Preventing
Disrespect and Abuse
of Women Giving Birth
in
Health Care Facilities
Mary Ellen Stanton
Inter-Agency Gender Working Group
October 29, 2014
Photo: Amy Cotter
Vaginal destruction
Displacement in War
Female Genital Cutting
Pregnancy
Early Sexual Initiation
Female Infanticide
Domestic
Violence
Seclusion
Honor Killings
Early Marriage
Girl Neglect
Rejection of Widows
Abortion
Trafficking
Abduction/Rape
Selective
Abortion
Women and girls are vulnerable
over their lifespan
Evidence for Disrespect and Abuse
in Facility-Based Childbirth
• Lack of informed consent
• Lack of confidentiality
• Discrimination
• Physical Abuse
• Undignified Care →
Humiliation
• Abandonment of Care
• Demand for payments →
Detention in Facilities
Source: Adapted from Bowser and Hill, Traction Project 2010
“…in the hospital they will be shouting on you
treating you like you are not a human being.”
…woman with infant in northern Ghana
describing her treatment in childbirth
Source: Moyer et al. Midwifery, 2013
“A nurse was attending to me, she told me I had to
help, to push. At the moment I couldn’t. I was
yelling. The nurse gave me a slap. That made me
very ashamed, she treated me as a bad girl.
…woman in Peru
Source: Silencio and y complicidad. CLADEM/CRLP
reported in Pires. Violence against women….The Lancet 2020.
Some key questions
How bad is the problem?
Will we know it when we see it?
How widespread? Do we have a set of bad anecdotes,
but incidence is low?
Where is it happening?
What can we do about it?
Some key questions
How bad is the problem? Significant…and “small” things to an
observer may be experienced as humiliation and cruelty
Will we know it when we see it? Not necessarily. Perceptions vary.
How widespread? Do we have a set of bad anecdotes, but
prevalence is low? No!
Where is it happening? Throughout the world…manifestations are
different.
What can we do about it? The big question. Strategies will depend
on type of abuse, context, whether it’s an egregious incident or a
systemic issue….
How can we measure progress? Work started on tools, indicators.
Will we know disrespectful and abusive treatment
when we see it?
“Normalized D & A”
- Behavior women say is D & A but providers do not
- Behavior women consider acceptable but others do not
Behavior all
agree is D & A
- Poor treatment or conditions
- Systemic problem
- All agree is D & A
- Poor treatment or conditions
- Systemic problem
- Deemed normal or acceptable
Deviation from national standards
of good quality of care
Deviations from human rights standards
Source: Adapted from Freedman and Kruk. The Lancet, 2014.
What about incidence of disrespect and abuse
of women in childbirth?
Depends upon (at least):
•
•
•
•
•
whether you observe or ask
whom you ask – women or health care provider
when you ask – in hospital before discharge or several months later
where you ask – at the health facility or in the community
how much you ask -- single item or multiple questions, with or
without probes
• how you ask…
Good studies are forthcoming. There is wide variability.
From the Heshima Project in Kenya, 2014
(Source: Population Council)
• 1 in 5 women interviewed (n=644) reported feeling humiliated at
some point during their most recent birth experience
• 9 out of 10 health care providers said they heard of or witnessed
colleagues treating women inhumanely
In seeking and receiving maternity care before,
during and after birth:
1. No one can physically abuse you.
2. No one can force you or do things to you without your
knowledge and consent.
3. No one can expose you or your personal information.
4. No one can humiliate or verbally abuse you.
5. No one can discriminate against you because of something
they do not like about you.
6. No one can prevent you from getting the maternity care you
need.
7. No one can detail you or your baby without legal authority.
Source: White Ribbon Alliance for Safe Motherhood.
Disrespect and abuse is a quality of care
issue: setting performance standards
Examples of standards and
verification criteria:
• The woman is protected from
physical harm or ill treatment:
Never physically restrains
woman
Photo: Jhpiego
• The woman’s right to information,
informed consent, and
choice/preferences is protected:
Responds to questions with
promptness, politeness, and
truthfulness
Source: MCHIP Respectful Maternity Care Toolkit
Photo: EngenderHealth
Source: WHO Prevention and Elimination of Disrespect and Abuse During Childbirth statement.
http://www.who.int/reproductivehealth/topics/maternal_perinatal/statement-childbirth/en/
The providers of maternity care
What role does “difficulty of circumstance”
or systemic factors play in the manifestation
of and lack of accountability for disrespect
and abuse of pregnant and childbearing
women?
Issues may include:
• Poor role models
• Low social status/social discrimination
• Exhaustion
• Frustration
• Fatalism
• Moral distress
Can lead to anger, rudeness, disrespect and
abuse of women in their care.
Attention to the providers’ issues in tackling
disrespect and abuse of childbearing women
Underway and completed
(selected)
 ICM, White Ribbon Alliance —
advocacy for midwives
 State of the World’s Midwifery
Reports and dissemination
 WHO systematic review of
interventions to address barriers
Source: Ngongo/EngenderHealth
 WHO consultation to
document midwives’ voices on
their reality
 WHO systematic mapping of
the literature—social,
economic and professional
barriers preventing midwifery
personnel providing quality of
care of women and newborns
Where do we go from
here?
We certainly need a vision of respectful maternity care that
is meaningful for all women and health care providers
everywhere. But when disrespect and abuse is called out
for what it is – the symptom of fractured health systems
and locally expressed power dynamics that conspire against
both patients and providers – then the real work of
improving quality and creating accountability can begin.
…Lynn Freedman and Margaret Kruk
Averting Maternal Death and Disability Program
References
Bohren et al. Barriers and facilitators to facility-based delivery in low- and middle-income countries: a qualitative evidence
synthesis. BMC Reproductive Health, 2014.
Bowser and Hill. Exploring Evidence for Disrespect and Abuse in facility-Based Childbirth, USAID TRAction Project, Sept. 20, 2010.
Confronting disrespect and abuse during childbirth in Kenya. Heshima Project Brief. USAID TRAction Project. Population Council 2014.
Freedman and Kruk, Disrespect and abuse of women in childbirth: challenging the global quality and accountability agendas. The
Lancet. June 2014.
Freedman et al. Defining disrespect and abuse of women in childbirth: A research, policy and rights agenda. Bulletin of the World
Health Organization. Published online 2014. (Final forthcoming.)
McMahon et al. Experiences and responses to disrespectful maternity care and abuse during childbirth: a qualitative study with
women and men on Morogoro Region, Tanzania. BMC Pregnancy Childbirth, Aug., 2014.
Moyer et. al. ‘They treat you like you are not a human being’: Maltreatment during labour and delivery in rural northern Ghana.
Midwifery. 2013.
Pires et. al. Violence against women in healthcare institutions: an emerging problem. The Lancet. May, 2002.
Respectful Maternity Care Toolkit. USAID MCHIP.
Warren, et.al. Study protocol for promoting respectful maternity care initiative to access, measure and design interventions to reduce
disrespect and abuse during childbirth in Kenya. BMC Pregnancy Childbirth. 2012.
White Ribbon Alliance . Respectful Maternity Care: The Universal Rights of Childbearing Women. White Ribbon Alliance, 2011.
WHO Prevention and Elimination of Disrespect and Abuse During Childbirth Statement. WHO. 2014.