“After the injection, I gave birth. The doctor had left by then and the nurse said she would not help me until the head of the baby came out. I was assisted by one of the patients who was waiting to give birth. [The nurse] later came and took the baby . . . [and] told me to get off the bed and wipe the bed.”1
This childbirth experience from a Kenyan woman is all too common in developing countries. Barriers such as costs, limited transportation, lack of information, cultural preferences, staff shortages, and poor quality of care2 discourage many women in low and middle income countries from seeking care in facilities because of perceptions and/on past experiences of disrespect and abuse during childbirth.3
Despite an increase in skilled birth attendance globally, about 50 percent of births in sub-Saharan African and Southeast Asia still occur outside of a health facility. Giving birth without a skilled provider significantly increases the risk of death for the mother and newborn.4 Almost three million women and infants die each year because they do not receive quality skilled care.5 Eliminating disrespect and abuse in health facilities during childbirth is an opportunity to improve quality of care and prevent maternal and infant deaths.
In 2009, the Health Research Program initiated research to generate evidence and focus global attention on disrespect and abuse during facility-based childbirth. As a result of USAID’s leadership, these efforts led to a global movement to promote Respectful Maternity Care (RMC) as a human right. Prior to 2009, there was limited documentation of the scope and impact of disrespect and abuse in health facilities during childbirth.6
In 2010, USAID’s Translating Research into Action Project (TRAction) convened a stakeholder meeting and commissioned a landscape analysis to shed light on the issue. This widely cited Landscape Analysis provided the first typology of disrespect and abuse and a frame for advocacy and research actions. USAID conducted subsequent studies on disrespect and abuse in Tanzania and Kenya to: 1) quantify and describe disrespect and abuse; 2) develop and test approaches to address it; and 3) generate evidence on how to better measure disrespect and abuse and implement interventions. Additional research on the types and manifestations of disrespect and abuse was conducted among an indigenous population in rural Guatemala. 7
In Tanzania, 19 percent of women reported experiencing disrespect and abuse upon facility exit, which increased to 28 percent at home during follow-up.7 In Kenya, 20 percent reported being humiliated upon facility exit.8 Further, findings from the Tanzania and Guatemala studies suggested that women who reported disrespect and abuse were less likely to plan delivery in a facility in the future. All three studies uncovered factors contributing to disrespect and abuse including societal factors such as historical marginalization of certain populations to institutional factors and a lack of accountability, substandard infrastructure, limited resources, stressful working conditions, and poor health worker supervision.
While TRAction focused on research and evidence generation, the White Ribbon Alliance (WRA) and other partners worked to advance the RMC agenda through global advocacy. In 2011, the RMC Charter was launched, which called for protecting human rights of childbearing women. By 2013, RMC was declared a human right at the Global Maternal Health Conference and included as a key tenet in the manifesto for maternal health. On April 11, 2014, the first International Day for Maternal Health and Rights was celebrated globally. In addition, the World Health Organization (WHO) endorsed the right to dignified, respectful maternal health care by publishing a statement on disrespect and abuse in facility-based birth. WHO identified RMC as a key component of quality care in the WHO Quality of MNH Care Framework.9 RMC continues to gain prominence around the world. Afghanistan, India, Kenya, Malawi, Nepal, and Nigeria integrated RMC into national policy, standards of maternal care, and training of providers.10
The Health Research Program’s support of implementation research coupled with global advocacy helped catalyze a movement to protect the safety and dignity of women during childbirth. The RMC agenda is now focused on supporting additional countries to mobilize against disrespect and abuse, scaling up locally appropriate interventions, and ensuring RMC is integrated into the broader quality of care movement.11
Check out the following videos to learn more about the global movement for RMC.
2Bohren, M.A., Hunter, E.C., Munthe-Kaas, H.M., Souza, J.P., Vogel, J.P., Gülmezoglu, A.M. (2014). Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reproductive Health. 11(71) doi:10.1186/1742-4755-11-71.
4Boerma, T., Mathers, C., AbouZahr, C., Somnath, C., Hogan, D., Stevens, G. (2015) Health in 2015: from MDGs, Millennium Development Goals to SDGs, Sustainable Development Goals. Retrieved from World Health Organization website
7Kruk, M.E., Kujawski, S., Mbaruku, G., Ramsey, K., Moyo, W., Freedman, L.P. (2014). Disrespectful and abusive treatment during facility delivery in Tanzania: a facility and community survey. Health Policy and Planning. 1(8). doi: 10.1093/heapol/czu079
8Abuya, T., Ndwiga, C., Ritter, J., Kanya, L., Bellows, B., Binkin, N., Warren, C.E. (2015). The effect of a multi-component intervention on disrespect and abuse during childbirth in Kenya. Pregnancy and Childbirth. 15(224). doi 10.1186/s12884-015-0645-6
9,10Ramsey,. K., Ateva, E., Peca, E. (2016). From Anecdote to Action: Catalyzing the Respectful Maternity Care Movement. [Power Points Slides].