Midwifery 30 (2014) 154–157
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Commentary
Respectful maternity care – How the UK is learning from the developing world Brigid McConville (Director, White Ribbon Alliance) White Ribbon Alliance for Safe Motherhood UK, London
How women are treated in childbirth is increasingly a hot topic. Campaigners are insisting that this is a fundamental issue of human rights and the media is taking up women's call for dignity and respect during childbirth We've long prided ourselves on our midwifery care in the UK. And rightly so. To have free access to the services of well trained professional midwives throughout pregnancy, birth and afterwards, is a dream still out of reach for millions of women in many less fortunate countries. Not to mention our excellent safety record; not to mention our hugely popular television documentaries and dramas! Why then are British midwives increasingly turning to the methodology of ‘Respectful Maternity Care’, with its Charter of Rights, as pioneered across Africa and Asia by the global network of maternal health advocates in the White Ribbon Alliance (WRA)? Since 2011, an international ‘community of concern’, convened by WRA, has been shining a light on the hitherto taboo subject of health workers' disrespect and abuse of women and girls. This is one strand in the range of efforts needed to tackle the scandal of deaths in childbirth, 99% of which happen in the developing world. Childbirth is still the biggest killer of young women globally, despite the fact that we know how to prevent this – as we largely have in the UK and other relatively wealthy countries. A clutch of low income countries have also made dramatic progress, showing that it can be done where there is the political will. Indeed the good news is that the numbers of women dying in childbirth have come down by half in the past decade. However this is not good enough and we are going to fall shamefully short of the Millennium Development Goal of a reduction of 75% by 2015. For some years now, the chronic shortage of trained health workers and how to address the human resource crisis in developing countries has been a priority. It is now widely accepted that we need many more professional midwives and others with midwifery skills, near where women live, if we are to prevent the deaths of mothers and newborns. Yet it has more recently become clear that putting health facilities and staff in place is not enough. Extensive research has not yet been done, but it is well known that women will stay at home to give birth – with only relatives and neighbours to help, so risking their lives should
E-mail address: [email protected] 0266-6138/$ - see front matter & 2013 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.midw.2013.12.002
things go wrong – rather than go to a health centre where they have heard they may be slapped or shouted at. Midwives like Frances Ganges, Chief Executive of the International Confederation of Midwives, talks of Africa's ‘ghost hospitals’ which may have all the latest drugs and equipment, but women will not go into them. When I asked her for a specific location for a ghost hospital, she said ‘this is so common that it could be almost any country’.
Charity begins at home? What can we learn from this in the UK? Our hospitals are far from empty. They are also far from perfect, whereas the principles of care and respect, the issue of midwives relationships with the women they serve, and women's rights in childbirth are the same all over the world. Respectful Maternity Care (RMC) is a continuum, and some UK health services are doing better than others. It is true in the UK, as in other countries, that women having babies may not realise that their rights have been violated. It is also true here, as elsewhere, that midwives are the chief agents of change on this issue. The UK work on Respectful Care initially took shape in the Barking Havering Redbridge University Trust (BHRUT), led by London midwives who are members of White Ribbon Alliance. In 2010, this NHS teaching hospital was subject to an investigation by the Care Quality Commission on attitudes to women's care following the deaths of five pregnant women within two years. Midwifery leaders responded with a range of initiatives, one of which was to provide staff with training in Respectful Care, using White Ribbon Alliance's RMC Charter, graphic film and a role play specially devised by midwives. According to Wendy Matthews, Director of Midwifery & Divisional Nurse Director who instituted the trainings in respectful care for maternity staff, satisfaction levels amongst women attending for maternity care improved dramatically: ‘Women were petrified to come to Queen's Hospital, because of all they had heard and read in the media,’ says Wendy Matthews, so when Felicity Ukoko (a White Ribbon Alliance member in the UK) showed her the short film about Respectful Maternity Care, ‘Break the Silence’, she said ‘how wonderful, we need to be doing this here. I made this mandatory training for staff. With our ethnic mix, we made it clear that what might be right in some cultures is not okay at work. We work as a team
B. McConville / Midwifery 30 (2014) 154–157
