Improving the experience of pregnant and birthing women

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HRP at 50 logoA growing body of evidence shows that the mistreatment of women in maternal health care is a reality worldwide. For several years, the World Health Organization (WHO) and HRP (the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction) have been documenting this human rights violation, and its impact on health and wellbeing.

The WHO guideline on intrapartum care for positive childbirth experience includes a number of related recommendations, but little research has been done into what interventions can be put into place to make a difference – until now.

HRP and WHO authors and collaborators have now published a special series of five papers in the journal PLOS Global Public Health exploring a range of strategies on different themes to end mistreatment of women during childbirth and improve respectful care.

The first of these papers looks at theories of interventions to reduce physical and verbal abuse. In this paper two themes emerge: first, that violence is normalized in society, particularly against “othered” groups; and second, the belief that mistreatment of women is necessary to reduce clinical harm.

The authors make the point that solutions must not focus merely on staff failures through trainings or audit procedures, but must, in addition, look for longer-term solutions that can encourage sustainable changes in attitudes and beliefs that then make a permanent change in behaviour. This would have the effect of changing behaviour at all levels of the health and social care system, from first-line health workers to senior staff and middle managers, and from organizational funders and auditors to leaders of local communities, politicians and any other key stakeholders.

The authors comment, “The intention is that resulting individual, group, institutional, and community norms change profoundly and sustainably to resist ‘othering’ at a fundamental level, and into the longer term, after the formal intervention programme is complete.” Implementation science tools, which integrate practical solutions, such as the theoretically informed Behavioural Change Wheel, might be helpful in designing tailored interventions suitable for each context.

The second article looks at strategies to reduce stigma and discrimination, an important part of the mistreatment experienced by women. Whilst much research has been done to describe stigma and discrimination experienced by women in sexual and reproductive healthcare settings, more needs to be done to better understand how to end it.

This new research therefore focuses on interventions that could make a difference and underlines how any policy relating to healthcare and improving equity, should consider including and measuring stigma and discrimination. What is more, and as the authors comment, “efforts to address mistreatment will not be effective when stigma and discrimination persist.”

This paper therefore provides an analysis and recommendations, including a multi-level stigma model for sexual reproductive health and rights, that can inform actions and implementation research to promote respectful, person-centered care for all. The authors note that more work is needed to challenge and dismantle societal conditions, sociocultural norms, and institutional policies that influence the opportunities and wellbeing of stigmatized groups.

A female health worker uses a flip chart during a consultation with a pregnant woman, CambodiaThe third article in the series, which has just been published, looks at communication strategies to improve interpersonal communication to reduce mistreatment of women. Two main approaches were identified: the training of health workers, and using communications tools. Whilst most interventions uncovered focus on providing information, incorporating other communication goals – such as building a relationship, including women and their partners in making decisions – could further improve the experience of care for women, their partners and their families.

The fourth article in the series looks at how factors relating to organizations and working environments can affect mistreatment in low- and middle-income countries.  There is growing evidence on how health systems staff shortages and other barriers can affect respectful maternal care, but this paper identifies and addresses significant gaps in research relating to multiple work and organizational factors. This includes key organizational challenges related to high workload; unbalanced division of work; lack of professional autonomy; low pay; inadequate training; poor feedback and supervision; and workplace violence – all of which are differentially influenced by shortages of resources.

In response, the broad strategies identified are planning for pressures and health worker and staff shortages, providing supportive supervision, boosting resilience through peer support, reshaping leadership and mitigating workplace violence.

The fifth paper was a “Critical Interpretive Synthesis”, which aims to increase understanding of the drivers of power-related mistreatment of women. It did this by exploring and consolidating literature from across different fields of study, to advance theory and practice on this theme.

The authors identified multiple, underlying power-related drivers behind mistreatment at diverse levels of society, including: intrapersonal (e.g. lack of knowledge about one’s rights); interpersonal (e.g. hierarchy between patients and health workers); community (e.g. pre-existing widespread discrimination against indigenous women); organizational (e.g. pressure for health workers to achieve performance goals), and law and/or policy (e.g. lack of accountability for violations of human rights). The authors conclude that addressing these drivers requires the engagement of different stakeholders, including women, community, health workforce, and policy-makers will be critical moving forward.

Taken as a whole, the authors of the series noted that whilst many powerful interventions with great potential for change have been unearthed by this research, much more needs to be done – particularly on how to develop and test context-specific models for optimal and sustainable implementation of respectful care for all.

What the authors say

Özge Tunçalp, one of the authors of the series and a medical officer at HRP commented, “These findings help inform interventions to make positive change for the quality of care experienced by pregnant and birthing women worldwide.”

She continues, “They don’t however give us a magical solution to end mistreatment and improve respectful care for all, right away. The drivers are much more complex than that. We therefore need to bring together people from across sectors and disciplines to make deep systemic change – specific to each particular context, and to be honest and proactive about this complexity.”

The authors underline the important implementation research agenda which is opened up by the special series – and the crucial need for more implementation research which demonstrates and replicates the usefulness of specific strategies to end mistreatment of women in maternity care and beyond.

These findings will be crucial in informing a new WHO knowledge translation companion for respectful maternal and newborn care, planned to be published in 2024, which will aim to support lasting positive change in health systems. 

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