2002)

Humanization of Childbirth in Bolivia
D. Onuki: Midwifery Today—International Midwife (2002)

From 'culture of dehumanization of childbirth' to 'childbirth as a transformative experience': changes in five municipalities in north-east Brazil
C. Misagoa et al: International Journal of Gynecology & Obstetrics (2001)

An evaluation of Health Workers for Change in seven settings: a useful management and health system development tool
Onyango-Ouma, et al: Health Policy and Planning (2001)

Why Do Nurses Abuse Patients? Reflections from South African Obstetric Services
R. Jewkes, N. Abrahams, Z. Mvo: Social Science and Medicine (1998)

Presentations

Exploring the Evidence: Dignified, Non-Abusive Maternal Care
Diana Bowser
TRAction/Harvard School of Public Health
June 9, 2010

Promoting Evidence and Action for Respectful Care at Birth
Kathleen Hill, TRAction, URC-CHS
Mary Ellen Stanton, USAID
USAID Mini-University
George Washington University
October 8, 2010

Other Resources

Promoting Evidence and Action for Respectful Care at Birth (2010), a brochure describing the problem of abuse at birth and efforts to overcome them

Related Activities

TRAction Project staff members are active participants of the recently formed Leadership Action Committee for the Promotion of Respectful Care at Birth, led by the White Ribbon Alliance. The Leadership Action Committee is a multidisciplinary working group made up of members from the advocacy, human rights, research, and technical/clinical communities to develop strategies to address the problem of disrespect and abuse of women during facility-based childbirth.