here, not as a hierarchy. Some staff have learned to leave their culture at home and to be professional at work.’ While stressing that the Respectful Care work is one initiative amongst many to improve services, Matthews says that complaints went down from 118 in 2011/12, to 64 the next year and to only nine in the first quarter of 2013. Ninety-five per cent of women said they would now recommend the maternity services at Queens to their family or friends. Of those who gave birth in the new, midwife-led Queen's Birth Centre, 100% said they would recommend it to their friends, and 65% gave birth in water – with fewer drugs, less analgesia and more mothers breast feeding. ‘Even women who have traumatic deliveries previously are now having fantastic experiences’ says Matthews, ‘which of course reduces depression and improves bonding with the baby.’ Feedback from staff has been very positive. The sessions have enabled health care professionals to talk about the issue of treating women with respect, to challenge bad behaviour and promote good quality care. We would like to encourage other hospitals to adopt the Respectful Maternity Care Charter on fundamental human rights of childbearing women and incorporate it into their training: It has been over a year now, and we are carrying on improving care, and we have taken things further by inviting women to tell us about their own experiences with us; hearing it from a woman's perspective is crucial, when one small thing we did can make all our excellent work seem inadequate. We have also begun working with the Royal College of Midwives to see how we can improve the behaviour not just of staff to women, but between all staff – doctors, nurses and others as well as midwives – to make sure we have a culture of staff behaving with respect towards each other. It's delightful that now women are saying ‘I've had a fantastic experience, it couldn't have been better’. Subsequently, White Ribbon Alliance was invited by the Greater London Heads of Midwifery Meeting (HOMS) in May 2013 to present on Respectful Care to 20 senior Midwifery Managers, who asked for further meetings to discuss the issue. Following this meeting, Francine Allen of the Royal College of Midwives (RCM) made a presentation on Respectful Care to a meeting of RCM representatives. Other London Hospitals are now showing interest in rolling out this work. Midwife and Midwifery Manager, responsible for standards in care, Felicity Ukoko, describes the sessions provided at Barking Havering Redbridge University Trust: The session kicks off with a presentation and gives a global perspective of the women's experience in maternity care systems. The emphasis is on the seven major categories of disrespect and abuse that child-bearing women encounter during maternity care. This is followed by the education team and supervisors of midwives providing the local perspective of women's experiences based on real complaints from women about their care. This is done via a presentation, with quotes from complaints as well as two role-plays. At the end of the play the Respectful Maternity Care video ‘Break the Silence’ is shown. The message is snappy, powerful and thought provoking. The sessions are attended by the Director of Midwifery who reiterates the importance of treating women with dignity and respect and also shares some positive feedback from women. Already we are seeing improvements. Complaints are down and women are reporting good care. We will continue to
155
further improve the care that we provide to women and their families.
Dignity for mothers Women's rights during childbirth – and the distress experienced by women who have been ill-treated – is also being addressed by a new UK charity, BIRTHRIGHTS, which sits with the WRA London office and which is using the Respectful Maternity Care Charter. BIRTHRIGHTS and WRA collaborated in the ‘Dignity in Childbirth’ conference in London on October 15th 2013, to address the issues of dignity and respect in maternity care. Carrie Longton, co-founder of Mumsnet, told the conference about her birth experience at a London hospital that left her with post traumatic stress disorder. Arriving there in labour to find the lift was broken, she climbed many flights of stairs, eventually to be examined while sitting on a toilet. The midwife then said ‘oh shit, that's not a head, that's a bum’, reported Longton. The forceps delivery that followed left Longton so traumatised that she could not contemplate anything other than caesarean sections for her subsequent births.
Learning from developing countries Meanwhile the Respectful Maternity Care work of White Ribbon Alliance and partners in developing countries has achieved remarkable results in a relatively short time. A key piece of learning has been that in all of these countries where Respectful Maternity Care has taken off in such a positive fashion, it is midwives who are leading the charge. Midwives have faced down the risk of being tarnished by a bad press; indeed, to the contrary, they see it as essential to root out bad practices in order to protect and promote the profession of midwifery. Rose Mlay, midwifery teacher and leader of WRA Tanzania: ‘Imagine walking through a hospital that is overcrowded and understaffed, and the help that you need to deliver your baby may come too late. An exhausted midwife finally makes her way to you, only to ask if your family is around, because somebody needs to pay for your delivery. You have no money, and you are told that if you don't pay, you and your newborn will be held until you do.’
