General Concepts and Considerations May 2013 RESPECTFUL MATERNITY CARE: A Worthwhile Investment for Health Care Services, Professionals, Clients and Communities General Concepts and Considerations May 2013

General and Specific Session Objectives General Objective: To share information concerning Respectful Maternity Care (RMC) and its promotion Specific Objectives: Define Respectful Maternity Care Describe the content of RMC Describe avenues for promotion of RMC Present key recommendations Today we want to share information concerning Respectful Maternity Care and its promotion, and specifically to: Define Respectful Maternity Care Contrast RMC with medicalized care Describe the content of RMC Describe avenues for promotion of RMC Present key recommendations

Respectful Maternity Care: General Concept “Respectful Maternity Care” (RMC) is an approach that: Focuses on the interpersonal aspect of maternity care Emphasizes the fundamental rights of the mother, newborn and families, including protecting the mother-baby pair Recognizes that all childbearing women need and deserve respectful care and protection of the women’s right to choice and preferences Respectful maternity care: -Focuses on the interpersonal aspect of maternity care - Emphasizes the fundamental rights of the mother, newborn and families, including protecting the mother-baby pair - Recognizes that all childbearing women need and deserve respectful care and protection of the women’s right to choice and autonomy

Rights in Respectful Maternity Care Type of Abuse and Disrespect Human Right in Maternity Care 1. Physical abuse Freedom from harm and ill treatment 2. Non‐consented care Right to information, informed consent and refusal, and respect for choices and preferences, including the right to companionship of choice wherever possible 3. Non‐confidential care Confidentiality, privacy 4. Non‐dignified care (including verbal abuse) Dignity, respect 5. Discrimination based on specific attributes Equality, freedom from discrimination, equitable care 6. Abandonment or denial of care Right to timely healthcare and to the highest attainable level of health 7. Detention in facilities Liberty, autonomy, self‐determination, and freedom from coercion Source: Bowser and Hill 2010

Characteristics of Healthcare to be Avoided Impersonal Centered on the professional and not on the woman and her family Disempowerment of the woman Family unit separated during labor and birth Often healthcare may be centered on the professional who is giving the care, and making the care convenient and comfortable for the healthcare provider rather than for the woman. This also disempowers the woman and robs her of the dignity she deserves.

Respectful Maternity Care Promotes: Respect for beliefs, traditions and culture Empowerment of the woman and her family to become active participants in health care Continuous support during labor Choice of companion during labor and birth The right to information and privacy Freedom of movement during labor In contrast to medicalized care, RMC promotes: Respect for beliefs, traditions and culture – these all form part of who the woman is Empowerment of the woman and her family to become active participants in health care – women should be participants rather than “objects” of care Continuous support with the companion of choice during labor – Continuous support during labor has been shown to facilitate improved health outcomes for mother and baby Freedom of movement during labor so that the woman is not confined to a bed or table The right to information and privacy – Keeping the woman and family “in the dark” is a barrier to effective and respectful care, just as failing to observe a woman’s need for privacy is a violation of her need for respectful care

RMC Promotes (continued): Choice of position during birth Good communication between client and provider Support of the mother-baby pair Improvement of working conditions and respectful and collaborative relationships among all cadres of health workers Prevention of disrespect and abuse and institutional violence against woman RMC also promotes: Choice of position during birth so that the woman is not forced to lie in a supine position Good communication between client and provider – the provider must seek to communicate effectively, speaking “with” the client rather than “down to” her and her family Protection of the mother-baby pair – Mother and baby should not be separated after birth. Unless the baby is ill, it should not be taken away to a nursery Improvement of working conditions and respectful and collaborative relationships among all cadres of health workers – Continuity of care requires effective communication among all people who have a part in care of the client Prevention of disrespect and abuse and institutional violence against woman – Violence can easily become institutionalized. RMC guards against the disrespect and abuse.

Respectful Maternity Care Can Be Life-Saving RMC is lifesaving— women may refuse to seek care from a provider who abuses them or does not treat them well, even if the provider is skilled in preventing and managing complications (ACCESS Program. 2008. Best Practices in MN Care: LRP) There is no value in having well equipped facilities or highly trained care providers if a woman will not seek services in that site or from that provider because she or her sister or a neighbor have received abusive or disrespectful care. Women may choose to stay at home without care or treatment rather than subject themselves to abuse and disrespect.

Historic Background 1975 Birth of the Humanizing Childbirth movement (Brazil) 1985 WHO/PAHO conference on appropriate technology for birth (Brazil) 1996 Mother-Friendly Childbirth Initiative (USA) 2000 First international conference on Humanizing Childbirth in Fortaleza (Brazil) 2010 USAID/URC–supported Landscape Analysis on abuse and disrespect in childbirth care 2011 Respectful maternity care charter, White Ribbon Alliance (WRA) Some providers, advocates and activists have been actively concerned for the respectful care of women seeking maternal health services. Many of the elements of the “Humanization of Childbirth” movement can be seen in the Respectful Maternity Care movement.

