Childbirth is hard: Health systems shouldn’t make it harder

Opinion: simple changes can improve the health of women and babies

This article was written by Dr. Patience Afulani, Assistant Professor at the University of California, San Francisco. 

“When I arrived at the health facility around 5pm in the evening, I just sat there and no one was ready to attend to me, they made a comment that if I want to deliver the baby I can just do it where I am sitting.” — Focus group discussion participant in Kenya

Motherhood should be a dignified experience. Yet many women start this journey stripped of their dignity and lacking support.

Growing evidence shows that globally women are mistreated during childbirth. This manifests as disrespect and abuse, poor communication, lack of respect for their autonomy or lack of supportive care.

Starting off on the wrong foot

My research collaborators and I talked to women in Kenya, Ghana and India about their childbirth experiences to explore the depth of the problem. They told us that providers rarely introduced themselves, asked permission to do exams or procedures, explained procedures and medications or created an environment where they felt comfortable asking questions.

There’s a ripple effect when women have a bad childbirth experience

Many women had little involvement in decisions about their care, including the option of having birth companions present and the ability to choose their preferred delivery positions.

These behaviours aren’t just disrespectful—they have serious consequences for women’s health.

There’s a ripple effect when women have a bad childbirth experience. It discourages other women from delivering their babies at a health facility. When women choose to give birth at home, they can die from complications that could have been easily treated at a facility.

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Mistreatment has also been linked with poor outcomes like post-traumatic stress disorder. For the sake of human rights and maternal health, we need to get this right.

What does respectful maternity care look like?

While much attention has been paid to eliminating abusive behavior, that’s a low bar. As one woman we interviewed put it, “Respect to me is like…how they’d want me to treat them if they were in my shoes.” We must hold healthcare providers to a higher standard of what respectful, person-centred care looks like:

  • Be responsive and timely. Everyone, from security personnel to medical staff, should provide the woman with a warm welcome. Respond to her needs in a timely manner, including acknowledging and controlling her pain.
  • Communicate. Introduce yourself and address her by her preferred name. Explain exams and procedures. Ask permission before you do them. Ask if she has questions and listen to her concerns,
  • Provide comfort. Make sure she has clean sheets, something to drink and warm water to bathe. Ask about her preferences for a companion during birth and what delivery position she would like, and make sure her requests are met.

What can we do to ensure women get respectful maternity care?

The drivers of poor childbirth experiences are complex and operate at multiple levels. There are strategies at the interpersonal, community and health system level that are feasible in low-resource settings.

  • Train providers to change the culture. Many healthcare providers are taught the basics of patient-provider interactions during training, but it’s quickly lost when they begin practicing. Creating a culture of respectful care means consistent emphasis during every level of provider training. Simulation trainings are a potential approach. Training on implicit bias can also reduce poor treatment of disadvantaged women. Providers can get complacent and need consistent messages to be accountable to a higher standard. These efforts can also be self-reinforcing. Our research shows that providers may be less likely to be disrespectful if they have introduced themselves because they can be easily identified.
  • Empower women and families to advocate for themselves. People may not feel empowered to demand respectful care, especially when they’re poorer, less well-educated or of low social status. Education can help women know and expect the respectful birth experience that is their right. Research in Kenya and Tanzania that included educating women on their rights showed some reductions in disrespect and abuse.
  • Invest in health facilities and the workforce. Reducing provider stress through increases in the number of staff, supportive supervision, and better pay can help providers be in a place to provide the best care. Investment in the physical space of labor ward to include adequate beds with clean sheets and privacy screens, and consistent availability of water, medicines, and supplies are also essential to improve women’s experience.
  • Government focus and accountability. Governments should demonstrate that this is a priority and hold health systems accountable for improvements in providing respectful care. Including measurement of person-centred care in health information systems will ensure women’s experiences are prioritised.

These changes reverberate, ensuring better health for women, their families and communities. As one woman told us, “[The nurse] did everything well until she finished. She took her time to be with me and handled me well. This made me to say it is good to go to the hospital to deliver.”

Policymakers and healthcare providers must come together to invest in women’s health by giving them the dignified birthing experience they deserve. — Patience Afulani. 

(Photo credit: Beth Novey//Bixby Center for Global Reproductive Health)


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