Mistreatment of
Women in
Childbirth:
How widespread
is the problem and
what can be
done?
Mary Ellen Stanton
Global Health Mini-University
March 4, 2016
Mistreatment of women during in health care
• How bad is the problem?
• What are the manifestations of the
problem?
• Will we know it when we see it?
• Where is it happening?
• How pervasive? Just anecdotes?
• Is this “simply” a problem of “bad
provider behavior”?
• Is this a “soft issue”?
• What can we do about it?
How bad is the problem?
In childbirth in health facilities it is
significant…and “small” things to an observer
may be experienced as humiliation and cruelty
How bad is the problem?
What are the manifestations of the problem?
•
•
•
•
Verbal abuse – accusations, threats, blame
Physical abuse – slapping, kicking, restraints
Sexual abuse – rape
Stigma and discrimination – based on age, ethnicity, tribe, religion, socioeconomic status, HiV status
• Failure to meet professional standards of care
– lack of informed
consent, breech of confidentiality, painful examinations, refusal of pain relief, neglect and
abandonment
• Poor rapport between women and providers – dismissal of concerns,
denial of birth companions, detainment in facilities
• Health systems conditions and constraints – sharing beds, staff and
supply shortages, bribery and extortion
Source: Bohren, et al, 2015 WHO The Mistreatment of Women During
Child Birth in Health Facilities. PLOS Med, 2015
Will we know mistreatment when we see it?
Not necessarily…
There are different opinions about the same behavior
-- such as the “obstetric slap”
Will we know mistreatment when we see it?
Will we know mistreatment when we see it?
From a blog
“…hospital treating human beings as
animals, where is the love? The
professional ethics? God help us” …. Nkoyo
Will we know mistreatment when we see it?
From blogs
“…hospital treating human beings as
animals, where is the love? The
professional ethics? God help us” …. Nkoyo
“Normalized Disrespect & Abuse”
- Behavior women say is D & A, but providers do not
- Behavior women consider acceptable, but others do not
- Poor treatment or conditions
- Systemic problem
- All agree is D & A
Behavior 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.
Where is it happening?
In childbirth -- everywhere…manifestations are
different.
• WHO systematic review 2015 – reports from 34
countries
• Reports from all continents
Source: Bohren et al, PLOS Med, 2015
How pervasive is the problem?
Do we have a set of bad anecdotes, but prevalence is low?
Prevalence depends upon (at least)…
•
•
•
•
whether you observe or ask
how you ask – personally, mobile phone, etc.
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 pervasive is the problem?
Where studied carefully, disrespect and abuse of women in childbirth in facilities
is a “common phenomenon”
• In Kenya:
Self report on exit survey
- 20% any disrespect /abuse
- 4% physical abuse
- 14% neglect/abandonment
• In Tanzania
Self report on exit survey
- 19% any disrespect /abuse
- 3% physical abuse
In home 5-10 weeks postpartum
- 28% any disrespect /abuse
- 5% physical abuse
Sources: Abuya et al, PLoS One 2015 (Kenya)
Kruk et al, Health Policy and Planning, 2014 (Tanzania)
Is this “simply” a problem of “bad provider behavior”?
“Wicked problems or wicked people?”
Among other things, disrespect and abuse of women in childbirth is
affected by…..
• Disrespect for and lack of empowerment of the provider
• Weakness of the health system, including standards of care and
infrastructure
Sources:
Wicked… : Burns et al, Sociology of Health and Illness, 2012
Provider issues: McConnville forthcoming
Health system issues: Bohren et al, PLOS Med, 2015
Disrespect for and lack of empowerment of the provider
“It is a struggle to feel like we are part of the health team, given
that health service provision is based on economic interests
rather than on service provision norms and scientific
evidence….In our country …the private sector maternal health
services have become a business which misinforms service
Isolation
users and limits autonomy – a practice
that verges on total lack of
ethical principles.”
Self doubt
Powerlessness
Source: Adapted from WHO-WRA-ICM forthcoming
Importance of health
system in respectful
maternity care….and
respect for health care
providers
•
•
•
•
•
•
Photo: Jhpiego
Standards of care
Electricity
Running water
Clean toilets
Bed space
Staff
Photo: EngenderHealth
What can we do about mistreatment?
Strategies will depend on type of abuse, context, whether
it’s an egregious incident or a systemic issue.
We need evidence and we can start work immediately.
Evidence of a multi-component intervention in Kenya
Interventions
Results
Facility
• Training in respectful care
• Quality improvement teams
• Caring for carers—site counselors
• Monitoring of mistreatment
• Mentorship
• Maternity open days
Decrease
• Any abuse from 20% to 13 %
• Physical abuse from 4 % to 2%
• Privacy violations 7% to 6% NS
• Verbal abuse 18% to 11%
• Detention 8% to 1%
Community
• Community workshops
• Mediation/alternative dispute
resolution
• Counseling community members
Increase
• Abandonment 13% to 17% NS
Note: Observations of treatment were
made, as well
Source: Abuya BMC Pregnancy and Childbirth, 2015
Going forward to eliminate disrespect
and abuse of women in childbirth….
