By Fiona Dickinson
In 2011, the International Confederation of Midwives (ICM) developed a Bill of Rights for Women and Midwives (ICM, 2017). This sets forth, in line with the United Nation’s Sustainable Development Goals, a set of rights for both women and midwives, including the right for women to be ‘respected as a person of value and worth’. Crucially, it also states that midwives have the ‘right to practise on their own responsibility’ and ‘to be recognised, respected and supported as a health professional’. The ICM states that ‘midwives are skilled to provide up to 87% of pregnancy-related services, making them the ideal health professional to support women through the maternity continuum of care’ (ICM, 2017). It should therefore be a priority on global health agendas, that midwives are supported to provide, compassionate, individualised, safe, high quality care to women, and respectful maternity care is a key marker of quality care.
As part of a study to develop a Patient Reported Outcome Measure for use in maternity services in Malawi and Kenya (MPROM study), I interviewed 137 women who had recently given birth about the quality of care they received whilst giving birth. Many of the women reported receiving good quality of care from midwives and other healthcare workers, but there were also a number of women who reported generalised or specific instances of verbal and physical abuse. It is not the first time that these issues have been reported. In their study in Tanzania, Freedman et al (2018) found a baseline incidence of disrespect and abuse of 70% when assessed by trained nurses stationed in maternity wards. Other studies have explored both women’s and healthcare worker’s perspectives on the quality of care provided: Lambert et al (2018) in South Africa, and Mgawadere et al (2019) and O’Donnell et al (2014) in Malawi. All of these studies found that the perceptions of what constituted good quality care differed, with healthcare workers being more focussed on structures and procedures, whilst women were more concerned about staff behaviour and how they related to women.
Normalisation and blame
The types of disrespect and abuse that women suffer varies, including being shouted at, being slapped or pinched to make them co-operate, being left to give birth to their baby unattended, being threatened with withdrawal of treatment, lack of privacy, and being kept in hospital due to failure to pay the bill (Freedman et al, 2018). Some of the women I spoke to explained that the abuse was “normal” and even “necessary” to ensure that the baby was delivered safely, and that if they did “as they were told” they would be OK. However, other women considered that it was a woman’s fault for not doing as she was told.
According to Oluoch-Aridi et al (2018), when interviewed, healthcare workers – particularly more junior members of staff – said that they were blamed if anything went wrong with the delivery, either by more senior colleagues, or by patient’s relatives. Yet they felt they were doing what was necessary to ensure a good outcome for mother and baby. In some instances, in my MPROM study, women ‘defended’ the healthcare workers’ behaviour, explaining that they were short-staffed and working long hours and could not be expected to be polite to all patients, particularly if women were “uncooperative”.
Causes and consequences
Whether women receive good or poor quality of care can have longer-term consequences. If they received good care, women said they were more likely to “rush to the hospital if there was a problem”, whilst conversely, if they received poor care they would be reluctant to attend a healthcare facility when needed or decide to deliver at home with a traditional birth attendant. Similar findings were reported by Maya et al (2018) in Ghana, suggesting that women might also be put off giving birth in hospitals because of hearing about other women’s experiences of mistreatment.
What can be done?
If we want to improve maternal mortality rates globally, we need to not only encourage women to give birth in healthcare facilities, but we also need to ensure that the quality of care provided in these facilities is safe and shaped around the individual needs of women and their families. It is unethical for women to be encouraged to attend a healthcare facility where they will be met with disrespect and abuse. Health services must also take into account the needs of healthcare workers and the environment in which they work. There needs to be sufficient numbers of staff, trained to a sufficient level, providing ‘skilled, knowledgeable, compassionate care’ (WHO 2016). These staff themselves, who are often working in difficult circumstances, require professional and emotional support, and appropriate recognition (Raven et al 2015). This will help them to practice at their highest standard, whilst being accountable for their practice.
A large proportion of the care provided for women in healthcare facilities is good, particularly in light of the sometimes difficult circumstances in which it is carried out. Unfortunately, however, the poor quality care women receive during birth and the blaming of healthcare workers who care for them, is still widely reported and documented. This is not a recent phenomenon and has a wide range of causes and contributory factors, many of which do not have quick or easy solutions. However, it is imperative that as a midwifery profession we do all that we can to ensure that women and babies not only survive childbirth but are able to report a positive experience, physically and psychologically. How can we ensure that the ICM Bill of Rights becomes a reality in practice and not merely an aspirational document?
About the Author
Fiona Dickinson qualified as a Midwife in the UK in 2001 and has since worked in a variety of roles both in the UK and in low- and middle-income countries. Her particular interests include assessing and promoting quality of care for women and babies. She is currently working as a Research Assistant at the Centre for Maternal and Newborn Health and is completing her PhD on exploring the use of patient reported outcomes for assessing quality of maternity care.