Learning from Nigeria In Nigeria, this September, the campaign to include Respectful Care in all health facilities passed a huge milestone when the National Council for Health (NCH) approved the Charter for respectful maternity care and established Respectful Maternity Care as a standard of practice. The NCH pledged to implement the Charter at Federal, State and Local Government levels. This was one of a series of ground breaking decisions taken by the NCH, which WRA believes will significantly improve Nigeria's health sector. Permanent Health Secretary in the Federal Ministry of Health, Ambassador Sani Bala, said ‘we are going to faithfully and effectively implement all the policies adopted at meeting.’ The next step says Dr Phillippa Momah of WRA Nigeria, is to make sure the professional associations take this on. WRA is in the process of convening the third national consultation on RMC with
156
B. McConville / Midwifery 30 (2014) 154–157
the Federal Ministry of Health, health workers, professional organisations and regulatory bodies to make sure that Respectful Care is incorporated into midwifery training and that the policy change results in improved care at health facilities nationwide. The loss of Mercy ‘The loss of a woman's life in childbirth is a terrible and unnecessary event which is devastating for all those who love and depend on her,’ says Tonte Ibraye, the National Coordinator of White Ribbon Alliance Nigeria. He is speaking from personal experience following the death of his beloved sister Mercy in 2010. Despite Tonte's pleas that his sister go to hospital, she tried to make savings for her daughter's schooling by giving birth without skilled care – at the cost of her own life. Since then Tonte has become an even more passionate advocate for safe birth, working with a broad coalition of organisations and individuals to press the Government to improve health services for women in Nigeria. ‘White Ribbon Alliance is now working with the government to ensure the Charter for Respectful Maternity Care is adopted,’ he says, ‘recognising every pregnant woman's right to quality care at birth – and that this principle is built into our national health system, from midwifery trainings to professional practice at health centres.’ ‘We are now a strong coalition of organisations, individuals, media supporters and human rights groups,’ says Tonte. ‘Together we will close the gap between what has been promised by our government and the reality of our health services, until women like my sister no longer die for lack of skilled maternity care.’
Yet the veil of silence over disrespect and abuse exists in the UK as elsewhere. We need to create mechanisms to report and monitor this. Midwives are the key to change. Although midwives are most often blamed for disrespectful and abusive care, they are not the only culprits and in the UK as elsewhere they are the ones leading the charge for Respectful Maternity Care. We need to make sure that midwives have the resources they need to provide RMC and that they are trained to do so. We must empower women to know their rights – whether that's about having a companion in the room, or agreeing to medical intervention – so that they can make informed decisions. Above all, we must ask women about their experiences, listen and respond.
Taking action – a new guide to RMC Developed with support from the USAID-funded Health Policy Project, A Guide for Advocating for Respectful Maternity Care is a comprehensive resource centred on the RMC charter, a groundbreaking consensus document that demonstrates the legitimate place of maternal health rights within the broader context of human rights. Written for national-level advocates, this guide presents a variety of ways to (1) build a sense of entitlement among women and communities regarding respectful maternity care (RMC) and (2) advocate for the institutionalisation of RMC as a core value of the maternal care system. Specifically, the guide provides information and user-friendly tools and techniques to help advocates
Raise awareness and generate demand from civil society for RMC rights;
Mobilise communities to hold local leaders and service providers accountable for RMC rights; and
Learning from Nepal In Nepal meanwhile, WRA has launched a sustained media campaign to make women aware of their rights in childbirth. This has culminated in the language of respectful care being included in a new Bill for safe motherhood which goes before Parliament in a few months' time, so that women's rights in childbirth will be enshrined in law. WRA recently handed over the ‘Safe Motherhood and New Born Health Care, Draft Bill 2013’ to the Hon Minister of Health, Dr Bidhyadhar Mallik, at the Health Ministry of Nepal. This bill includes the right to Respectful Maternity Care, as spelled out in the RMC Charter. Ministry officials have been open about the difficulties, with 70% of all qualified doctors based in Nepal's towns and cities. This means that there is only one medic to care for every 3000 women in the rural areas, leading to neglect of women's care and rights in childbirth. But the tremendous response of the media to recent meeting on RMC heralded a change in thinking. Sixty journalists attended a Kathmandu event highlighting Respectful Care (May 2013), leading to four major newspaper features in English and Nepali, national radio broadcasts and a national TV programme. In the words of Arzu Deuba, leader of the White Ribbon Alliance (SMNF) in Nepal, ‘A woman's relationship with caregivers when she gives birth, if positive, can be reaffirming and lead to an increase in self-esteem and confidence. If the relationship is negative or neglectful, it can inflict lasting damage and emotional trauma.’ What can the UK learn from this? Wherever we live, women's birth experiences stay with us for a lifetime, influencing our decisions on where to seek care in future.
