Respectful Care: It’s What Women Want, But Can We Ensure It during the COVID-19 Pandemic?

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Respectful Maternity Care is a term that only came into recognized use in the last ten years and has truly gone global. It was preceded by the movement for the humanization of childbirth in Latin America that dates to the 1970s. In 2009-2010, human rights organizations such as Amnesty International and Human Rights Watch connected violations in childbirth to the broader human rights framework. In 2010, this work was followed by a landscape analysis and creation of a framework, followed by a few research projects and advocacy efforts supported by USAID. The World Health Organization issued a statement on Prevention and Elimination of Disrespect and Abuse during Facility-Based Childbirth in 2014 and then included the concept of “experience of care” in its Quality of Care Framework in 2015.

The White Ribbon Alliance has advocated in support of Respectful Maternity Care. In 2018, more than 1.2 million women from 114 countries took part in the global “What Women Want” campaign and identified respect and dignity as their number one priority for their health. Making women’s voices heard through the “What Women Want” campaign was an unprecedented, focused, one woman-at-a-time inquiry into what experts want for their own maternal and reproductive healthcare. It was an inquiry into values: how women value themselves, how women are valued, how we value the evidence supplied by their voices. For some women, the simple act of being asked for their views has been a first. The campaign made clear that women and girls have an innate power that begins with their knowledge and experience. However, that power is often systematically lessened through socio-cultural, economic, and gender-based constraints.

From a small community of concern to an international multi-sectoral group of more than 150 organizations, representing over 350 members from 45 countries worldwide, the Global Respectful Maternity Care Council (GRMCC), led by the White Ribbon Alliance, has grown substantially in the last decade. Today, GRMCC includes researchers, clinicians, technical advisors, program managers, advocates, professional associations, UN agencies, and donors, all working together to ensure that women’s rights in childbirth are acknowledged everywhere. We work at global, national, and sub-national levels and are happy to report some significant achievements:

• WHO standards that include experience of care
• Legislation in Nepal in 2018 guaranteeing respectful care
• A large-scale government initiative in India focusing on respect in maternal and newborn care; and
• Inclusion of the RMC charter in standards of care and curricula for providers.

Under the USAID-funded Maternal and Child Survival Project (MCSP) and Momentum Country and Global Leadership (MCGL), multiple countries are engaged in a facility and community-based programs to understand the drivers of mistreatment and how that mistreatment manifested, then to collaboratively design the interventions that together they will implement to promote respectful care.

However, nothing prepared us for the derogation of rights that occurred during the COVID-19 pandemic. Within days of COVID-19 being declared a global pandemic by the WHO, stories immediately emerged of women’s rights being withheld or violated during childbirth without scientific evidence nor any sufficient and transparently reasoned justification for restriction of those rights. What was stated was that choices were necessary for ‘security, safety, or emergency resource management’. In some cases, these rollbacks started as countries scrambled to prepare for a pandemic that had not yet reached them. The hasty imposition of these rights infringements and service suspensions within reproductive and maternal healthcare marked not only serious human rights violations but also a gap in understanding how these rights ensure optimal outcomes for women and newborns but present a risk that the precarious wins made thus far in reducing maternal mortality and asserting women’s reproductive rights will disappear. At the same time, there were governmental, non-governmental and professional actors who were at the forefront of defending women’s and newborns’ rights to respectful care, during the COVID-19 pandemic, with midwives often leading the way:

• In Malawi, a group led by midwives, working together with the Reproductive Health Directorate at the Ministry of Health, developed the Maternal, Newborn Health and Family Planning Service Guidelines during COVID-19, incorporating respectful care rights and principles.
• In Mexico, following engagement with civil society and professional associations, including midwifery associations, the Mexican government issued a statement to all states to guarantee access to sexual and reproductive health services during the COVID-19 emergency and expanded the scope of pre-existing SRHR guidelines to include the Respectful Maternity Care Charter.
• Midwives in the United Kingdom continued to advocate for continuity of care for their clients and the provision of home birth services.

Even in times of crisis, midwives continue to be “with women”, and the current COVID-19 pandemic is no exception. Midwives play a vital role in ensuring respectful maternity care – from advocating at the facility level so that women and newborns are not separated to creating national policies to ensure respectful care for all. No matter what is happening globally, women will continue to deliver babies and will need their midwives right there with them. You can learn more about Respectful Maternity Care in the Time of COVID: A Global Perspective at the upcoming ACNM 66th Annual Meeting, held virtually May 23 – 25, 2021.

Authors:

Elena Ateva, JD, Advocacy Manager, White Ribbon Alliance
Elena Ateva is the Advocacy Manager at White Ribbon Alliance and the Maternal Health lead for the USAID/Health Policy Plus Project. She is responsible for facilitating the work of the Global Respectful Maternity Care Council, leading global advocacy efforts to strengthen the midwifery workforce, and assisting WRA National Alliances. Elena is an attorney and a human rights advocate who has been involved in the movement for respectful care and the prevention of other forms of gender-based violence.

Deborah Armbruster, CNM, MPH, FACNM, Senior Maternal Health Adviser, Global Bureau for Health, USAID
Deborah Armbruster is a nurse-midwife with a Master’s in Public Health and a fellow of the American College of Nurse-Midwives. She is currently a Sr. Maternal and Newborn Health Advisor with USAID and assists in managing the Advancing PPH Care project, the White Ribbon Alliance, and the Global Health Supply Chain – PSM project. She is also one of the coordinators for MCHN Quality of Care work. She has over 30 years of experience in safe motherhood and reproductive health programs in over 25 countries.

Suzanne Stalls, CNM, MA, FACNM, Director, Maternal and Newborn Health, Jhpiego/Momentum Country and Global Leadership
Ms. Stalls is currently director of the maternal newborn health team for Momentum Country and Global Leadership, a global technical leadership award funded by USAID in a consortium directed by Jhpiego. In her role, she contributes to global technical leadership and learning. She supports the policy dialogue required to achieve global MNCH/FP/RH goals through MNCH/FP/RH initiatives, strategies, frameworks, guidelines, and action plans that have been endorsed worldwide.