Addressing disrespect and abuse during childbirth in facilities

Global policy attention to maternal health only began in the mid-twentieth century, and has had a controversial past. While the promotion of maternal and child health and welfare was included in the World Health Organisation’s (WHO) Constitution (Article 2(l)) in 1948, international cooperation for maternal health began seriously only in the mid-1960s.¹ In the 1970s and 1980s, instrumental rather than intrinsic rationales for maternal health came to the fore. As pointed out in Rosenfield and Maine’s influential paper, “Maternal mortality – a neglected tragedy. Where is the M in MCH?”,² child health was the engine driving attention to pregnant women, not women’s own health, let alone human rights. More questionably, family planning programmes in this period typically used prevention of maternal mortality as a key justification for their aggressive expansion and intensification.^3,4

Even where women’s own health gained intrinsic attention, much of it was technical and medical, focusing, for example, on the relative importance of antenatal versus intrapartum care,⁵ the best methods for reducing micronutrient deficiencies in pregnancy, and the role of traditional birth attendants in maternal care.⁶ It was the push by feminists for sexual and reproductive health and rights (SRHR) at the International Conference on Population and Development in 1994, preceded by almost two decades of mobilisation, that brought women’s human rights to the centre of maternal health.⁷ Alongside the technical controversies, there arose political contention about the impact of gendered and intersecting power structures, and the deeper societal roots of sexual and reproductive ill-health, and violations of human rights. Feminist concerns were many. They included, among others, the physical and mental health effects of early marriage, female genital cutting and mutilation, intimate partner violence during pregnancy, maternal ill-health and deaths due to unsafe abortion, and unavailability and inaccessibility of health services, especially for poor marginalised women.

Debates at and around ICPD laid the basis for greater attention to sexual and reproductive rights and wrongs, including in the context of pregnancy. Mistreatment, abuse and violations of girls’ and women’s human rights during pregnancy and childbirth are all too common and occur in households, communities, work-places and in health and other institutions. This Special Issue focuses specifically on what happens when pregnant women approach health institutions to deliver babies. Its importance derives from recent policy drives in low- and middle-income countries (LMICs) to increase the number of institutional births. Unfortunately, as the papers in this Special Issue argue, disrespect and abuse of women in the maternal care provided by health institutions is wide-spread. Far too often, and especially if they are poor or otherwise marginalised and oppressed, women suffer violations of their dignity, unnecessary procedures, harmful practices, and physically and psychologically abusive treatment.

In the 1980s and 1990s feminists in Latin America, responding to excessive medicalisation of maternal care in the region had begun calling to humanise childbirth in institutions and to prevent obstetric violence.

These calls have now spread and given rise to a global movement fighting disrespect and abuse in child birth with multiple foci and considerable energy.⁸ Activism has resulted in notable progress and a recognition of disrespect and abuse in child birth as a public health concern and as a violation of women’s human rights. The issue has gained considerable traction from global initiatives. The WHO has provided stronger guidance for the prevention and elimination of disrespect and abuse in child birth,⁹ issued new recommendations on intrapartum care for a positive birth experience,¹⁰ and developed an agenda (along with UNAIDS) for zero discrimination in health care.¹¹ Importantly, two Resolutions recognising maternal mortality as a serious human rights concern have been adopted by the UN Human Rights Council in recent years (2010, 2016).^12,13 In addition, following the adoption of the 2030 Agenda by the UN General Assembly in September 2015, a Joint Statement was issued by UN human rights experts, the Rapporteur on the Rights of Women of the Inter-American Commission on Human Rights and the Special Rapporteurs on the Rights of Women and Human Rights Defenders of the African Commission on Human and Peoples’ Rights.¹⁴ The statement called on States to

address acts of obstetric and institutional violence suffered by women in health care facilities, including with respect to forced or coerced sterilization procedures, refusal to administer pain relief, disrespect and abuse of women seeking healthcare and reported cases of women being hit whilst giving birth.