Respectful Maternity Care Charter The charter can be used to talk about the problem of disrespect and abuse during maternity care within a positive, right-based framework, so we can start to lift the “Veil of Silence” on this issue. The charter builds a strong positive global standard for Respectful Maternity Care and affirms maternal health rights as basic human rights grounded in international declarations We hope the Charter can be used to: Raise awareness of the problem in a way that avoids blaming/shaming Show that the rights of childbearing women have already been recognized in guarantees of human rights Provide a tool for advocacy at all levels and a basis for accountability Provide a platform for building childbearing women’s sense of entitlement to quality maternity care by aligning it with international human rights

Respectful Maternity Care: Recognizes Multiple Stakeholders Respect for women’s rights and preferences Appreciation, compensation and respect for health care providers Central involvement of women – community and national leaders – in planning and evaluating maternal health programs Respectful maternity care respects the woman’s rights and preferences, but also appreciates, compensates and respects healthcare providers. Healthcare providers who feel respected and valued are more likely to show respect to the woman seeking maternity care. Likewise, the community and national leaders have a vital role to play in ensuring respectful maternity care for women seeking maternity care.

Key Stakeholders in RMC Pregnant women Families Communities Healthcare Providers Individual providers Professional associations Women’s Advocates RESPECTFUL MATERNITY CARE In fact, the inter-connectedness of key stakeholders is made more apparent in this graphic. Each of these entities has a vital role to play. Human Rights Activists Training Institutions Policy Makers Donors

Contributors to and Impact of Disrespect and Abuse in Childbirth on Skilled Care Utilization Here is another graphic that goes beyond the stakeholders to listing the contributors to disrespect and abuse. It shows how these contributers influence the use of skilled care at birth, and the connection to MDG-5. Source: Hill K and Stanton ME, 2010

Key Action Points POLICY RESEARCH LEGAL ACTION ADVOCACY EDUCATION Here we see the key action points for RMC: Policy that supports RMC is necessary for the proper laws, regulations, and protocols to be upheld. Research is needed to inform policy and to measure the attainment and gaps in RMC. Advocacy may be needed even before policy is developed or a need is recognized. Advocacy may be required with policy makers, politicians, care providers and communities Education in RMC is essential if care providers are to learn RMC as an essential competency when providing maternity care. And legal action may be necessary to ensure adherence to policy and ensure that standards are observed. COMMUNITY/ SOCIAL ACTIVISM SERVICE DELIVERY HEALTH SYSTEM

General Recommendations Include advocacy at all levels to create functional networks among the wider body of stakeholders Involve community and media in each step of the process Where data is absent, conduct studies on women’s preferences and choices related to respectful maternity care Ensure political commitment at the national, district and local levels so that appropriate policies and standards are in place. Some general recommendations when the vision is to see RMC for all women would be to: Include advocacy at all levels to create functional networks among the wider body of stakeholders – We’ve spoken of the various stakeholders who can collaboratively be involved in RMC. Advocacy may be needed among each group. Involve community and media in each step of the process – This is another part of advocacy and ensuring broad community involvement Where data is absent, conduct studies on women’s preferences and choices related to respectful maternity care – In some places you may have a good understanding of women’s preferences and choices, but in other places research may be needed Ensure political commitment at the national, district and local levels so that appropriate policies and standards are in place – Commitment, including budgetary commitment must be present at all levels

General Recommendations (continued) Professionals and communities should collaborate in all planning, implementation, and evaluation of RMC Knowledge, skills and attitudes that support RMC must be required in all education and training programs that involve healthcare workers Mobilize resources to support implementation of RMC Professionals and communities should collaborate in all planning, implementation, and evaluation of RMC – Planning and evaluation are just as important as implementation. All stakeholders must be involved at each step. Knowledge, skills and attitudes that support RMC must be required in all education and training programs that involve healthcare workers – Graduates from medical and nursing and midwifery schools must be competent in respectful maternity care; and inservice training must incorporate these competencies as well in order to have sustained institutionalize RMC in place Mobilize resources to support implementation of RMC – Not only financial resources are needed, but also human resources and resources for communication are necessary.

WE ALL HAVE A ROLE IN ASSURING THAT ALL WOMEN HAVE RMC! THANKS!

References Bowser and Hill. 2010. "Exploring Evidence and Action for Respectful Care at Birth”. USAID, TRAction Project. Hill K. and M.E. Stanton. 2010. Promoting Evidence and Action for Respectful Care at Birth, a presentation at the USAID Mini-University at Georgetown University. ACCESS Program. 2008. Best Practices in Maternal and Newborn Care: Learning Resource Package. Module 4: Women-friendly Care. Jhpiego: Baltimore-MD, USA. White Ribbon Alliance website: http://www.whiteribbonalliance.org/ URC website: http://www.urc-chs.com/