Amidst advance action to increase positive pregnancy outcomes globally, sufficient focus and considerations have not being given to the human element, specifically the interpersonal relationships between care providers and the childbearing family. The attitude and behaviours of healthcare practitioners are critical to the overall delivery of quality maternity care and the mother's experience during childbirth. Women's experience with maternity care providers can empower and comfort them, or inflict lasting damage and emotional trauma. A lack of respectful care during childbirth is increasingly being recognized as both an indicator of poor quality of care as well as an obstacle to obtaining the infant and maternal health Sustainable Development Goal (SDG).
The purpose of this paper is to highlight the importance of Respectful Maternity Care (RMC) as a key element of broader efforts to provide quality care, which underscore the need to generate evidence on the extent to which disrespect and abusive care is practiced and its effects on mother and child and how it may impact Jamaica achieving the maternal health and gender SDGs.
Disrespectful care, Midwives, Respectful maternity care, Sustainable development goals
The Disrespect and Abuse (D&A) of women during childbirth appears to be widespread but its prevalence is not well documented. Stories of disrespect and abusive treatment meted out to women during childbirth, in healthcare facilities are shared anecdotally among families and friends generally, and it is only brought into the public domain when the outcomes are deleterious and traumatic for families. The problem for countries like Jamaica is that there is a lack of comprehensive documentation of D&A experienced by women in childbirth facilities, specifically its nature, forms, causes and prevalence.
Abuya, et al. [1], Freedman [2] have found that as many as 19% to 28% of women will experienced disrespectful and/or abusive treatment from health providers in healthcare facilities during childbirth in low and middle income nations. Prior to their findings a landscape analysis was conducted by Bowser & Hill in 2010 [3] grouped disrespect and abusive care into seven major categories which they stated tend to overlap and occur on a continuum from subtle disrespect and humiliation to overt violence. The categories are physical abuse, care that was given without consent, treating the woman with disrespect, not adhering to confidentiality, discrimination, detention in the facilities and abandonment of care [3]. Subsequent studies carried out in countries like Kenya, Peru, Zimbabwe, Ethiopia and the United States of America have used this typology as the basis to study D&A its form, causes, consequences and prevalence in the respective countries. Bohren, et al. [4] have also developed an evidenced based typology of mistreatment to include physical abuse, sexual abuse, verbal abuse, stigma and discrimination, failure to meet professional standard of care, poor rapport between women and providers, and health system conditions and constraints. These researchers have concluded that mistreatment can occur at the level of interaction between the woman and provider, as well as through systemic failures at the health facility and health system level. Additionally, it was found that poor treatment of women tend to flourish in countries where there are huge budgetary constraints, shortage of staff, poor data management, public silence, lack of standards and socio-cultural norms and practices that disempower women which can result in it becoming normalized [3,5-7]. These studies support the assertion that D&A in maternity care is widespread and require appropriate actions by policy makers and hospital administrators, but also that it is complex and multifactorial.
The World Health Organization [8] has declared that every woman has the right to the highest attainable standard of health which includes the right to dignified, respectful healthcare. Advocacy groups such as the White Ribbon Alliances have observed that D&A meted out to women in maternal healthcare continues to occur in part because governments have not committed to or invested in participatory accountability mechanisms that ensure women's rights to RMC are upheld [9]. While RMC primarily emphasizes professional ethics and respect for human rights two key aspects in the bid to eradicate the practice of D&A by healthcare providers and other staff, it also advocates positive and supportive staff attitudes and behaviors that increase a woman's satisfaction with her birth experience. This model when practiced provides safe and individualized care with excellent outcomes. This however, can only be achieved if the woman and the healthcare provider's relationship is characterized by caring, empathy, support, trust, confidence, and empowerment, as well as gentle, respectful, and effective communication to enable informed decision making. Respectful maternity care is a universal human right that is due to every childbearing woman in every health system, Therefore, the mistreatment of women in childbirth is clearly a health system failure and violation of this right. We believe that including RMC as a strategy to achieve SDGs # 3 & 5 is an opportunity for Health care providers to play a key role in putting women and children at the centre of maternity care in countries, such as Jamaica.