Secure commitment at the national level to institutionalise RMC as the standard of care. ○ Every woman needs access to skilled health care if she is to be safe during childbirth – but the quality of that care is crucial. Women's memories of their childbearing experiences stay with them for a lifetime. ○ Unfortunately, too often, pregnant women seeking maternity care receive varying degrees of ill treatment: from relatively subtle disrespect of their autonomy and dignity to outright abuse – physical assault, verbal insults, discrimination, abandonment, or detention in facilities for failure to pay. Evidence is now emerging that this fear of being badly treated and abused in health facilities is holding women back from seeking help. It is proving to be as big a deterrent as cost of care and transport. ○ Building on our experience in mobilising citizens at the grassroots, the White Ribbon Alliance network – which includes thousands of midwives and midwifery organisations globally – is focusing on promoting Respectful Maternity Care. In partnership with the Health Policy Project, White Ribbon Alliance wants the world to follow one standard best practice on maternity care. ○ White Ribbon Alliance aims to make the seven aspects of the Universal Rights of Childbearing Women Charter the basis of maternity care systems around the world. We advocate with national policy makers to endorse the Charter. We hold workshops to help midwives understand their rights and to respect their patients. ○ In Nepal, White Ribbon Alliance has supported National Alliance members to ensure the Charter is incorporated into the new, National Safe Maternity Bill. In countries such as Kenya, Bangladesh and Yemen, we have helped create action plans to address disrespect and abuse, and in London,
B. McConville / Midwifery 30 (2014) 154–157
regular meetings to raise awareness of Respectful Maternity Care are organised by midwives and health workers. As I wrote recently following the recent Dignity in Childbirth conference in London ‘…through the lens of all women's right to dignity in childbirth, we are connected. A woman in the UK, hurt and depressed after a sudden forceps delivery, now feels common cause with the Asian or African woman who was neglected on the overcrowded maternity ward. Birth is essentially the same wherever we live in the world, but the investment in it has been dramatically different, leading to the biggest health inequality on the planet. ‘Dignity’ gives us a language to close the gap… It remains a scandal that childbirth is the leading cause of death for young women in many countries – and that is fortunately a far cry from birth in the UK. But the concept of dignity, our universal
157
rights to respect and care during childbirth, connect all mothers and midwives’ (McConville, Huffington Post, October 22nd 2013).
Web-links Health Policy Project link: 〈http://www.healthpolicyproject.com〉. McConville, B., Respectful Care with a Sense of Momentum. Posted October 22nd 2013, Huffington Post 〈http://www.huffingtonpost.com/brigid-mcconville/〉. White Ribbon Alliance. The Respectful Maternity Care Guide: 〈http://whiteribbonal liance.org/wp-content/uploads/2013/10/RMC-Guide_FINAL.pdf〉. White Ribbon Alliance. The Respectful Maternity Care film: 〈http://whiteribbonal liance.org/campaigns/respectful-maternity-care/〉. White Ribbon Alliance. The Universal Rights of Childbearing Women Charter: 〈http://whiteribbonalliance.org/wpcontent/uploads/2013/10/Final_RMC_Char ter.pdf〉. The Respectful Maternity Care poster: 〈http://whiteribbonalliance.org/wp-content/ uploads/2013/10/RMC_Poster.pdf〉.
