Physical abuse, shaming, and harsh words have no place in the birthing environment. Yet many people world-wide face disrespect and abuse when receiving maternal care. Alongside the damaging psychological toll this treatment can have, disrespectful care can contribute to adverse birth outcomes, including maternal death. Over the past 10 years a grassroots movement for Respectful Maternity Care, or RMC as it is commonly known, has emerged to address this problem.

Canadian Association of Midwives (CAM) spoke with Canadian midwifery educator, Karline Wilson-Mitchell about this important issue and her work on RMC. Karline shared with us her experience of working with midwives across the globe (Jamaica, Canada, Burundi and Tanzania) to understand the context and risk factors for disrespectful care and to promote compassionate care. She notes that this growing movement is lead by organizations such as the White Ribbon Alliance, the World Health Organization, Jhpiego and the International Confederation of Midwives. Following the Lancet Medical Journal series (Source #1 – Lancet Series) on midwifery and global health, consensus emerged on best practices, bench marks, and substantive measures for seven domains of RMC (see below). Definitions such as this can help to create a common language and understanding of what respectful care is, and what it is not.

Seven pillars of Respectful Maternity Care training:

  1. Freedom from harm and ill treatment (including abuse and the withdrawal or denial of treatment)

  2. Informed consent/refusal

  3. The right to privacy and confidentiality

  4. Right to dignity and respect

  5. Equality and freedom, equitable care

  6. Access to health care and the highest achievable level of health

  7. Liberty and autonomy, self-determination, freedom from coercion

Learning how to identify and address disrespectful care is an important part of combatting it. Aside from more obvious physical abuse, Wilson-Mitchell describes the many ways in which health care can fail to attain the desired quality. For example, people may face discrimination and stigma in the birth environment that adversely affects their care. In Jamaica, where Wilson-Mitchell conducted her research, she found that adolescent mothers sometimes faced harsh judgement from their health care providers. Others world-wide may face stigma regarding HIV, lifestyle, and gender. When health care providers carry prejudice, for example in the case of adolescent girls or Trans people, they may undermine the clients’ right to make choices about their pregnancy and labour.

Karline Wilson-Mitchell, Canadian midwife
Karline Wilson-Mitchell with babies whose mothers were lost in childbirth, CEPBU Orphanage, Kiremba

Institutional culture and infrastructure

Institutional culture and infrastructure can also play a strong role in setting the stage for disrespectful care. For example, midwives working in packed and under-staffed labour wards may experience extreme “burn-out and compassion fatigue”. Many midwives, particularly in low-resource health care settings, are working in cramped hospitals where there is little space for privacy.  This discourages midwives from permitting the mother access to a desired supportive labour companion. Wilson-Mitchell notes that “something as simple as a privacy curtain” can go a long way towards ensuring dignity in the birth environment. She further underscores that disrespectful care is a world-wide problem and our understanding of the issues should not focus just on low-resource settings. For example, in Canada, some groups still face discrimination in the birth setting. Advocacy and informed choices for clients are an ongoing effort.

Disrespectful care has a negative impact on both the experience of the client and on birth outcomes. Wilson-Mitchell notes that “women may even choose to forego birth attendance by a skilled provider for fear of this abuse”. For example Tanzanian midwives are promoting the use of a skilled birth attendant to tackle the high maternal mortality rate of 398 per 100,000 births (source #2 – WHO). Unaccompanied birth increases all risks associated with the birth.

Promoting respectful maternity care Kiremba, Burundi
Birth means – carrying your loved one or neighbour, on a dirt road lit only by a flashlight, on a hand-made straw and wood stretcher (ambulance Burundian style) over mountainous terrain in the dark for 5 hours. But it is rewarded with a healthy mother and baby this morning. Smiles of relief – “We made it in time.” Family members are welcomed into a small anteroom right outside of the birthing room, where both mother and significant others can hear and encourage each other verbally. Ambulating in labour with an inviting breeze, on a soft bed of grass in the presence of comforting mountains and valleys promotes labour progress. Low tech methods of promoting respectful maternity care.

CAM’s global program

The emerging RMC movement has brought these issues to the forefront of the project and policy development. RMC is an important component of CAM’s global programs. “No matter what we are doing, whether it is emergency skills, curriculum development, or association strengthening, the principles of respectful care are a foundation”, notes Emmanuelle Hébert, CAM Global Operations Director.

Karline Wilson-Mitchell, currently on sabbatical from Ryerson University, is working with three Tanzanian midwives to develop a stand-alone Respectful Care training workshop for midwives and midwifery educators through the More and Better Midwives for Rural Tanzania Project (MBM-RTz). This CAM Global project is funded by Global Affairs Canada, and headed by Jhpiego (the non-profit affiliate of the Johns Hopkins University). The training will be delivered to over 175 practitioners in rural Tanzania over the next 3 years.

  1. Lancet Series:  Van Lerberghe, W., Matthews, Z., Achadi, E., Ancona, C., Campbell, J., Channon, A., … & Turkmani, S. Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality. The Lancet 2014; 384(9949): 1215-1225
  2. WHO, 2015. Trends in Maternal Mortality 1990-2015

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