This report describes the experiences gained during local and national efforts to prevent disrespect and abuse in maternity care. These efforts also promoted respectful maternity care (RMC), which recognizes that safe motherhood must be expanded beyond the prevention of morbidity or mortality to encompass respect for women’s basic human rights, including respect for women’s autonomy, dignity, feelings, choices, and preferences, such as having a companion wherever possible. Recognizing the importance of this subject, the United States Agency for International Development (USAID) has supported a three-pronged approach of advocacy, research, and support for implementation. With the White Ribbon Alliance working on advocacy for RMC and the Translating Research into Action (TRAction) project working on research, the Maternal and Child Health Integrated Program (MCHIP) has focused on support for field-level implementation. In this context, MCHIP conducted the RMC survey with the objective of collecting information from key stakeholders about their experience implementing interventions to promote RMC. A convenience sample of 48 individuals from 19 countries responded to a survey about disrespectful care and abuse in maternity care, approaches for prevention, and ways to promote RMC.
The RMC approach is centered on the individual and based on principles of ethics and respect for human rights. The Respectful Maternity Care Charter,1 developed by the White Ribbon Alliance and RMC partners, is based on a framework of human rights and is a response to the growing body of evidence documenting disrespect and abuse of childbearing women.
USAID has long recognized the importance of prevention of disrespectful and abusive care and has long supported integration of respectful care in maternal health projects. Currently, USAID is supporting specific and coordinated efforts in advocacy and promotion through the White Ribbon Alliance, in research and the development of a strong evidence-based through University Research Co., LLC (URC), and in implementation through MCHIP, USAID Bureau for Global Health’s flagship maternal, neonatal, and child health (MNCH) program. Therefore,
MCHIP developed and conducted a survey with the objective of collecting information from key country stakeholders about their experiences implementing RMC interventions. Anecdotally, it was already known that disrespect and abuse is common in maternal health care, contributing to untold suffering, and discouraging women from seeking care in facilities. Further confirmation of these reports came from a landscape study by Bowser and Hill in 2010.2 This survey was based on a literature review of existing materials and documents related to
promotion of RMC as well as humanization of birth, a similar movement that originated in Latin America. Potential respondents were identified through elaboration of contact lists of individuals and groups working in the RMC area. The initial list was drawn from the participant list for the III Conference on Humanization of Childbirth 2010 and expanded through networks of known participants involved with RMC. Surveys were sent electronically to this purposive sample of potential participants. Data collection was conducted March–May 2012.
This survey identified key areas of disrespect and abuse and associated factors related to: policy, infrastructure and resources, health care management; ethics and culture; knowledge, skills, attitudes and standards of practice in facilities and communities. This report summarizes the experiences of selected countries, including programs, interventions, results, challenges, and recommendations.
A number of strategies and interventions to promote RMC were reported (Annex D). These are grouped into the categories of: 1) advocacy; 2) legal approaches; 3) interventions focused on the health facility (management, infrastructure, clinical practices, and interpersonal communications); 4) educational and training programs; 5) community; and 6) research and monitoring and evaluation.
Despite the challenge and the complexity of this subject, we found that there is interest in promoting RMC in many countries, that various interventions have been implemented to address this issue, that a variety of tools are available and that some consistent results have been produced. Finally, we describe the challenges, lessons learned, and recommendations provided by the key informants. We hope that this report will help inform actions to strengthen efforts to prevent disrespect and abuse and promote RMC around the world.
The survey information included here does not permit broad generalization for the represented countries. However, this report captures the perceptions and experiences of informants who have been working within the maternal health context. The information analyzed in this report can inform actions that can be applicable in similar contexts, and may enable readers to apply lessons learned in other settings with similar contexts.
1 Respectful Maternity Care Advisory Council, White Ribbon Alliance for Safe Motherhood (WRA). (2011). Respectful maternity care: the universal rights of childbearing women. Washington, DC. http://www.whiteribbonalliance.org/WRA/assets/File/Final_RMC_Charter.pdf.
2 Bowser D and Hill K. 2010. Exploring Evidence for Disrespect and Abuse in Facility-Based Childbirth: Report of a Landscape Analysis. USAID TRAction Project.
