Several people tagged me in or sent this article to me via Facebook when it was published in the NY Times on June 30th. Shortly thereafter, I was invited to attend a two day meeting here in Dar es Salaam related to Respectful Maternity Care (RMC) and how it can be further incorporated into the activities already in place by NGOs, the Tanzanian Ministry of Health and Social Welfare, and organizations such as USAID. I was included by the invitation of the head of a multi-NGO project and I was really the only person there who was not affiliated with a large organization. Abuse during childbirth, or what is being called, perhaps more positively, Respectful Maternity Care, has interested me since the first time I was in a Tanzanian labor ward and knew enough Swahili to understand what was being said. Some of the abuse isn't verbal and it's clear what is happening even without knowing the language. The article in the Times was basically a short press release about a new review article that was recently published. The original journal article sought to review a number of previously published studies in an attempt to define and count what the authors more generally called mistreatment during childbirth.
In the meeting, we heard presentations on projects that have been done in Kenya and Tanzania both to describe the extent of mistreatment during childbirth, as well as interventions that have been meant to improve the interactions between providers and women. We discussed the "drivers" of the abusive or disrespectful behavior, public health speak for motivating factors. Basically, the behaviors can be explained in a number of ways, with major factors in Tanzania being things like severe staff shortages and burden of work, nurses who don't have sufficient skills when faced with a difficult delivery, who then resort to hitting patients or yelling at them to "make the baby come out," and the normalization of poor treatment that is transferred from older, more experienced nurses to those who have recently graduated, to name a few. On the community side, there is a lack of avenues for addressing complaints in a safe and anonymous way, as well as a lack of knowledge about what is and is not appropriate treatment by providers in the health care setting. The people from USAID, particularly from the Washington DC offices, were framing the issue in the language of human rights. Now, while I don't have any problem with this and do, personally, believe that women have a right to respectful and dignified care that is culturally appropriate, I was wondering whether or not that rhetoric really resonates with community members here. I only say this because, during a couple focus group discussions we did in the villages, people complained about the concept of human rights and the rights of the child. They saw these ideas as taking away some of their autonomy as parents, as a way for the state to claim ownership of their children and push its way into their families. I do, however, think it's important to discuss with men, women, and community leaders so that they are aware when providers are not behaving at the highest level of care and ethics.
Another issue is in the training of healthcare providers. We discussed modifying the curriculum for nursing students but it seems to me that one of the biggest challenges is when nursing students start doing practicals in hospitals. That's where they learn and are enculturated into this system and mode of behavior. If you see all of the older, experienced nurses doing it, it makes sense that you might think it was actually acceptable in practice, even if your textbook said it's not. I've seen it in action and it's nearly impossible for newer nurses to resist assimilating onto the maternity ward in this way, even if they never yelled at or were disrespectful to any patient on a different ward. I had one nurse tell me that when she first started on maternity, she was determined to not yell at or hit patients but she "quickly learned you had to hit them and yell at them sometimes to make them give birth." Nurses often explain this to me by saying that women in labor, especially the second stage, when they are pushing, are not in their right minds and don't always listen well or know what they are doing. Therefore, to cut through that and make the woman pay attention and push the baby out, they yell or hit her or are otherwise forceful.
The disrespect goes beyond those issues of physical and verbal abuse to more subtle forms of abuse such as denying privacy, not giving sufficient explanations necessary for obtaining consent, and not providing women with information about taking care of themselves and their baby after birth.
In one area of Tanzania, they were experimenting with the use of a Patient Rights Charter. The charter included the rights and responsibilities of both the patients and the providers. In the district hospital where the organization was using the charter, they cited an increase in patient satisfaction and perceived quality of care. One of the reasons this issue is perceived of as so important is because nearly half of women in places like Tanzania are still not making it to health facilities to give birth, putting them at greater risk if they develop complications, and contributing to a rather stubborn maternal mortality rate that hasn't really seen any significant reductions in recent years. The thought is that with more respectful care, women will be more likely to avail themselves of biomedical healthcare, facility-based services. We discussed some other ideas for improving care and fostering respect, including encouraging birth companions, which are thought to be a very powerful tool for reducing disrespect and abuse that doesn't require a multi-prong approach. The problem with this is that the infrastructure of most places in Tanzania just will not accommodate this. Perhaps in dispensaries or health centers that see only a few births per month, but district and regional hospitals are often so overcrowded already that the thought of where a birth companion for every woman would go is enough to make most doctors, nurses, and administrators dismiss the idea out of hand. There just physically isn't any place to put more people in many labor wards and even in ante or post-natal rooms where, in Sumbawanga, women were nearly always sharing a bed with at least one other woman. The idea behind birth companions is that they would act as an advocate and a watchdog for the woman. They would be able to make sure she is getting attention and care, as well as being able to deter or report any instances of disrespect and abuse. I think this will also only be truly effective if these people, the companions, also know the rights of women and the best ways to interface with the hospital system and its procedures. Otherwise, as I've seen happen, it's possible the companion could even become complicit in the abuse, allowing it to happen because they think it is being done by the nurses in order to help the woman giving birth.
I'll just end with a link to this article, which is a heartbreaking look at a maternity ward in India that chronicles the abuse that is all too common in many places throughout the world.