1
• Turn back the “veil of silence” – document and disseminate information
• Stop the justification
• Recognize mistreatment as a quality of care and a human rights issue
• Use the powerful statements:
• WHO Statement: The prevention and elimination of disrespect and abuse during
facility-based child birth
• WHO Framework for Quality of Maternal Newborn Care
• Universal Rights of the Childbearing Woman
• Pulling Back the Curtain on Disrespect and Abuse policy brief
Sources: WHO; Hasting, White Ribbon Alliance/Health Policy Project
The Universal Rights of the
Childbearing Woman
Source: White Ribbon Alliance
Source: WHO Prevention and Elimination of Disrespect and Abuse During Childbirth statement.
http://www.who.int/reproductivehealth/topics/maternal_perinatal/statement-childbirth/en/
2
• Listen to women
• Use all tools available – policy, health standards, the law (carefully
and selectively)
• Allow/encourage companion of choice at birth
• Encourage stakeholders to own and address the problem
3
• Document/research the interventions to build the evidence base
on what works
• Champion and inspire health care personnel to change behavioral
norms toward respectful maternity care
• Beware of “minimal, negligible and negligent interventions” that
are not disruptive enough*
*Source: Hawe, Social Science and Medicine, 2015.
“It is time to be maximally
disruptive of the patterns that
currently entrench poor health
and health inequities.”
…Penelope Hawe
References
Abuya et al. The effect of a multi-component intervention on disrespect and abuse during childbirth in Kenya.
2015.
BioMed Central,
Bohren et al. The Mistreatment of Women During Childbirth in Health Facilities. PLoS Med, 2015.
Burns et al. Wicked problems or wicked people? Reconceptualising institutional abuse. Sociology of Health and Illness, 2012.
Freedman and Kruk, Disrespect and abuse of women in childbirth: challenging the global quality and accountability agendas. The
Lancet. June 2014.
Hawe. Minimal, negligible and negligent interventions. Social Science and Medicine. May, 2015.
Kruk et al. Disrespectful and abusive treatment during facility delivery in Tanzania. Health policy and Planning, 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.
Prevention and Elimination of Disrespect and Abuse During Childbirth. WHO. 2014.
Respectful Maternity Care: The Universal Rights of Childbearing Women. White Ribbon Alliance, 2011.
Resources
RIGHTS-BASED REPRODUCTIVE HEALTH
Engender Health. Human Rights-Based Family Planning Resources.
https://www.engenderhealth.org/pubs/family-planning/human-rights-based-family-planning.php
Family Planning 2020. FP2020 Rights and Empowerment Principles for Family Planning. 2014.
http://www.familyplanning2020.org/resources/4697
WHO. Ensuring human rights in the provision of contraceptive information and services: guidance and recommendations. 2014.
http://apps.who.int/iris/bitstream/10665/102539/1/9789241506748_eng.pdf
WHO and UNFPA. Ensuring human rights within contraceptive service delivery: implementation guide.
http://apps.who.int/iris/bitstream/10665/158866/1/9789241549103_eng.pdf
IPPF. Sexual and reproductive health and rights – the key to gender equality and women’s empowerment.
http://www.ippf.org/sites/default/files/2020_gender_equality_report_web.pdf
Youth Health and Rights Coalition and Pathfinder International. Promoting the sexual and reproductive rights and health of adolescents and
youth: Building on the Global Health Initiative country strategies and supplemental guidance on the women, girls and gender equality principle.
http://www.pathfinder.org/publications-tools/pdfs/Promoting-the-sexual-and-reproductive-rights-and-health-of-Adolescents-and-Youth.pdf
Resources
RESPECTFUL MATERNITY CARE
White Ribbon Alliance. Respectful Maternity Care: The Universal Rights of Childbearing Women
http://whiteribbonalliance.org/wp-content/uploads/2013/10/Final_RMC_Charter.pdf
Maternal and Child Survival Program. Respectful Maternity Care Toolkit
https://www.k4health.org/toolkits/rmc
WHO. The prevention and elimination of disrespect and abuse during facility-based childbirth: WHO Statement
http://apps.who.int/iris/bitstream/10665/134588/1/WHO_RHR_14.23_eng.pdf?ua=1&ua=1
White Ribbon Alliance and Health Policy Project. Pulling Back the Curtain on Disrespect and Abuse
http://whiteribbonalliance.org/wp-content/uploads/2015/10/Pulling-back-the-curtain-on-d-and-a.pdf
Kruk et al. Disrespectful and abusive treatment during facility delivery in Tanzania. Health Policy and Planning, 2014.
http://heapol.oxfordjournals.org/content/early/2014/09/21/heapol.czu079.abstract
Abuya et al. The effect of a multi-component intervention on disrespect and abuse during childbirth in Kenya. BioMed Central, 2015.
http://www.biomedcentral.com/1471-2393/15/224