As is well known, the target set by the MDGs to reduce global maternal mortality by 75% has fallen short – only a 45% reduction was observed between 1990 and 2015. As a reminder: 50% of global maternal deaths occurred in 5 developing countries (India, Nigeria, DRC, Ethiopia, and Pakistan) in 2015; 66 % of all deaths took place in Sub-Saharan African countries. This stems from non-utilization of and lack of access to life saving obstetric and maternal health care services, mainly in developing regions of the world.
Fear of mistreatment or Disrespect and Abuse (D&A) during facility-based childbirth is one of the main drivers of home deliveries which predispose women to death from highly preventable causes of maternal mortality. D&A is not only a deterrent to service utilization, but also a violation of basic human rights. A landscape analysis revealed seven categories of D&A during facility based childbirth: physical abuse, non-consented care, non-confidential care, non-dignified care, discriminatory care, abandonment of care, and detention in health facilities. D&A is fast becoming a global concern due to its increasing prevalence in health facilities. Following the categorization of D&A in 2010, the Respectful Maternity Care Charter: Universal Rights of Childbearing Women was developed by the White Ribbon Alliance (in 2011)and adopted by several countries and organizations in order to promote Respectful Maternity Care (RMC) across the globe. In 2014, the WHO released its statement on the prevention and elimination of D&A in light of the urgent need to address the high level of D&A and to promote human rights.
“Every woman has the right to the highest attainable standard of health, which includes the right to dignified, respectful health care.” WHO, 2014
The tragic story of Salome Karwah, a Liberian Ebola fighter and survivor and a TIME person of the year, who recently passed away, shows that the road towards RMC is still long in (too) many health systems. Karwah did not discriminate against people during the Ebola epidemic, but showed empathy and cared for them, while others turned them away. Unfortunately, what she experienced during her own recent postpartum convulsion was rather different. Instead of getting the urgent treatment she deserved, she faced stigma and lack of care because she was seen as “an Ebola survivor” and health care workers did not want contact with her body fluids. In short, this would have been a preventable death if the health system had provided the RMC Karwah deserved for treatment of her convulsion.
Respectful maternity care, defined as “the humane and dignified treatment of a childbearing woman throughout her pregnancy, birth, and the period following childbirth” is an approach to mitigate D&A in health facilities. Contributors to D&A cover broad arrays of the health systems, ranging from individual to policy level factors. Hence, the main principles of RMC are drawn from the concept of people-centred health care, comprising micro, meso, and macro level health systems factors. Tremendous efforts are required to halt these multifaceted drivers of D&A, which often include – let’s not forget – overburdened and underpaid staff.
To better promote RMC, the “Quality” aspect of UHC should be given due emphasis apart from the global commitment to expand geographical and financial access to maternal health care services. The (just launched) Lancet Global Health Commission on High-Quality Health Systems in the SDG era is thus very timely – it will prioritize defining and researching health systems quality in the context of developing countries to better address the challenges in meeting the SDGs. RMC is not just about health facility related quality improvement activities; it should also engage in and capitalize on women’s empowerment to claim their rights, and community participation in the process. Taking into account the global burden of maternal mortality, equitable investment should also be allocated by international development agencies. Besides, countries should also increase their own commitment to finance the health sector in general and maternal health services more specifically to address issues related to D&A.
If the world is to achieve SDG target 3.1 of reducing the maternal mortality rate to below 70 per 100,000 live births, a concerted effort by all stakeholders will be needed to promote and invest in RMC. Last but not least, Respectful Maternity Care is not only about dealing with “women’s issues”; it’s also about creating healthier families, communities and nations.
We better don’t wait till 2030 to make substantial progress on this key SDG agenda.