Respectful Maternity Care includes protection from verbal and physical abuse, disrespect and discrimination during care. It allows a woman to make informed choices about her pregnancy and delivery.
By Dr Evita Fernandez
After travelling miles to reach the local hospital, tired and nine months pregnant, she awaits the joy of motherhood. But first, she is greeted with filthy toilets, an indifferent staff and a stone-cold floor where she lies, clutching her belly and crying out in pain. Later, when asked how she felt about being a mother, she says that she is grateful her baby is physically healthy, but is emotionally devastated by her birthing experience.
This is the story of many women who face disrespect and abuse during delivery in many countries. In India, instances of such misconduct exist both in public as well as private hospitals. It is not unusual to find long queues of pregnant women waiting for a health check-up outside of government facilities and being ordered to stand in line by security staff wielding sticks in their hands. This harsh treatment, which begins during pregnancy, continues into the labour room.
Women’s memories of disrespect during birth last a lifetime. These memories instill fear and lead to distrust in the health care system. And evidence shows that, across countries with highest maternal deaths, respectful care during labour and birth is a key determinant of whether pregnant women will seek professional help or even consider another pregnancy. Overall, negative attitudes and behaviours of maternal health care providers undermines well-being and health outcomes.
One approach to this problem, Respectful Maternity Care, includes protection from verbal and physical abuse, disrespect and discrimination during care. It also encompasses giving a woman the right and complete information to make informed choices about her pregnancy and delivery. The woman in labour is therefore empowered to remain mobile and upright and is free to give birth in the position of her choice.
Natural births, when possible, are an important component of respectful care because they minimise the risks associated with surgeries like a Caesarean section (C-section) including infection, haemorrhage and risks with anaesthesia. Natural births make it easier to establish skin-to-skin contact with the child and establish early breastfeeding. However, it is good to remember that even with a C-section a woman can enjoy skin-to-skin care and early breastfeeding, a practice we encourage in our hospitals.
Another important approach to improving quality, respectful care during pregnancy and delivery is midwifery. Over the last 10 years, I have committed myself to advocating for increased use of midwives, including by training many midwives to make pregnancy safe for women and babies. Midwives are an important cadre in many countries and help to humanise the experience of birthing for women. But in India, there is no formal structure to train them and bring them into the health system. Midwifery presents a tremendous opportunity for India and resources need to be allocated to further developing this area.
Respectful Maternity Care is not a skill that one has to be trained to acquire. However, it calls for a change in attitude and an openness to being sensitised to the issue. While several interventions aim to improve access to skilled care around labour and birth, the aspects of respect, dignity, privacy and confidentiality were never traditionally considered important quality indicators.
Through government programs like Janani Suraksha Yojana (JSY)and Janani Shishu Suraksha Karyakram (JSSK), the government has increased the volume of institutional deliveries by about 40 percentage points in recent years. However, improvements in infrastructure and human resources (skilled professionals) have not been commensurate with the increase in patient volume. As a result, we have a workforce that is exhausted and stretched beyond human capacity. In such an environment, mothers are subjected to a greater degree of abuse and rude behaviour by a weary and overburdened health care staff. The government must scale up skilled human resource in labour rooms to meet the increasing demand of institutional births.
Fortunately, with the launch of LaQshya, a Labour Room Quality Improvement Initiative, India is now acknowledging and promoting the concept of birth companionship, a key component of Respectful Maternity Care. In an innovative move aimed at reducing maternal and child mortality, the government has taken a transformative decision to allow a companion of choice for all women in labour. The presence of a birth companion helps reduce the risk of disrespect and abuse in the birthing room. It is a tragedy that the majority of women in India, despite the government’s directive, continue to birth alone. No woman should birth alone. This too is a violation of her human rights in childbirth.
Undergraduate medical education must include teaching students about Respectful Maternity Care and why kindness and compassion are important in the birthing process. Teaching young minds the essence of humanised birth will go a long way in establishing Respectful Maternity Care as a norm.
The obstetric community in this country must make Respectful Maternity Care a vital component of childbirth. We must all work towards shaping a world where everyone who is a part of a women’s journey to motherhood is sensitised to be respectful and compassionate towards women in labour. We must remember it is not a privilege, but the basic human right of every pregnant woman.
(Dr Evita Fernandez is the Managing Director and Senior Consultant Obstetrician at Fernandez Hospital, Hyderabad.)