These directions point to the emergence of new norms and standards and better integration of disrespect and abuse as a core SRHR mandate.¹⁵

The objective of this Special Issue is to explore what research is needed to bring about changes that will promote a culture of more respectful care for pregnant women. A first and necessary step is to gain more clarity about what actually constitutes disrespect or abuse. This highlights the importance of pressing for greater clarity about concepts and methods, and stronger empirical studies. The second is to deepen our understanding of causal drivers, such as how disrespect and abuse may be rooted in socioeconomic or other inequalities and oppression, and in the institutional imperatives of modern medical facilities.

Power dynamics in healthcare settings often reflect entrenched biases on the basis of gender, class, caste, race, ethnicity or other sources of marginalisation, which may influence how providers treat pregnant and labouring women. Intersecting inequalities shape women’s experiences, and exacerbate the social distance between patients and providers, resulting in differential care for some groups.^16,17 When women perceive, expect or experience discrimination in health institutions, it can become a powerful barrier to maternal care.^16,18

Power imbalances between patients and providers, and the role of medical education have been highlighted before,¹⁹ yet few studies²⁰ have documented the actual processes and structures through which medical education and training institutionalise disrespect and abuse of pregnant women. Some of the papers in this Special Issue show how the values and practices imbibed by health providers through the teaching and learning processes of institutionalised medicine intersect with socioeconomic inequalities.

The Special Issue attempts to break fresh ground by bringing together research from LMICs that explores these two interacting themes as major drivers of disrespect and abuse. It begins with an overview by the guest editors, Gita Sen and colleagues, who trace the growth of the field from diverse points of origin. The authors call for clearer concepts, point out some of the limitations of current methods and put forward a working definition of disrespect and abuse, something that has been missing in the field until now. The overview also focuses on how social underpinnings throw up responses and practices that vitiate the provision of care to pregnant women in resource-constrained contexts. By identifying gaps and raising questions about the drivers of disrespect and abuse, the paper points to potentially useful directions for research and meaningful entry points for action.

Three papers on the structures and practices of institutionalised medicine follow the overview. Diniz and colleagues trace 25 years of social action in Brazil to assess the many achievements in areas of health policy and legislation against the challenges of impacting medical education and training – the spheres that hold critical levers for change towards respectful, evidence-based care. The paper demonstrates how efforts need to operate at multiple levels, both within and outside the health system, to truly transform care.

Through qualitative investigation of organisational culture in obstetric care provision in India, Madhiwalla et al. find both teaching and non-teaching hospital settings marked by social and professional inequalities, hierarchical functioning and bureaucratic processes that marginalise women. Drawing from in-depth interviews and observations, their work illustrates the mechanisms through which provider responses to health system constraints and institutional processes can lead to disrespect and abuse and impinge on maternal safety and dignity.

Abuya et al.’s study in Kenyan facilities raises a number of questions about the relationship between disrespect and abuse, clinical aspects of care and facility conditions. Capturing disrespect and abuse across defined dimensions of admission, delivery and immediate postpartum, their findings from observations reflect the ways disrespect and abuse can vary across the continuum of care. Highlighting how facility constraints influence the ways in which clinical and interpersonal aspects of care are patterned, the paper contributes to our currently limited understanding of how care is rationed in contexts of health system shortages. These findings also help substantiate that the areas of care that are prioritised are those that are tethered to tangible mechanisms of accountability.

The following three papers elucidate how inequalities, intersectional discrimination and power hierarchies play out. Chattopadhyay uses a historical lens to trace relationships between several marginalised but differently unequal groups in a conflict-sensitive state in north-eastern India. Drawing on ethnographic work on institutional childbirth among ethnically diverse women, her commentary illustrates how histories and relationships with the state that lie well outside the health system can shape provider attitudes and experiences of care. A sobering implication of the study is that quick techno-fixes to the problem may be stymied by history and geography, and may need more nuanced and contextual remedies.