One of Jamaica's most successful programmes to reduce maternal mortality is having a skilled birth attendant at every birth. However, anecdotal reports have indicated that many women in Jamaica are experiencing abusive care by healthcare workers, many have vowed never to return to some of Jamaica's major maternity centres [10,11]. Despite several public outcries and the promise by authorities to overhaul the public healthcare system, pockets of reports of D&A remain in Jamaica. Documented evidence has shown that failure of government to act can lead to lack of local accountability of services by providers and lack of action taken by managers against those who are at the higher levels of their profession [3]. Additionally, institutional factors such as professional insecurities, perceived need to assert "control" over the environment and sanctioning of the use of coercive and punitive measures to do so, and an underpinning ideology of patient inferiority are some underline causes [12]. Without meaningful mitigation strategies however, these practices could lead to the normalization of abuse by healthcare providers and health facilities. Such practices could also result in women delaying, withholding pertinent information from care providers or avoid seeking appropriate and timely care at health facilities [3,6].
Interpersonal care that is disrespectful and abusive to women before, during and after child birth is unacceptable and a violation of their basic human right. Human rights are fundamental entitlements due to all people, recognized by societies and governments and are enshrined in international declarations and conventions. All childbearing women need and deserve respectful care and protection of their dignity, autonomy and right to self-determination from their care providers especially at this time when they are most vulnerable and emotional. Consequently interpersonal care that is abusive and disrespectful has the potential to form negative, disempowering and traumatic experiences for women that will inform their future relationships with care providers and the healthcare facilities. Therefore, now is an opportune time for all stakeholders to recognize that poor treatment of women in maternity centres could be a significant barrier to realizing the international goals such as maternal health and women's empowerment.
We believe that Sexual Reproductive Health Practitioners such as midwives who are trusted and competent to safely and positively welcome children into the world have a moral obligation to these pregnant families. As frontline workers, midwives have an integral and joint role to play in the healthcare delivery system for any country to achieve its maternal goals. Importantly, midwives are predominately women as such they are in a position to ensure that women, their babies and families receive sensitive care with respect, compassion, kindness and dignity in a safe environment. It is well documented that relationship-based care practiced by midwives can lead to successful breastfeeding, reduce pre-term births, increase vaginal births, decrease surgical interventions during births, decrease admissions of neonates and see women having more positive experience of labour and birth [13]. Very importantly, the framework for quality maternal and newborn care falls within the remit of midwifery practice. They should therefore seize this critical moment to raise awareness and agitate civil society demand for RMC rights, mobilize communities to hold local leaders and service providers accountable for RMC rights; and secure commitment at the national level to institutionalize RMC as the standard of care [14].
There is currently an urgent need to generate local evidence to ascertain the magnitude, type, prevalence and causes of disrespect and abuse towards childbearing women in our context [8]. Local data can influence policies and procedures in tandem with evidence-based practice guidelines that have proven to work, can lead to the development of context appropriate strategies and interventions. Coupled with continued education, building midwives' capacity for research and RMC, revision of midwifery curriculum and changes in public policy are concrete steps to address the issue of disrespectful and abusive care. Little is known on whether or not D&A during childbirth could compromise the achievement of the SDGs # 3 & 5. Currently, there is an established interdisciplinary team, led by a midwife, to undertake a study to explore the extent to which RMC is being practiced in Jamaica.
This paper has highlighted that it is important that women's relationship and interactions with care providers are premised on respect for fundamental rights including mutual respect, dignity, autonomy and self-determination [9]. Negative attitude and behaviours of healthcare practitioners can greatly compromise pregnancy outcomes and the quality of maternity care. Putting mothers and their needs at the centre with midwives playing a key role is an important strategy that could mitigate the occurrence of disrespect and abuse during childbirth. Therefore, creating a culture of respectful care among sexual and reproductive health workers, such as midwives will minimise the occurrence and tolerance for negative attitudes and behaviours that undermine and disempower women when they are most vulnerable. This will also create a culture of accountability and supportive environment for women using a rights-based approach. We are therefore urging the Jamaican authorities to implement programmes that integrate the principles of RMC in the national strategies to ensure that it is on target to achieve the maternal health and gender SDGs for 2030.