Hear me speak at the Maternity and Midwifery Festival

#MyBirthToo

After the Shropshire baby deaths scandal, we need more mothers speaking about their own traumatic childbirths.

More than 200 new families have contacted an inquiry into mother and baby deaths at a hospital trust in Shropshire. Investigators were already looking at more than 600 cases where newborns and mothers died or were left injured while in the care of the Shrewsbury and Telford Hospital Trust.

Maternity services need improving at home and abroad  

We need mothers to share their childbirth stories #MyChildbirthToo 

We need to hear them for change to happen #MyBirthToo #MyBabyToo

Disrespect and Abuse Indicators in Childbirth – Bowser and Hill

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). 

The Respectful Maternity Care Charter

The Respectful Maternity Care Charter 

The Respectful Maternity Care (RMC) Charter is a normative document that was developed collaboratively by researchers, clinicians, program implementers, and advocates, outlines a rights-based approach to many aspects of care. The Charter is based on universally recognised international instruments to which many countries are signatories, such as the International Covenant on Civil and Political Rights; International Covenant on Economic, Social, and Cultural Rights; and the Convention on the Elimination of all Forms of Discrimination against Women. 

The seven rights of childbearing women it describes are the rights to: 

1)  Freedom from harm and ill treatment; 

2)Information,informedconsent,andrefusal,andrespect for choices and preferences, including the right to a companion of choice wherever possible; 

3) Confidentiality and privacy; 

4) Dignity and respect; 

5) Equality, freedom from discrimination, and equitable care; 

6) Timely healthcare and the highest attainable level of health; 

7) Liberty, autonomy, self-determination, and freedom from coercion 

Campaigners have called for respectful care and protection of all childbearing women, especially the marginalised and vulnerable, such as adolescents, minorities, and women with disabilities (Amnesty International, 2010; White Ribbon Alliance, 2011; World Health Organization, 2015). 

Although there is no consensus on what constitutes respectful care, the emerging respectful maternity care (RMC) movement generally advocates for a patient-centered care approach based on respect for women’s basic human rights and clinical evidence. The RMC Charter, a normative document that was developed collaboratively by researchers, clinicians, program implementers, and advocates, outlines a rights-based approach to many aspects of care. The Charter is based on universally recognized international instruments to which many countries are signatories, such as the International Covenant on Civil and Political Rights; International Covenant on Economic, Social, and Cultural Rights;and the Convention on the Elimination of all Forms of Discrimination against Women.

Complaints about childbirth

Did you complain about your childbirth? If so, I would like to interview you.

My current research project at University College London explores childbirth and maternal health experiences. Furthermore, I am exploring mothers’ experiences of making complaints - and whether mothers need greater support in making complaints - and the results of such complaints.

Some mothers have a great childbirth experience, while others feel angry, guilty and disappointed with the events that occur during childbirth. In my interviews with mothers we discuss both the positive and negative experiences of events during labour and birth, and how this has made us feel. Finally, we discuss why the decision was made to complain about the childbirth experience and how was it to complain, and whether more support have been offered in the process?

Anthropology of Childbirth

What is an anthropology of childbirth? Perhaps we can say that an anthropology of childbirth is the study of childbirth in human populations.

Anthropologists had only studied childbirth in different cultures to a limited extend until Margaret Mead and psychologist Niles Newton in 1967 conducted a survey to assess childbirth practices cross-culturally. Their survey found that available data on the topic was limited, so they proclaimed a need for quality birth ethnographies in anthropology. 

Brigitte Jordan published an ethnographic account of childbirth titled Birth in Four Cultures: A Cross-cultural Investigation of Childbirth in Yucatan, Holland, Sweden, and the United States in 1978. Her work emphasised the idea that, although birth is a biological process it is also clearly "everywhere socially marked and shaped" (1997: 1).

The book on Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives published in 1997, saw Robbie Davis-Floyd and Carolyn Sargent call for anthropologists to gather women's birth narratives for their valuable insight into the language women use to describe their birth experiences (1997: 12).

Women's Perceptions and Experiences of a Traumatic Birth

This article by R. Elmir, V. Schmied, L. Wilkes and D. Jackson highlights the importance of mothers being involved in the decisions taking in their childbirth.

Childbirth is viewed by many as a life transition that can bring a sense of accomplishment. However, for some women, birth is experienced as a traumatic event with a minority experiencing post-traumatic stress. A traumatic birth experience can have a significant impact on the physical and emotional well-being of a woman, her infant and family.

The authors used a meta-ethnographic approach was used as well as ten qualitative studies. Six major themes were identified: 'feeling invisible and out of control', 'to be treated humanely', 'feeling trapped: the reoccurring nightmare of my childbirth experience', 'a rollercoaster of emotions', 'disrupted relationships' and 'strength of purpose: a way to succeed as a mother'.