Rapport d’enquête sur les soins respectueux en maternité. 19 pays dont: USA, Canada, Royaume-Uni, Pays-Bas, Nouvelle-Zélande.
Notamment proposition de stratégies et interventions pour la promotion des soins
respectueux en maternité:
- militantisme (“Advocacy“)
- approches législatives (“legal approaches“)
- interventions visant les établissements de santé (gestion, infrastructure,
pratiques cliniques, communication inter-personnelle)
- communauté (?)
- recherche, surveillance (monitoring), évaluation
Exemples de questions
Quels exemples de soins respectueux font l’objet de promotion dans votre paysN
a. Soins respectueux, y compris respect des croyances, traditions et cultures
b. Le droit à l’information, à la confidentialité et au respect de la vie privée (privacy)
c. Choix d’un accompagnant (“companion“) pendant le travail
d. Choix d’un accompagnant (“companion“) pendant l’accouchement
e. Soins fondés sur des données prouvées qui améliore et optimise les processus normaux de la grossesse, de la naissance et du
f. Liberté de mouvement pendant le travail (marcher, se déplacer)
g. Fourniture de boisson et nourriture pendant l’accouchement normal
h. Méthode non médicamenteuse de soulagement de la douleur pendant le travail [ndlr: ne comprend pas si soulagement
médicamenteux de la douleur fait partie de la questions] (“Provision of drug-free comfort and pain relief methods during
i. Soutien continu pendant le travail (pas d’abandon)
j. Choix de la position d’accouchement
k. Peau à peau dès la naissance pendant au moins une heure
l. Allaitement précoce (dans l’heure suivant la naissance)
m. Proximité mère-enfant 24/24
n. Promotion de l’allaitement à la demande
o. Utilisation appropriée des technologies est des intervention efficaces (life-saving interventions)
p. Soins qui cherchent à éviter les procédure et pratiques potentiellement dangereuses
q. Respect mutuel et collaboration entre tous les types de professionnels de santé
r. Continuité des soins entre les établissements et professionnels de santé (“Provision of a continuum collaborative care with
all relevant health care providers, institutions, and organizations“)
s. Eviter la sur-utilisation des médicaments et technolgies (comme accélération par ocytocine, épisiotomie, césariennes,
“newbor blood gases“, incubation, s“onograms“
t. Eviter la détention des les établissements pour cause d’impayé
u. Prévention de la violence institutionnelle contre les femmes et les nouveaux-nés, y compris les soins non respectueux
A number of strategies and interventions to promote RMC were reported (Annex D).
These are grouped into the categories of: 1) advocacy; 2) legal approaches; 3) interventions focused on the health facility (management, infrastructure, clinical practices, and interpersonal communications); 4) educational and training programs; 5) community; and 6) research and monitoring and evaluation.
What examples of respectful care aspects have been promoted in your country
(or in the countries where you work)?
a.Respectful care, including respect for beliefs, traditions and culture
b. The right to information, confidentiality, and privacy
c. Choice of companion during labor
d. Choice of companion during delivery
e. Evidence based care that enhances and optimizes the normal processes
of pregnancy, birth and postpartum
f. Liberty of movement during labor (e.g., walking, moving around)
g. Provision of drink and food during normal labor
h. Provision of drug-free comfort and pain relief methods during labor
i. Provision of continuous support during labor (i.e., lack of abandonment)
j. Choice of position for delivery
k. Contact of the newborn skin-to-skin with the mother immediately after
the delivery for at least the first hour
l. Early breastfeeding (within the first hour after birth)
m. Keeping mother and baby together 24 hours a day
n. Promoting breastfeed on demand
o. Appropriate use of technology and effective lifesaving interventions
p. Provision of care that seeks to avoid potentially harmful procedures and
q. Mutually respectful and collaborative relationship among all types of care
r. Provision of a continuum collaborative care with all relevant health care
providers, institutions, and organizations
s. Avoidance of the overuse of drugs and technology(such as oxytocin
augmentation, episiotomy, cesarean section, newborn blood gases,
t. Avoidance of detention in facilities due to lack of payment
u. Prevention of institutional violence against women and newborns,
including disrespectful care