Many women experience disrespect and abuse (D&A) during facility-based childbirth, emerging evidence shows. In a moment of acute vulnerability, women face undignified care at the hands of a health care provider. This element of quality has far reaching consequences for facility-based delivery, often attributed to good maternal health outcomes. A recent study from Ethiopia cites cultural sensitivity of providers as one of the main barriers to mothers seeking skilled birth attendance in health care facilities. In Tanzania, provider attitudes have been shown to be one of the strongest predictors of where a woman decides to deliver her child; a woman will even bypass facilities near her home in search of more respectful care.
As part of the Lancet’s Midwifery series, Freedman and Kruk contend that D&A and women-centered care constitute a “blind spot” in the current model of providing maternal health services. Further, they argue, “D&A is a signal of a health system in crisis—a crisis of quality and accountability. At the most fundamental level, a health system that tolerates D&A devalues women, which itself is an underlying cause of slow progress on reduction of maternal mortality. Moreover, D&A represents a breakdown in accountability of the health system not only to its users but also to the women and men it employs as service providers.”
To build people-centered health care systems, respect and dignity, this “human element,” should extend to the rights and needs of those providing care. This includes not only adequate physical infrastructure, but also sufficient emotional support and adequate training for health providers in order to promote quality care and prevent provider demoralization.
One training program that attempts to facilitate respectful care through empowering the health workforce is the Health Workers for Change curriculum. The goals of the Health Workers for Change (HWFC) workshop curriculum are to lead providers through the process of examining their views about their patients, develop a better understanding of their patients’ backgrounds and constraints, and empower them to seek and make changes in their working environment to make it a more respectful place to work. Further, the workshop assists health workers to identify avenues for improved job satisfaction, which can help lead to better provider-client interactions.
The curriculum is designed in six modules that take place over several weeks. The modules and their respective objectives are:
- Why I am a health worker: To examine the reasons why people become health workers, and how these reasons influence their relationship with women clients,
- How do our clients see us?: To investigate health workers’ ideas about how their clients see them, and how this influences their relationship with women clients,
- Women’s status in society: To explore health workers’ understanding of the most important factors that influence the degree of control that women have over their day-to-day lives and the decisions that they make about themselves, their families and their homes,
- Unmet needs: To explore needs women have related to health that are often ignored, and to identify possible solutions,
- Overcoming obstacles at work: To find out what problems health workers have at workand how these problems affect relationships with women clients,
- Solutions: To draw together what has been learned at the previous sessions and conclude by developing an action plan on what can be done to improve quality of care.
In an evaluation of HWFC curriculum implementation in Zambia, Senegal, Mozambique and Uganda, it was found that the curriculum was generalizable enough to cross multiple health settings and language barriers. The workshops allowed health care providers to recognize areas of stress in their daily work, both structural (e.g. lack of commodities) and interpersonal (e.g. harsh attitudes), which affect the quality of care for their clients. It also afforded providers the opportunity to discuss and acknowledge areas for change to provide more respectful care that were within their locus of control. However, all providers noted that additional health system support was critical to ensure better quality of care.
Respectful care is a principle that is essential to both demand- and supply-side maternal health programming. Championing health workers and supporting their ability to work effectively is a fundamental component to this process. Only when respect and dignity pervade maternal health efforts will the highest level of quality be achieved.