The authors found that although some women who experience a traumatic birth do not necessarily have physical or psychological adverse outcomes, others identify a significant personal impact. Healthcare professionals should recognise women's need to be involved in decision-making and to be fully informed about all aspects of their labour and birth to increase their sense of control.

https://www.ncbi.nlm.nih.gov/pubmed/20636467

Checklist for Respectful Maternity Care

10 Steps of the International MotherBaby Childbirth Initiative

Taken from the IMBCI website:

Step 1

Treat every woman with respect and dignity, fully informing and involving her in decision making about care for herself and her baby in language that she understands, and providing her the right to informed consent and refusal.

Step 2

Possess and routinely apply midwifery knowledge and skills that enhance and optimize the normal physiology of pregnancy, labor, birth, breastfeeding, and the postpartum period.

Step 3

Inform the mother of the benefits of continuous support during labor and birth, and affirm her right to receive such support from companions of her choice, such as fathers, partners, family members, doulas, or others. Continuous support has been shown to reduce the need for intrapartum analgesia, decrease the rate of operative births and increase mothers’ satisfaction with their birthing experience.

Step 4

Provide drug-free comfort and pain-relief methods during labor, explaining their benefits for facilitating normal birth and avoiding unnecessary harm, and showing women (and their companions) how to use these methods, including touch, holding, massage, laboring in water, and coping/relaxation techniques. Respect women’s preferences and choices.

Step 5

Provide specific evidence-based practices proven to be beneficial in supporting the normal physiology of labor, birth, and the postpartum period, including:

• Allowing labor to unfold at its own pace, while refraining from interventions based on fixed time limits and utilizing the partogram to keep track of labor progress.
• Offering the mother unrestricted access to food and drink as she wishes during labor.
• Supporting her to walk and move about freely and assisting her to assume the positions of her choice, including squatting, sitting, and hands-and-knees, and providing tools supportive of upright positions.
• Techniques for turning the baby in utero and for vaginal breech delivery.
• Facilitating immediate and sustained skin-to-skin motherbaby contact for warmth, attachment, breastfeeding initiation, and developmental stimulation, and ensuring that motherbaby stay together.
• Allowing adequate time for the cord blood to transfer to the baby for the blood volume, oxygen, and nutrients it provides.
• Ensuring the mother’s full access to her ill or premature infant, including kangaroo care, and supporting the mother to provide her own milk (or other human milk) to her baby when breastfeeding is not possible.

Step 6

Avoid potentially harmful procedures and practices that have no scientific support for routine or frequent use in normal labor and birth. When considered for a specific situation, their use should be supported by best available evidence that the benefits are likely to outweigh the potential harms and should be fully discussed with the mother to ensure her informed consent.

• shaving
• enema
• sweeping of the membranes
• artificial rupture of membranes
• medical induction and/or augmentation of labor
• repetitive vaginal exams
• withholding food and water
• keeping the mother in bed
• intravenous fluids
• continuous electronic fetal monitoring
• insertion of a bladder catheter
• supine or lithotomy position
• caregiver-directed pushing
• fundal pressure
• episiotomy
• forceps and vacuum extraction
• manual exploration of the uterus
• primary and repeat caesarean section
• suctioning of the newborn
• immediate cord clamping
• separation of mother and baby

Step 7

Implement measures that enhance wellness and prevent emergencies, illness, and death of MotherBaby:

• Provide education about and foster access to good nutrition, clean water, and a clean and safe environment.
• Provide education in and access to methods of disease prevention, including malaria and HIV/AIDS prevention and treatment, and tetanus toxoid immunization.
• Provide education in responsible sexuality, family planning, and women’s reproductive rights, and provide access to family planning options.
• Provide supportive prenatal, intrapartum, postpartum, and newborn care that addresses the physical and emotional health of the motherbaby within the context of family relationships and community environment.

Step 8

Provide access to evidence-based skilled emergency treatment for life-threatening complications. Ensure that all maternal and newborn health care providers have adequate and ongoing training in emergency skills for appropriate and timely treatment of mothers and their newborns.

Step 9

Provide a continuum of collaborative maternal and newborn care with all relevant health care providers, institutions and organizations. Including traditional birth attendants and others who attend births out of hospital in this continuum of care. Specifically, individuals within institutions, agencies and organizations offering maternity-related services should:

• Collaborate across disciplinary, cultural, and institutional boundaries to provide the motherbaby with the best possible care, recognizing each other’s particular competencies and respecting each other’s points of view.
• Foster continuity of care during labor and birth for the motherbaby from a small number of caregivers.
• Provide consultations and transfers of care in a timely manner to appropriate institutions and specialists.
• Ensure that the mother is aware of and can access available community services specific to her needs and those of her newborn.

Step 10—Strive to achieve the 10 Steps to Successful Breastfeeding as described in the WHO/UNICEF Baby-friendly Hospital Initiative:

• Have a written breastfeeding policy that is routinely communicated to all health care staff.
• Train all health care staff in skills necessary to implement the policy.
• Inform all pregnant women about the benefits and management of breastfeeding.
• Help mothers initiate breastfeeding within a half-hour of birth. Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognize when their babies are ready to breastfeed, offering if needed.
• Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.
• Give newborn infants no food or drink other than breast milk, unless medically indicated.
• Practice “rooming in”—allow mothers and infants to remain together 24 hours a day.
• Encourage breastfeeding on demand.
• Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
• Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Childbirth Experience Focus Group

Please join our focus group on Thursday at 10.00 in Manor Park, Lewisham at the ArtsCafe to discuss your childbirth experiences.