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Commentary
Respectful maternity care – How the UK is learning from the developing world Brigid McConville (Director, White Ribbon Alliance) White Ribbon Alliance for Safe Motherhood UK, London
How women are treated in childbirth is increasingly a hot topic. Campaigners are insisting that this is a fundamental issue of human rights and the media is taking up women's call for dignity and respect during childbirth We've long prided ourselves on our midwifery care in the UK. And rightly so. To have free access to the services of well trained professional midwives throughout pregnancy, birth and afterwards, is a dream still out of reach for millions of women in many less fortunate countries. Not to mention our excellent safety record; not to mention our hugely popular television documentaries and dramas! Why then are British midwives increasingly turning to the methodology of ‘Respectful Maternity Care’, with its Charter of Rights, as pioneered across Africa and Asia by the global network of maternal health advocates in the White Ribbon Alliance (WRA)? Since 2011, an international ‘community of concern’, convened by WRA, has been shining a light on the hitherto taboo subject of health workers' disrespect and abuse of women and girls. This is one strand in the range of efforts needed to tackle the scandal of deaths in childbirth, 99% of which happen in the developing world. Childbirth is still the biggest killer of young women globally, despite the fact that we know how to prevent this – as we largely have in the UK and other relatively wealthy countries. A clutch of low income countries have also made dramatic progress, showing that it can be done where there is the political will. Indeed the good news is that the numbers of women dying in childbirth have come down by half in the past decade. However this is not good enough and we are going to fall shamefully short of the Millennium Development Goal of a reduction of 75% by 2015. For some years now, the chronic shortage of trained health workers and how to address the human resource crisis in developing countries has been a priority. It is now widely accepted that we need many more professional midwives and others with midwifery skills, near where women live, if we are to prevent the deaths of mothers and newborns. Yet it has more recently become clear that putting health facilities and staff in place is not enough. Extensive research has not yet been done, but it is well known that women will stay at home to give birth – with only relatives and neighbours to help, so risking their lives should
E-mail address: [email protected] 0266-6138/$ - see front matter & 2013 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.midw.2013.12.002
things go wrong – rather than go to a health centre where they have heard they may be slapped or shouted at. Midwives like Frances Ganges, Chief Executive of the International Confederation of Midwives, talks of Africa's ‘ghost hospitals’ which may have all the latest drugs and equipment, but women will not go into them. When I asked her for a specific location for a ghost hospital, she said ‘this is so common that it could be almost any country’.
Charity begins at home? What can we learn from this in the UK? Our hospitals are far from empty. They are also far from perfect, whereas the principles of care and respect, the issue of midwives relationships with the women they serve, and women's rights in childbirth are the same all over the world. Respectful Maternity Care (RMC) is a continuum, and some UK health services are doing better than others. It is true in the UK, as in other countries, that women having babies may not realise that their rights have been violated. It is also true here, as elsewhere, that midwives are the chief agents of change on this issue. The UK work on Respectful Care initially took shape in the Barking Havering Redbridge University Trust (BHRUT), led by London midwives who are members of White Ribbon Alliance. In 2010, this NHS teaching hospital was subject to an investigation by the Care Quality Commission on attitudes to women's care following the deaths of five pregnant women within two years. Midwifery leaders responded with a range of initiatives, one of which was to provide staff with training in Respectful Care, using White Ribbon Alliance's RMC Charter, graphic film and a role play specially devised by midwives. According to Wendy Matthews, Director of Midwifery & Divisional Nurse Director who instituted the trainings in respectful care for maternity staff, satisfaction levels amongst women attending for maternity care improved dramatically: ‘Women were petrified to come to Queen's Hospital, because of all they had heard and read in the media,’ says Wendy Matthews, so when Felicity Ukoko (a White Ribbon Alliance member in the UK) showed her the short film about Respectful Maternity Care, ‘Break the Silence’, she said ‘how wonderful, we need to be doing this here. I made this mandatory training for staff. With our ethnic mix, we made it clear that what might be right in some cultures is not okay at work. We work as a team
B. McConville / Midwifery 30 (2014) 154–157
