Disrespect and Abuse (D&A) Indicators in Childbirth
In their landscape analysis, Bowser and Hill (2015) provided an overview of seven indicators of disrespect and abuse (D&A) that can take place during childbirth. These include
1) Physical Abuse
2) Non-Consented Care
3) Non-Confidential Care
4) Non-Dignified Care
5) Discrimination
6) Abandonment of Care
7) Detention
Please find a more comprehensive overview below:
1) Physical Abuse
There are numerous reports of physical abuse during childbirth from health facilities around the world. In South Africa, women report being beaten, threatened with beating, and slapped during childbirth at midwifery units, clinics, and hospitals (Jewkes, Abrahams, & Mvo, 1998). In Peru, multiple reports describe nurses slapping women when they are pushing during delivery (d'Oliveira, Diniz, & Schraiber, 2002; Latin American and Caribbean Committee for the Defense of Women‘s Rights (CLADEM)/ Legal Center for Reproductive Rights and Public Policies (CRLP), 1998). It is reported that women in Kenya do not attend the hospital for fear of being beaten and ―roughed up‖(Family Care International, 2003). In Burkina Faso, a male nurse reported that he occasionally had to ―slap or pinch pregnant women because they don‘t want to push and this can harm the baby‖(Amnesty International, 2009b). In Tanzania, a woman reported ―some nurses are good, they console. Others are quite irksome. They are so discouraging, even slapping pregnant women‖(Family Care International, The Skilled Care Initiative, 2005). In Lebanon, women in 23 out of 39 hospitals surveyed reported being tied down during labor (Khayat & Campbell, 2000). There are widespread reports of the practice of birth attendants strenuously pushing on a woman‘s abdomen to try to force the baby out as well as excessive physical force to ―pull babies out‖. Physical abuse has also been described in the context of unnecessary extensive episiotomies (sometimes for financial gain) and post-partum suturing of vaginal tears or episiotomy cuts without the use of anesthesia (Center for Reproductive Rights & Federation of Women Lawyers- -Kenya (FIDA), 2007).
2) Non-Consented Care
There is evidence of a widespread absence of patient information processes or informed consent for common procedures around the time of childbirth in many settings (e.g. cesarean sections, episiotomies, hysterectomies, blood transfusions, sterilization, or augmentation of labor). Interviewees from LAC, sub-Saharan Africa and Eastern Europe regions all confirmed the lack of routine patient information communication and consent protocols for obstetric procedures in their respective settings, including the widespread practice of episiotomy without patient notification or consent. Escalating and excessive rates of unnecessary cesareans have been documented by many in the LAC, Asia, North American and other regions. Reports from Kenya, the United States, Dominican Republic, and Peru document women‘s stories of feeling coerced into a cesarean section (Center for Reproductive Rights & Federation of Women Lawyers--Kenya (FIDA), 2007; S. Miller et al., 2003; Physicians for Human Rights, 2007; Amnesty International, 2010). A soon to be released report from the Center for Reproductive Rights documents non-consented sterilization at the time of childbirth in Chile (Center for Reproductive Rights/Vivo Positivo, Forthcoming 2010).
3) Non-Confidential Care
A recurrent theme in the literature and communication with expert informants is the lack of privacy and confidentiality for many women around the world who deliver in facilities. Lack of privacy relates to both a physical lack of privacy in facilities where women may often labor and deliver in public view (without any privacy barriers) and lack of privacy related to sensitive patient information such as HIV status, age, marital status, medical history, etc. Non- confidential care is an especially important problem in high-prevalence HIV settings, where failure to respect the confidentiality of a woman‘s HIV status may increase the discrimination a woman experiences in a facility and her community and act to deter her use of facility-based childbirth care.
