From the synthesis of many studies by Bohren et al (2015) and the previous review by Bowser and Hill (2010), there is a clear message that, across cultures and countries, women are receiving care that does not respect their human rights and amounts to intended or non-intended mistreatment. However, we also know from the World Health Organization (2016) review, as well as from some of our research at the Centre for Maternal and Newborn Health (CMNH), that midwives are not always able to give the care that they want to give due to the environment and systems in which they practice.
Therefore, in some instances, the care women receive is not of the quality that women want to receive, or that midwives and doctors want to provide. While the Millennium Development Goals focused on improving ‘technically competent care’ (i.e. skilled birth attendance), and on improving the identification and management of obstetric emergencies, it is now recognised that the culture and relationships around care provision is of equal importance if the quality of care is to improve. This is supported by de Souza et al, 2014 and van den Broek and Graham, 2009.
There are now many training programmes for healthcare providers which focus on the need for respectful maternity care. However, as Bowser and Hill (2010) and Bohren et al (2015) evidenced, it is too simplistic to attribute poor care solely to individual behaviours. The converse to this is that expecting improvement by focusing on individual behaviours is unlikely to effect change.
A new qualitative study conducted by CMNH researchers and the South African Medical Research Council (SAMRC) unit in Pretoria took a systems approach to identifying barriers and facilitators to provision of quality care in 11 maternity hospitals in the Tshwane and Limpopo districts. In the study, urban and rural hospitals representing all levels of care were included and over 90 individuals were interviewed including 49 postnatal mothers, 33 healthcare providers of all cadres and 10 managers and clinical leads.
A descriptive phenomenological approach was taken to help understand the lived experience of both providers and recipients of care. It was very clear that midwives as the “face of the service” were often held responsible for poor care, when structural and policy factors were in fact impacting their ability to provide care that was valued by both them and the women they cared for.
In addition, reports of poor care in the media and poor experiences of women who received care resulted in midwives often feeling alone and unsupported, with a level of mutual distrust being apparent between staff and women. Women also largely felt alone and unsupported at time of birth. This demonstrates that a non-supportive system impacted negatively on both care providers and care recipients.
On the other hand, it was really encouraging to hear about many examples of good care provided in some healthcare facilities. There was clear triangulation in these healthcare facilities between the information provided by key informants, midwives and women. In these hospitals, the common finding was not that there was more staff or better facilities, but that there was on the ground supportive clinical leadership. These leaders created a culture that was supportive to both midwives and women, resulting in care that was valued by women and that midwives were proud to provide.
This supports the findings of a study by Freedman and Kruk (2014) which reported that disrespect and abuse are often signs of a health system in crisis. While a functioning system leads to improved care, there is a danger that functioning is equated with more resources if qualitative experience is not monitored effectively.
These studies also reflect the importance of the implementation research carried out by CMNH. Through developing and evaluating programmes relating to service delivery skills and quality improvement strategies, CMNH works to support real change by taking a systems approach to quality improvement. By working in partnership with the Ministries of Health, our programmes impact on the individual, structural and policy level. Unless all aspects of health systems are engaged, there is a risk that well-intentioned investment provides minimal returns and staff feel further undermined trying hard to do a good job in challenging circumstances.
About the author
Jaki Lambert is the Head of Midwifery for NHS Highland, the largest remote and rural health board in the United Kingdom. She is also a consultant midwife for Argyll and Bute. Jaki was seconded to the post of Senior Research Associate with the Centre for Maternal and Newborn Health for 2 years. She has a continued interest in finding innovative solutions to providing maternity care in remote and rural settings.
Photo Credit: Marilyn Keegan, 2008 South Africa, Courtesy of Photoshare