here, not as a hierarchy. Some staff have learned to leave their culture at home and to be professional at work.’ While stressing that the Respectful Care work is one initiative amongst many to improve services, Matthews says that complaints went down from 118 in 2011/12, to 64 the next year and to only nine in the first quarter of 2013. Ninety-five per cent of women said they would now recommend the maternity services at Queens to their family or friends. Of those who gave birth in the new, midwife-led Queen's Birth Centre, 100% said they would recommend it to their friends, and 65% gave birth in water – with fewer drugs, less analgesia and more mothers breast feeding. ‘Even women who have traumatic deliveries previously are now having fantastic experiences’ says Matthews, ‘which of course reduces depression and improves bonding with the baby.’ Feedback from staff has been very positive. The sessions have enabled health care professionals to talk about the issue of treating women with respect, to challenge bad behaviour and promote good quality care. We would like to encourage other hospitals to adopt the Respectful Maternity Care Charter on fundamental human rights of childbearing women and incorporate it into their training: It has been over a year now, and we are carrying on improving care, and we have taken things further by inviting women to tell us about their own experiences with us; hearing it from a woman's perspective is crucial, when one small thing we did can make all our excellent work seem inadequate. We have also begun working with the Royal College of Midwives to see how we can improve the behaviour not just of staff to women, but between all staff – doctors, nurses and others as well as midwives – to make sure we have a culture of staff behaving with respect towards each other. It's delightful that now women are saying ‘I've had a fantastic experience, it couldn't have been better’. Subsequently, White Ribbon Alliance was invited by the Greater London Heads of Midwifery Meeting (HOMS) in May 2013 to present on Respectful Care to 20 senior Midwifery Managers, who asked for further meetings to discuss the issue. Following this meeting, Francine Allen of the Royal College of Midwives (RCM) made a presentation on Respectful Care to a meeting of RCM representatives. Other London Hospitals are now showing interest in rolling out this work. Midwife and Midwifery Manager, responsible for standards in care, Felicity Ukoko, describes the sessions provided at Barking Havering Redbridge University Trust: The session kicks off with a presentation and gives a global perspective of the women's experience in maternity care systems. The emphasis is on the seven major categories of disrespect and abuse that child-bearing women encounter during maternity care. This is followed by the education team and supervisors of midwives providing the local perspective of women's experiences based on real complaints from women about their care. This is done via a presentation, with quotes from complaints as well as two role-plays. At the end of the play the Respectful Maternity Care video ‘Break the Silence’ is shown. The message is snappy, powerful and thought provoking. The sessions are attended by the Director of Midwifery who reiterates the importance of treating women with dignity and respect and also shares some positive feedback from women. Already we are seeing improvements. Complaints are down and women are reporting good care. We will continue to
155
further improve the care that we provide to women and their families.
Dignity for mothers Women's rights during childbirth – and the distress experienced by women who have been ill-treated – is also being addressed by a new UK charity, BIRTHRIGHTS, which sits with the WRA London office and which is using the Respectful Maternity Care Charter. BIRTHRIGHTS and WRA collaborated in the ‘Dignity in Childbirth’ conference in London on October 15th 2013, to address the issues of dignity and respect in maternity care. Carrie Longton, co-founder of Mumsnet, told the conference about her birth experience at a London hospital that left her with post traumatic stress disorder. Arriving there in labour to find the lift was broken, she climbed many flights of stairs, eventually to be examined while sitting on a toilet. The midwife then said ‘oh shit, that's not a head, that's a bum’, reported Longton. The forceps delivery that followed left Longton so traumatised that she could not contemplate anything other than caesarean sections for her subsequent births.
Learning from developing countries Meanwhile the Respectful Maternity Care work of White Ribbon Alliance and partners in developing countries has achieved remarkable results in a relatively short time. A key piece of learning has been that in all of these countries where Respectful Maternity Care has taken off in such a positive fashion, it is midwives who are leading the charge. Midwives have faced down the risk of being tarnished by a bad press; indeed, to the contrary, they see it as essential to root out bad practices in order to protect and promote the profession of midwifery. Rose Mlay, midwifery teacher and leader of WRA Tanzania: ‘Imagine walking through a hospital that is overcrowded and understaffed, and the help that you need to deliver your baby may come too late. An exhausted midwife finally makes her way to you, only to ask if your family is around, because somebody needs to pay for your delivery. You have no money, and you are told that if you don't pay, you and your newborn will be held until you do.’