4) Non-Dignified Care
Non-dignified care during childbirth is described in the literature as intentional humiliation, blaming, rough treatment, scolding, shouting, publicly divulging private patient information, and negative perceptions of care.1 It is important to note that a woman‘s description of and perception of non-dignified care may be very context specific, so that an example from one country may not be relevant in other countries. For example, eye contact, a smile, and a handshake from a male provider in one culture may be perceived as disrespectful by a woman in another culture. In contrast to more overt forms of abuse such as hitting or abandonment of care, the defining characteristics of the sub-category of non-dignified care may be more nuanced and context specific.
5) Discrimination
Race/Ethnicity: Data from an Ecuadorian household survey show that 18% of the time, Indian women in Ecuador who preferred to deliver at home did so because of poor interpersonal behavior by providers (―Maltrato‖) (ENDEMAIN, 2004). In a report from Peru, providers were reported to demonstrate little respect for local cultures (Kayongo et al., 2006) and the indigenous population has been forced to deliver in health facilities through use of police or threats of incarceration in health facilities (Physicians for Human Rights, 2007). In the United States, a woman reported that the staff at the hospital where she delivered ―were racist and assumed that because I am black, poor, and live in this neighborhood, I must have had many abortions‖(Esposito, 1999).
Age: In Kenya, nurses tell young, teenage mothers: ―You young girl, what were you looking for in a man? Now you can‘t even give birth‖(Center for Reproductive Rights & Federation of Women Lawyers--Kenya (FIDA), 2007). In India, the Janani Suraksha Yojana program is only available to women over age 19 and those with two children or less, discriminating against young mothers (Human Rights Watch, 2009).
Traditional beliefs: Traditional beliefs may influence care during childbirth. For example, in some areas in Sierra Leone it is believed that obstructed labor is caused by infidelity, which may result in a blaming of the obstructed labor on a woman‘s past behavior and an insistence on confession and addressing the ―immoral behavior‖instead of a focus on managing the health situation at hand (Amnesty International, 2009b).
Economic Status/Education: A human rights report from Burkina Faso states that one of the reasons that poor and rural women in Burkina Faso do not use health care facilities is because they are treated with disrespect (Amnesty International, 2009a). The focus group discussants reiterated that being ―low status‖and ―less educated‖leads to discriminatory behavior on the part of the health care provider because he/she knows that this woman will be ―more likely to accept that sort of treatment and this is why they get treated this way.....she will accept it and she won‘t yell back at you and say, ̳I deserve to be treated better‘‖.
6) Abandonment of Care
Several examples of abandonment that include women being left alone during labor and birth as well as failure of providers to monitor women and intervene in life-threatening situations are given in the box below.
In Sierra Leone, there are citations of women being denied care and dying because hospital staff are not called, or report being ―too tired‖to work. One woman arrived to the hospital with obstructed labor. However, upon arrival the doctor was away on another assignment. Even though it was an emergency, the staff did not call the doctor until the next day and the woman died (Amnesty International, 2009b).
7) Detention in Facilities
Detention of recently delivered women and their babies in health facilities, usually due to failure to pay, has been described in a number of countries, including: Kenya, Ghana, Zimbabwe, Peru, Burundi, and the United States. A woman from Burundi is quoted in the box above after having a caesarean delivery. She reported that life in detention was difficult and she did not have permission to leave with her baby, she was often hungry, and could not stand the situation for much longer (Human Rights Watch, 2010). In Burundi, it has been reported that patients may be held for weeks and months and in one case for over a year until the bill could be paid (Human Rights Watch, 2006). In Ghana, a woman reported visiting her baby in a large hospital for up to three weeks in order to breast feed as the baby was being detained because she could not pay the bill (IRIN, 2005). Detentions in Kenya have been documented including detention of women who have lost their babies (Center for Reproductive Rights & Federation of Women Lawyers- Kenya (FIDA), 2007). In the United States, there are reports of deaths of pregnant women while being detained in immigration facilities (Human Rights Watch, 2010). There are similar stories in the Democratic Republic of the Congo (Initiative Congolaise pour la Justice et la Paix, 2006), Zimbabwe (The Herald, 2004), India (Human Rights Watch, 2009).
