The WHO recommendation on respectful maternity care, during labour and childbirth asserts that care must be organized for and provided to all women in a manner that maintains their dignity, privacy, and confidentiality and ensures freedom from harm and mistreatment and enables informed choice and continuous support during labour and childbirth. India has a maternal mortality ratio of about 174 per 100,000 live births and most of the cases are attributed to complications during labour and childbirth. The quality of care before, during and after birth can considerably reduce the ratio in developing nations.
What is Respectful Maternity Care (RMC)?
In the 1990s, the global maternal health community advocated against ‘obstetric violence’ during a childbirth activism movement in Latin America. From then to now, the dehumanizing treatment of mothers during childbirth by health professionals has become a global topic of concern. Disrespect and abuse during childbirth can include physical, sexual or verbal abuse, stigma, and discrimination, low standards of care, absence of rapport between health personnel and mothers as well as health system conditions and constraints.
Respectful maternity care aims to end the disrespect and abuse of mothers by focusing on the interpersonal aspect of maternity care. It emphasizes the fundamental rights of both the mother and the infant and recognizes that all women need and deserve respectful care during childbirth. In 2016, the WHO published, ‘Standards for improving quality of maternal and newborn care in health facilities,’ a set of guidelines that underline the urgent need for the humanisation of childbirth through improved clinical and experiential standards for all mothers.
Core Characteristics of Respectful Maternity Care
According to former FIGO President Mahmoud F Fathalla, ‘Women have a human right to go safely through the risky journey of pregnancy and childbirth, a right that should be respected, protected, and implemented.’ This encompasses rights like freedom from harm and ill-treatment, right to information, informed consent and refusal, and respect for choices and preferences, including the right to companionship, choice, dignity, respect, and confidentiality.
All expectant mothers have a right to equitable care, freedom from discrimination, timely health care and the highest attainable level of health. It also means liberty, autonomy, self-determination for women, and freedom from coercion or detention in health facilities. Women in India have stressed on privacy and the need for a companion during childbirth.
Recommended Practices for Respectful Maternity Care
To work towards respectful maternity care, health facilities must respect the beliefs, traditions, and culture of expectant women. Medical professionals must empower the woman and her family to actively participate in health care. Women must be given a choice of a companion, continuous support, privacy, right to information and freedom of movement during labour and childbirth. These practices can be life-saving as women might abstain from seeking medical care in the future after being abused by a health provider. Natural birth is a prime example of respectful care as it facilitates one of its important components skin-skin contact with the child through early breastfeeding. Federation of Obstetric and Gynaecological Societies of India (FOGSI) with Indian Academy of Pediatrics (IAP) recognising the need has released guidelines vis a vis early breastfeeding even after Caesarian sections.
Gaps in Medicalized Care for Mothers
In Tanzania, among 3003 women participated in a discrete choice experiment and it was revealed that the greatest predictor of their health facility preference was kind treatment by doctors. The medicalized model has come under criticism for failing to provide respectful maternal care to women. Some of the practices are said to be unwarranted or unnecessary and shift power from woman to provider. They may even harm the mother and baby and are solely reliant on technology despite no proven benefits.
Procedures that may be harmful to the mother and baby are cesarean sections, episiotomy, electronic fetal monitoring, induction or augmentation of labour. Harmful medical practices include administration of oxytocin at any time before delivery in such a way that the effect cannot be controlled, early cord clamping, over-use of anesthesia/analgesia, lack of companion/family during labor among others. These gaps must be bridged to bring about a change in maternity care in India.
Making RMC a Norm in Healthcare
The key stakeholders that can help in making RMC a norm are expectant mothers, families, communities, women’s advocates, health care providers, and policymakers. Advocacy of RMC at all levels can foster equal participation of all stakeholders. Studies on women’s choices and preferences can aid RMC in the absence of data. Medical professionals and communities should plan, implement and evaluate RMC together. Healthcare personnel must be trained with requisite skills to provide respectable maternity care and resources must be mobilized for effective implementation. This Mother’s day, let’s pledge to sensitize health professionals to the issue of respectable maternity care and work towards upholding the dignity of all expectant women.
Dr. Nandita P Palshetkar
MBBS, MD – Obstetrics & Gynaecology
President – FOGSI (2019)