Learning from Nigeria In Nigeria, this September, the campaign to include Respectful Care in all health facilities passed a huge milestone when the National Council for Health (NCH) approved the Charter for respectful maternity care and established Respectful Maternity Care as a standard of practice. The NCH pledged to implement the Charter at Federal, State and Local Government levels. This was one of a series of ground breaking decisions taken by the NCH, which WRA believes will significantly improve Nigeria's health sector. Permanent Health Secretary in the Federal Ministry of Health, Ambassador Sani Bala, said ‘we are going to faithfully and effectively implement all the policies adopted at meeting.’ The next step says Dr Phillippa Momah of WRA Nigeria, is to make sure the professional associations take this on. WRA is in the process of convening the third national consultation on RMC with
156
B. McConville / Midwifery 30 (2014) 154–157
the Federal Ministry of Health, health workers, professional organisations and regulatory bodies to make sure that Respectful Care is incorporated into midwifery training and that the policy change results in improved care at health facilities nationwide. The loss of Mercy ‘The loss of a woman's life in childbirth is a terrible and unnecessary event which is devastating for all those who love and depend on her,’ says Tonte Ibraye, the National Coordinator of White Ribbon Alliance Nigeria. He is speaking from personal experience following the death of his beloved sister Mercy in 2010. Despite Tonte's pleas that his sister go to hospital, she tried to make savings for her daughter's schooling by giving birth without skilled care – at the cost of her own life. Since then Tonte has become an even more passionate advocate for safe birth, working with a broad coalition of organisations and individuals to press the Government to improve health services for women in Nigeria. ‘White Ribbon Alliance is now working with the government to ensure the Charter for Respectful Maternity Care is adopted,’ he says, ‘recognising every pregnant woman's right to quality care at birth – and that this principle is built into our national health system, from midwifery trainings to professional practice at health centres.’ ‘We are now a strong coalition of organisations, individuals, media supporters and human rights groups,’ says Tonte. ‘Together we will close the gap between what has been promised by our government and the reality of our health services, until women like my sister no longer die for lack of skilled maternity care.’
Yet the veil of silence over disrespect and abuse exists in the UK as elsewhere. We need to create mechanisms to report and monitor this. Midwives are the key to change. Although midwives are most often blamed for disrespectful and abusive care, they are not the only culprits and in the UK as elsewhere they are the ones leading the charge for Respectful Maternity Care. We need to make sure that midwives have the resources they need to provide RMC and that they are trained to do so. We must empower women to know their rights – whether that's about having a companion in the room, or agreeing to medical intervention – so that they can make informed decisions. Above all, we must ask women about their experiences, listen and respond.
Taking action – a new guide to RMC Developed with support from the USAID-funded Health Policy Project, A Guide for Advocating for Respectful Maternity Care is a comprehensive resource centred on the RMC charter, a groundbreaking consensus document that demonstrates the legitimate place of maternal health rights within the broader context of human rights. Written for national-level advocates, this guide presents a variety of ways to (1) build a sense of entitlement among women and communities regarding respectful maternity care (RMC) and (2) advocate for the institutionalisation of RMC as a core value of the maternal care system. Specifically, the guide provides information and user-friendly tools and techniques to help advocates
Raise awareness and generate demand from civil society for RMC rights;
Mobilise communities to hold local leaders and service providers accountable for RMC rights; and
Learning from Nepal In Nepal meanwhile, WRA has launched a sustained media campaign to make women aware of their rights in childbirth. This has culminated in the language of respectful care being included in a new Bill for safe motherhood which goes before Parliament in a few months' time, so that women's rights in childbirth will be enshrined in law. WRA recently handed over the ‘Safe Motherhood and New Born Health Care, Draft Bill 2013’ to the Hon Minister of Health, Dr Bidhyadhar Mallik, at the Health Ministry of Nepal. This bill includes the right to Respectful Maternity Care, as spelled out in the RMC Charter. Ministry officials have been open about the difficulties, with 70% of all qualified doctors based in Nepal's towns and cities. This means that there is only one medic to care for every 3000 women in the rural areas, leading to neglect of women's care and rights in childbirth. But the tremendous response of the media to recent meeting on RMC heralded a change in thinking. Sixty journalists attended a Kathmandu event highlighting Respectful Care (May 2013), leading to four major newspaper features in English and Nepali, national radio broadcasts and a national TV programme. In the words of Arzu Deuba, leader of the White Ribbon Alliance (SMNF) in Nepal, ‘A woman's relationship with caregivers when she gives birth, if positive, can be reaffirming and lead to an increase in self-esteem and confidence. If the relationship is negative or neglectful, it can inflict lasting damage and emotional trauma.’ What can the UK learn from this? Wherever we live, women's birth experiences stay with us for a lifetime, influencing our decisions on where to seek care in future.