As part of WHO’s multi-country study for developing consensus definitions, and validating indicators and tools for measuring the burden of disrespect and abuse, Maya et al. share qualitative insights from focus group discussions and in-depth interviews conducted in Ghana. Among their findings, they identify disrespect and abuse being heightened by women failing to follow provider instructions, more common among adolescents, and how well-meaning programmes (such as the provision of birth kits) can be leveraged by providers in ways that are against women’s best interests. This evidence points to the themes of differential power and control inherent to institutionalised medicine, and the need to better understand how intersecting inequalities contribute to women’s perceptions and experiences of abuse.

Solnes-Miltenburg et al. interviewed women and observed their interactions with providers in Tanzanian hospitals across pregnancy, birth and the postpartum period, examining women’s expectations, reactions and rationalisations of disrespect and abuse against local norms and values. They document how gender bias operates to control and discipline women through the care experience and also illustrate how poverty and gender intersect to trigger disrespect and abuse. Troublingly, they found that women who were not accompanied by their husbands for antenatal visits could be denied care, indicating that even policies designed to promote gender equality by increasing male involvement in pregnancy can sometimes be used to discriminate against women.

In another paper based on work in Tanzania, Freedman et al. share methodological insights from a mixed-methods intervention study on disrespect and abuse. Finding considerable differences in the prevalence and forms of disrespect and abuse as measured through observation by nurse researchers and self-reporting by the same women observed, they explore how abuse is normalised and internalised by both providers and women. Situating these findings within key strengths and weaknesses of human rights-based approaches to addressing maternal health, they demonstrate the need to recognise how power operates in different health system contexts. This is essential if ingrained behaviours and health system structures that enable disrespect and abuse are to change.

Finally, the commentary by the Center for Reproductive Rights traces a recent public interest litigation on behalf of a woman who faced serious neglect and abuse during childbirth at a county referral hospital in Kenya. The court’s ruling in favour of the woman provides a major boost to women’s human rights by placing disrespect and abuse in a human rights framework and pointing to government accountability to address such violations. The case recognises systemic failures and lack of quality within the health care sector as human rights violations, thereby setting a powerful precedent to demand legal redress for disrespect and abuse. It raises critical questions of accountability and the rights of women to remedial and redress mechanisms and access to justice when disrespect and abuse occurs.

This work points to the importance of legal actions, and their advantages in protecting women’s human rights in the context of disrespect and abuse, but also the difficulties in going further to fulfil and promote those rights. Such efforts at the national level are essential to complement advances at the global level through bodies like the International Accountability Panel of the UN’s Every Woman, Every Child, Every Adolescent Initiative.²¹

Translating such initiatives into positive change in institutional structures and practices requires, inter alia, a robust framework of accountability. Changes in laws, standards and guidelines must be matched by a growing body of case law, and by the creation of context-specific and practical institutions for complaints, redressal and removal of impunity. The case highlights the importance of linking judicial accountability to political accountability processes at both national and global levels.

Working toward greater accountability will complement needed advances towards better concepts, improved methods and deeper understanding of causal drivers of disrespect and abuse. Of particular concern in some of the studies presented here is the finding that apparently well-intentioned policies, even those that are meant to empower women, may have perverse effects, creating incentives that reward, or pressures that drive, an increase in disrespect and abuse towards some or all women who seek institutional care. We hope this Special Issue will encourage researchers to examine their material from multiple perspectives, and along with advocates and policy makers, to explore the pathways through which maternal safety and rights get systematically abrogated at different levels of the health system, and to find the remedies for often egregious violations of women’s human rights. RHM welcomes continued contribution on this topic in line with its commitment to generate and disseminate robust evidence that can promote, advance and protect women’s SRHR.

Acknowledgements

We thank the Open Society Foundation for its support to RHM for the publication of this Special Issue and the Bill and Melinda Gates Foundation for supporting the contribution of the Guest Editors. Authors are responsible for the content of their articles which do not necessarily reflect positions or policies of the funders.

ORCID

Gita Sen http://orcid.org/0000-0001-9010-074X

Aditi Iyer http://orcid.org/0000-0002-2177-0755