Improving the experience of pregnant and birthing women

A growing body of evidence shows that mistreatment of women in maternal health care is a reality around the world. For several years, the World Health Organization (WHO) and PRH (the UNDP/UNFPA/UNICEF/WHO/World Bank Special Research, Development and Training Program in Human Reproduction Research) have documented this violation of human rights and its impact on health and well-being.

The WHO guideline on intrapartum care for positive birth experiences includes a number of related recommendations, but little research has been done on what interventions can be implemented to make a difference – until now.

HRP and WHO authors and collaborators have now published a special series of five articles in the journal PLOS Global Public Health explore a range of strategies on different topics to end mistreatment of women during childbirth and improve respectful care.

O first of these articles reviews theories of interventions to reduce physical and verbal abuse. Two themes emerge in this article: first, that violence is normalized in society, particularly against “other” groups; and second, the belief that mistreatment of women is necessary to reduce clinical harm.

The authors argue that solutions should not just focus on staff failures through training or audit procedures, but should also look for long-term solutions that can encourage sustainable changes in attitudes and beliefs that then trigger a permanent change in behavior. This would have the effect of changing behavior at all levels of the health and social care system, from frontline health professionals to senior management and middle managers, and from organizational funders and auditors to local community leaders. , politicians and any other important stakeholders. .

The authors comment: “The intent is that the resulting individual, group, institutional, and community norms will change profoundly and sustainably to resist ‘change’ at a fundamental level, and in the long term, after completion of the formal intervention program.” . Implementation science tools, which integrate practical solutions such as theoretical knowledge Behavioral Change Wheelit can be useful in designing personalized interventions appropriate to each context.

The second article analyzes strategies to reduce stigma and discrimination, an important part of the mistreatment suffered by women. While much research has been done to describe the stigma and discrimination experienced by women in sexual and reproductive health care settings, more needs to be done to better understand how to end it.

This new research therefore focuses on interventions that can make a difference and highlights how any policy related to healthcare and improving equity must consider the inclusion and measurement of stigma and discrimination. Furthermore, as the authors comment, “efforts to combat mistreatment will not be effective when stigma and discrimination persist.”

This document therefore provides an analysis and recommendations, including a multi-level stigma model for sexual and reproductive health and rights, that can inform action and implementation research to promote respectful, person-centered care for all. The authors note that more work is needed to challenge and dismantle the social conditions, sociocultural norms, and institutional policies that influence the opportunities and well-being of stigmatized groups.

The third article in the series, which has just been published, analyzes communication strategies to improve interpersonal communication and reduce mistreatment of women. Two main approaches were identified: the training of health professionals and the use of communication tools. Although the majority of interventions discovered focus on providing information, incorporating other communication goals – such as building a relationship, including women and their partners in decision-making – could further improve the care experience for women. women, their partners and their families.

The fourth article in the series analyzes how factors related to organizations and work environments can affect mistreatment in low- and middle-income countries. There is growing evidence about how staffing shortages in health systems and other barriers can affect respectful maternal care, but this article identifies and addresses significant gaps in research related to multiple professional and organizational factors. This includes key organizational challenges related to high workload; unbalanced division of labor; lack of professional autonomy; low pay; inadequate training; poor feedback and supervision; and workplace violence – all of which are influenced differently by resource scarcity.

In response, the general strategies identified are planning for pressures and shortages of health professionals and staff, providing supportive supervision, increasing resilience through peer support, reshaping leadership and mitigating violence. in the workplace.

O fifth article was a “Critical Interpretive Synthesis,” which aims to increase understanding of the drivers of power-related mistreatment of women. She did this by exploring and consolidating literature from different fields of study, to advance theory and practice on this topic.

The authors identified multiple underlying power-related factors behind mistreatment at various levels of society, including: intrapersonal (e.g., lack of knowledge about one’s rights); interpersonal (e.g. hierarchy between patients and healthcare professionals); community (e.g., pre-existing widespread discrimination against indigenous women); organizational (e.g. pressure for healthcare professionals to achieve performance targets) and legal and/or political (e.g. lack of accountability for human rights violations). The authors conclude that addressing these factors requires the involvement of different stakeholders, including women, the community, health professionals and policy makers, will be fundamental to moving forward.

Taken together, the series authors note that while many powerful interventions with great potential for change have been revealed by this research, much more needs to be done – particularly on how to develop and test context-specific models for optimal and sustainable improvement. . implementing respectful care for all.

What the authors say

Özge Tunçalp, one of the series’ authors and a physician at HRP, commented: “These findings help inform interventions to make positive changes to the quality of care provided to pregnant and giving birth women around the world.”

She continues: “However, they do not give us a silver bullet to end mistreatment and improve respectful care for everyone, immediately. Drivers are much more complex than that. We therefore need to bring together people from all sectors and disciplines to make deep systemic changes – specific to each particular context, and to be honest and proactive about this complexity.”

The authors highlight the important implementation research agenda that is opened by the special series – and the crucial need for more implementation research that demonstrates and replicates the utility of specific strategies to end mistreatment of women in maternity care and beyond. .

These findings will be crucial in informing a new WHO Knowledge Translation Companion for Respectful Maternal and Newborn Carewith publication scheduled for 2024, which will aim to support positive and lasting changes in health systems.