So today I’m going to talk about mistreatment of women during labour and childbirth. As you’ve learned in the previous steps, ensuring quality of care means application of evidence-based obstetric and neonatal care practices, and efforts to ensure positive birth experiences for women. Earlier this week we looked at what is quality of care. And later this week we will look in greater depth at care that is “too little, too late” and “too much, too soon”. One element of quality, woman-centred maternal health care is respectful care, which I will talk about in this step. Mistreatment of women during labour and childbirth is against women’s basic human rights, their choices, and preferences, and it is a type of poor quality care.
There is now increasing evidence that mistreatment occurs in all settings– in low-income, in middle-income, as well as in high-income settings. And mistreatment has also been described as “obstetric violence”, “dehumanised care”, and “disrespect and abuse”. A recent WHO systematic review proposed the typology of items considered to be mistreatment and they proposed
the following: physical, sexual, or verbal abuse; stigma and discrimination; failure to meet professional standards of care; poor rapport between women and health workers; and health system conditions or constraints. So what does mistreatment look like in actual practice? Let’s reflect back on some of our own experiences. You may have seen health workers hit, slap, push, pinch a woman– maybe in cases where the woman in labour was shouting or was in distress during labour. How about situations where health workers conduct examinations without ensuring appropriate privacy. Or, when health workers talk down to pregnant women, particularly if they are poor, illiterate, or belong to marginalised communities. Have you personally experienced this suspected abuse in a maternity setting?
The main point I want to emphasise here is that these practices routinely occur irrespective of the setting. I would suggest that this is a global issue, and often such practices also tend to be accepted as harmless or even normal in most settings. So this is a serious issue that needs to be tackled. So mistreatment can be measured through clinical practice observations– that is, direct observations– or by asking women questions about their maternity experiences, either at the hospital exit interviews or at household surveys in their own communities. Having said that, it can sometimes be difficult to distinguish mistreatment from lack of adherence to evidence-based practices.
So for example, is delivery by an unqualified professional in an unhygienic maternity care setting an indicator of mistreatment, since it’s against the rights of childbearing women, or just an indicator of lack of resources or quality of care? Similarly, there are also many practices that are frequently used without appropriate indications– like labour augmentation without indications or caesarean-sections. Are these just indicators of poor quality care, or should we also consider this to be mistreatment? Lynn Freedman, who you heard from in the earlier sections, has suggested that we look at individual level factors. So specific health worker behaviours that are intended to be disrespectful or harmful.
So for example, shouting, or scolding, or talking down to women, but we also need to look at systemic conditions and constraints– so health system-related issues. So for example, in understaffed maternity facilities, delivery by unqualified personnel or in unhygienic settings. We need to look at all of these issues when we talk about mistreatment of women. There are also local societal norms. For example, patient and provider dynamics or sociocultural issues that may influence perception of mistreatment in different settings.
For example, in certain settings health workers may feel like they can mistreat women– maybe those that belong to certain religious groups, certain ethnic groups, or maybe are HIV-positive or have some certain characteristics– because they feel that these women are less empowered, so they are more likely to get away with mistreatment. A recent WHO systematic review in 2015 tried to establish the evidence base for mistreatment globally. And amongst the 15 studies– the quantitative studies that they found– only three studies reported on a prevalence which ranged from 15% to 98%.
As a part of my own research work, we looked at mistreatment during labour and childbirth using clinical observations and we found that 100% of women underwent some practices that we considered were mistreatment. The prevalence of mistreatment also varies depending on how mistreatment is conceptualised, but also on the research method used. For example, in Tanzania, researchers found that 19% of women perceived that they underwent some sort of mistreatment when they were interviewed at health facilities. Whereas 28% of the same women that were followed up later on at their home perceived mistreatment. And researchers attributed this to courtesy bias during the interviews at the hospital.
So available research evidence indicates that unfavourable institutional policies, resource constraints, infrastructural constraints, the low social status of women, health system constraints, limited knowledge and skills of health workers, and also limited supervision and mentorship are all underlying causes for mistreatment of women during labour and childbirth. The first step is to recognise the problem and the recent WHO statement on suspected abuse in 2014, indicates that this is a serious issue at the global level. The United Nations also brought out a resolution on preventable maternal mortality as a human rights violation. And in 2012, they also issued technical guidance to support countries to end preventable maternal deaths.
Bodies such as the Federation of International Obstetricians and Gynaecologists, the International Confederation of Midwives, and the WHO, have also come out with the Mother- and Baby-Friendly Facilities Initiative, which amongst other things states that, “Every woman and newborn baby should be protected from unnecessary interventions, practices, procedures that are not evidence-based, and any practices that are not respectful of their culture, bodily integrity, and dignity.” So there are some approaches like social audits, community scorecards, citizen’s report cards, partnership-defined quality, verbal and social autopsies, that appear to be promising interventions to reduce the suspected abuse. Essentially, these mechanisms allow women citizens and civil society to hold decision-makers accountable for ensuring high quality, respectful maternal care at health facilities.
But we still need further research to identify context-specific approaches to improve interpersonal care and social support for women at maternity facilities, without blaming health workers themselves, who also work in a resource-constrained environment. Lastly, regardless of the terminology used, mistreatment of women during labour and childbirth relates to poor quality of care. It is both a rights-based issue as well as a medical issue. Overall, mistreatment intersects quality of maternal health care and is related to care that is “too much, too soon” and “too little, too late.” So we know that the time of labour and childbirth is an important time for women and their families. And all women have the right to high quality, respectful care at facilities.
In addition to poorer outcomes, both maternal and neonatal in the current pregnancy, women that are mistreated are less likely to come back to facilities for future pregnancies. So this is an important issue that we need to tackle.