Well into labour, Meera lay ignored on a bed in the labour room of a Sub-divisional District Hospital. She lay there in pain, alone and without a birth companion. She received no information about the birthing procedure or what was about to happen to her. The labour room was managed by a lone nurse, who was busy with other cases or documenting birth and discharge notes. An hour into labour, with no baby in sight, the nurse brusquely asked Meera to push more often and exited the labour room. The verbal and physical abuses Meera faced that day were terrifying. There were no doctors, nurses or skilled birth attendants in the labour room. Eventually, Meera delivered the baby with the help of a sweeper (a non-technical staff responsible for cleaning) who had no expertise in obstetric care. The sweeper not only attended the delivery but even performed an episiotomy, stitched up the incision, removed the placenta and provided new-born care. I was deeply troubled by the fact that a sweeper who had no formal medical training, actually delivered a baby!
In 2017, I witnessed dreadful mistreatment and abuse of a pregnant woman in a public health facility in the state of Odisha, India. At that time, I was interning with the Johns Hopkins Program for International Education in Gynaecology and Obstetrics (JHPIEGO). In this blog, I would like to discuss the mistreatment of pregnant women seeking maternal health services from public health facilities and the gross violation of their human rights. I have presented my professional understanding and experiences in relation to respectful maternity care.
If we consider ‘health’ as a state of complete physical, mental and social well-being of an individual, a valid question is: where do we, as a society, stand in relation to mental well-being in maternal ‘health’?
Across the world, pregnancy and birthing babies are generally exciting and significant for most women and their families. When seeking care from health facilities, one usually expects a relationship of care, love, support, respect, empathy and effective communication with the healthcare staff. Unfortunately, in many developing countries, pregnant women seeking maternal health services are often subjected to unimaginable mistreatment and abuse, leaving them with long-lasting physical and mental trauma. While we are (slowly) moving towards achieving Millennium Development Goals and now even aim for Sustainable Development Goals, we still fall short in achieving even ‘safe motherhood’—a global initiative started in 1987 aimed at improving maternal health and reducing maternal deaths in developing countries. The concept of safe motherhood goes beyond the physical safety of mother and child and is also about providing respect, dignity, humanity, preference and choice.
The ‘Respectful Maternity Care Charter’, produced by the White Ribbon Alliance, includes rights of childbearing women against disrespect and abuse across 7 categories and has been adopted by many developing counties. The ‘WHO Recommendation on Respectful Maternity Care’ refers to care organized for and provided to all women in a manner that maintains their dignity, privacy and confidentiality. The recommendation ensures freedom from harm and mistreatment and enables informed choice and continuous support during labour and childbirth. While these recommendations are publicly available, they are often ignored in many developing countries.
The Government of India has implemented various initiatives including Janani Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram (JSSK), Reproductive, Maternal, New-Born, Child And Adolescent Health (RMNCH+A), deworming in pregnancy and Dakshata. These initiatives are primarily meant to reduce maternal and child mortality. Of these schemes, the JSY, introduced in 2005, provides cash incentives of INR 1400/- to promote institutional deliveries at public health facilities. A program evaluation of the JSY scheme conducted in 2012 suggested about 40% home deliveries; however, statistics from the National Family Health Survey and District Level Household Survey, conducted in 2015, indicate that institutional deliveries increased from 46% in 2005 to 78% in 2015. A study on the utilization of JSY in 2016, suggested that JSY-eligible women were 1.5-times more likely to deliver in government institutions compared to JSY-non-eligible women, and with no incentive, the likelihood of institutional delivery was halved. The JSSK scheme, launched in 2011, was also aimed at motivating pregnant women to opt for institutional delivery over home delivery. This scheme supplements the JSY by mitigating the burden of out-of-pocket expenses by providing absolute free medical and health care services including caesarean section, free medication and essential diagnostics and free transport.
As a woman, despite the cash incentive, the idea of seeking maternity services from a public health facility scares me. I often ponder on behalf of Indian women: “Are my dignity, respect and privacy while delivering a baby only worth INR 1400/-?” The current health system makes me question why I shouldn’t choose a home delivery over an institutional one.
We (the public health research community) often discuss the quality of care, scarcity of human resources and respectful maternity care in public health facilities in various meetings, conferences and workshops; however, real action lags behind —to bring a paradigm change in the health system’s practices. Jan Swasthya Abhiyan, a national platform of patient groups and civil society organisations, working on health and healthcare services, has suggested initiating a ‘National Level Charter’ to ensure human rights as a part of the delivery procedure and in obstetric care. A human-rights-based framework related to preventing obstetric violence should also be declared internationally.
In recent decades, reducing maternal mortality and universal access to reproductive healthcare became global priorities for United Nations agencies, national governments and civil society organizations. These priorities empower women and their communities and inspire other stakeholders to commit to broader socio-economic and political change to improve women’s health, at least in principle. However, as is clear from this blog, there’s still a long way to go before respectful maternity care will be a reality in many settings. Informed and aware people can significantly contribute to ensure respect, reduce abuse and eventually safeguard the human rights of childbearing women.
All of us should contribute to this aim.