Secure commitment at the national level to institutionalise RMC as the standard of care. ○ Every woman needs access to skilled health care if she is to be safe during childbirth – but the quality of that care is crucial. Women's memories of their childbearing experiences stay with them for a lifetime. ○ Unfortunately, too often, pregnant women seeking maternity care receive varying degrees of ill treatment: from relatively subtle disrespect of their autonomy and dignity to outright abuse – physical assault, verbal insults, discrimination, abandonment, or detention in facilities for failure to pay. Evidence is now emerging that this fear of being badly treated and abused in health facilities is holding women back from seeking help. It is proving to be as big a deterrent as cost of care and transport. ○ Building on our experience in mobilising citizens at the grassroots, the White Ribbon Alliance network – which includes thousands of midwives and midwifery organisations globally – is focusing on promoting Respectful Maternity Care. In partnership with the Health Policy Project, White Ribbon Alliance wants the world to follow one standard best practice on maternity care. ○ White Ribbon Alliance aims to make the seven aspects of the Universal Rights of Childbearing Women Charter the basis of maternity care systems around the world. We advocate with national policy makers to endorse the Charter. We hold workshops to help midwives understand their rights and to respect their patients. ○ In Nepal, White Ribbon Alliance has supported National Alliance members to ensure the Charter is incorporated into the new, National Safe Maternity Bill. In countries such as Kenya, Bangladesh and Yemen, we have helped create action plans to address disrespect and abuse, and in London,
B. McConville / Midwifery 30 (2014) 154–157
regular meetings to raise awareness of Respectful Maternity Care are organised by midwives and health workers. As I wrote recently following the recent Dignity in Childbirth conference in London ‘…through the lens of all women's right to dignity in childbirth, we are connected. A woman in the UK, hurt and depressed after a sudden forceps delivery, now feels common cause with the Asian or African woman who was neglected on the overcrowded maternity ward. Birth is essentially the same wherever we live in the world, but the investment in it has been dramatically different, leading to the biggest health inequality on the planet. ‘Dignity’ gives us a language to close the gap… It remains a scandal that childbirth is the leading cause of death for young women in many countries – and that is fortunately a far cry from birth in the UK. But the concept of dignity, our universal
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rights to respect and care during childbirth, connect all mothers and midwives’ (McConville, Huffington Post, October 22nd 2013).
Web-links Health Policy Project link: 〈http://www.healthpolicyproject.com〉. McConville, B., Respectful Care with a Sense of Momentum. Posted October 22nd 2013, Huffington Post 〈http://www.huffingtonpost.com/brigid-mcconville/〉. White Ribbon Alliance. The Respectful Maternity Care Guide: 〈http://whiteribbonal liance.org/wp-content/uploads/2013/10/RMC-Guide_FINAL.pdf〉. White Ribbon Alliance. The Respectful Maternity Care film: 〈http://whiteribbonal liance.org/campaigns/respectful-maternity-care/〉. White Ribbon Alliance. The Universal Rights of Childbearing Women Charter: 〈http://whiteribbonalliance.org/wpcontent/uploads/2013/10/Final_RMC_Char ter.pdf〉. The Respectful Maternity Care poster: 〈http://whiteribbonalliance.org/wp-content/ uploads/2013/10/RMC_Poster.pdf〉.
