At a training center in Tanzania, Jhpiego’s Senior Maternal Health Advisor, Sheena Currie, addressed the group of brightly dressed nurse-midwives and doctors. As part of an overview about respectful maternity care (RMC), Sheena used role-play to show these health care providers how to warmly greet pregnant women with a smile and kind words when they arrive at the health facility to give birth. “Hello, I am Sheena your midwife and I will be looking after you,” she said. Her words were met with giggles and snickers, and several training participants shook their heads skeptically. Sheena described this type of reaction as common: “Disrespectful and abusive (D&A) care is the elephant in the room; everyone knows it takes place, but it makes them uncomfortable to talk about it.”
USAID’s flagship Maternal and Child Health Integrated Program (MCHIP), led by Jhpiego, has always incorporated RMC in quality improvement (QI) approaches, for example, by integrating RMC in provider trainings on checklists and clinical standards. “But,” noted Sheena, “practicing RMC is completely behavioral, and requires changing attitudes, especially in more hierarchical cultures where doctors typically tell midwives what to do, and midwives in turn may tell women what to do.”
“The reasons for this are many,” she added. “Providers themselves may be treated poorly, be underpaid, or face harassment and difficult working conditions—overcrowding, understaffing—so we need to address RMC holistically and look at how to create more supportive work environments.”
Addressing health system factors, as well as professional behavior, are compelling health priorities, since D&A care is one of the top reasons women cite for not seeking care from skilled health care providers. When women choose not to give birth in health facilities, due to fears of being treated poorly, their chances of having a clean and safe birth are reduced, and maternal and newborn health (MNH) outcomes are threatened.
As a lead implementer in RMC, MCHIP has made important progress in advancing RMC globally by developing and disseminating key resource materials to address factors that compromise the quality of MNH care. MCHIP launched the RMC toolkit on the K4Health website in June 2013, introducing RMC implementation materials to a broad audience and providing the necessary guidance to program implementers looking to strengthen RMC in their countries.
MCHIP maternal and newborn trainings always emphasize women-friendly care, by introducing skills checklists which providers use to evaluate their ability to provide RMC. However, training in RMC is often inadequate: it is not typically well addressed in pre-service programs for health providers, and students may not learn about respectful professional behavior.
To address this, the RMC toolkit includes a short training module devoted to the topic, which encourages group discussion. In this way, participants better understand the evidence demonstrating how key components of respectful care—such as involving women in their care and allowing them to have a birth companion of their choice—make the birth experience go more smoothly for both the woman and the health care provider. Additionally, MCHIP is collaborating with TRAction to develop a training toolkit to more comprehensively address RMC in both pre-service and in-service training.
MCHIP has also worked to promote the integration and measurement of RMC as a critical aspect of quality of care (QoC). The program conducted QoC assessments in seven African countries —Ethiopia, Kenya, Tanzania, Madagascar, Rwanda, Mozambique, and Zimbabwe—with the overall objective of measuring the quality of facility-based care. These QoC assessments focused on measuring RMC through direct observations of labor and delivery at selected facilities, and included data collection on RMC and D&A. Alarmingly, results of these studies confirm that women routinely experience care that is disrespectful and abusive during facility-based labor and delivery. MCHIP shared these results at international and national conferences as well as online, drawing greater attention to important, specific quality challenges, and contributing to a growing emphasis—at the global level—on quality and the notion that RMC should be a central component of high-quality services.
Building on the current momentum to include RMC within the QoC framework and promote its measurement, MCHIP expanded the QoC study methodology to incorporate questions looking at RMC in a Pakistan QoC assessment carried out in April 2014. Assessment tools included questions on:
- Provider working conditions
- Whether providers encouraged women to have a support person present during labor and birth
- If providers asked these women (and support persons) if they had any questions
In Ethiopia, RMC is also a central component of MCHIP’s Quality Improvement approach, and figures prominently in an upcoming assessment to measure the outcomes of the Program’s QI efforts. The study will assess facility readiness, provider performance, job satisfaction, and client perspectives (specifically, experiences and satisfaction with antenatal care, labor and delivery, postnatal care and RMC). Providers’ perceptions and practices will be explored on the seven dimensions of RMC.
Documenting client’s perspectives—whether through anonymous client interviews or other innovative data collection mechanisms—helps to focus attention on the importance of institutional and personal accountability during labor and delivery. “Currently there are not many professional regulatory frameworks to ensure safe quality services,” Sheena noted. “If a provider treats a woman poorly, there are generally no consequences. This is an area that needs strengthening, since facilities and providers are not often accountable to women or the communities.”
In countries like Ethiopia, Pakistan and Yemen, MCHIP and Jhpiego are looking more closely at QI processes and how they can be linked with community mobilization to ensure that facilities and their staff are more accountable, and that women understand their right to respectful and dignified care. Future activities should build on current efforts under way to incorporate women (and community) perspectives more routinely into quality assessments, whether through direct observation (QoC assessments), client exit interviews (Ethiopia) or other innovative mechanisms. Further refinement of research and assessment methods to determine the prevalence of RMC (and D&A) will help to inform policy and spur grassroots changes toward greater adoption of RMC globally.
This post was originally posted by the White Ribbon Alliance.