Some mothers have a great childbirth experience, while others feel angry, guilty and disappointed with the events during childbirth. In this focus group we will discuss both the positive and negative experiences of events during labour and birth, and how this has made us feel. 

All childbirth experiences will form part of a University College London research project, but everything said is confidential and everyone participating will be anonymous in the final study. 

There will be free refreshments and snacks. Also, there will be toys available and a free babysitter to help play with your children.

A human rights-based approach to maternal health

Maternal Health

Maternal health refers to the health of women during pregnancy, childbirth and the postpartum period.

A Human Rights-Based Approach

There is no clear definition of a human rights-based approach, but these approaches within the development field generally seek to empower people to claim their human rights, and support duty-bears to deliver particular services anchored by human rights.

Human Rights-Based Approaches to Maternal Health

Human rights-based approaches to maternal health therefore seeks to empower women during pregnancy, childbirth and the postpartum period to enjoy and claim their rights, as well as build the capacity of duty-bearers to deliver maternal health services.

A human rights-based approach to maternal health aims at supporting better maternal health outcomes by analysing and addressing the inequalities, discriminatory practices (de jure and de facto) and unjust power relations which can be at the heart of maternal morbidity and mortality.

The conceptual framework for a human rights-based approach to maternal health rests upon a number of international human rights treaties [1] and general comments, recommendations and concluding observations of several treaty bodies; recognising that maternal mortality implicates a wider range of human rights and recommending that States parties take effective measures to improve maternal health.[2]

Human rights-based approaches to maternal health are informed by two reports produced by the Office of the United Nations High Commissioner for Human Rights (OHCHR). The first OHCHR report identifies seven human rights principles fundamental for understanding maternal mortality and morbidity as a human rights issue: accountability, participation, transparency, empowerment, sustainability, international assistance and non-discrimination.[3] The second OHCHR report outlines categories of good practices to address maternal mortality and improve maternal health in compliance with human rights obligations.[4] 

State parties should do all they can to ensure that maternal health care services are available to everyone in their jurisdiction. This includes facilities, adequate human resources and drugs, supplies and equipment. Maternal health services should also be accessible to everyone without discrimination. This includes safe physical accessibility for all, economic accessibility, including to women living in poverty, and access to information. Maternal health care should be acceptable, respectful of individuals, their culture, sensitive to gender and includes the principle of confidentiality. Finally, maternal health services should be of adequate quality, which requires skilled health workers and respect for evidence-based norms and standards.[5] 

Overall, a human rights-based approach to maternal health can be viewed as a conceptual framework that is normatively based on international human rights standards and norms relevant to maternal health.

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[1] These including the International Covenant on Civil and Political Rights (ICCPR); the International Covenant on Economic, Social and Cultural Rights (ICESCR); and the Convention on the Elimination of All Forms of Discrimination against Women.

[2] See for example: Concluding observations of the Committee on the Elimination of Discrimination against Women: Algeria (A/60/38), para. 131; Czech Republic (A/57/38), para. 85; India (CEDAW/C/IND/CO/3), para. 40; Saint Kitts and Nevis (A/57/38), para. 88; Sri Lanka (A/57/38), para. 217; Turkey (CEDAW/C/TUR/CC/4-5), para. 38; concluding observations of the Human Rights Committee: Bolivia (CCPR/C/79/Add.74), para. 22; Libyan Arab Jamahiriya (CCPR/C/79/Add.101), para. 9; Mongolia (CCPR/C/79/Add.120), para. 8(b); Paraguay (A/51/38),para. 123; Senegal (CCPR/C/79/Add.82), para. 12; concluding observations of the Committee on the Elimination of Racial Discrimination (CERD): Benin (E/C.12/BEN/CO/2), para. 25; Brazil (E/C.12/1/Add.87), para. 27; China (E/C.12/1/Add.107), para. 36; Democratic People’s Republic of Korea (E/C.12/1/Add.95), para. 23; Mexico (E/C.12/MEX/CO/4), para. 25; Morocco (E/C.12/MAR/CO/3), para. 13(f); Paraguay (E/C.12/PRY/CO/3), para. 21; Poland (E/C.12/1/Add.82), para. 29; Senegal (E/C.12/1/Add.62), para. 26; concluding observations of the Committee on the Rights of the Child: Argentina (CRC/C/15/Add.187), para. 46; Azerbaijan (CRC/C/AZE/CO/2), para. 49(b); Benin (CRC/C/BEN/CO/2), para. 51; Botswana (CRC/C/15/Add.242), para. 48; Colombia (CRC/C/COL/CO/3), para. 68(b); Philippines (CRC/C/PHL/CO/3-4), para. 55; Yemen (CRC/C/15/Add.128), para. 55(c).

[3] UN Human Rights Council, 'Report of the Office of the United Nations High Commissioner for Human Rights on Preventable Maternal Mortality and Morbidity and Human Rights.' (2010)  A/HRC/14/39

[4] UN Human Rights Council, 'Practices in Adopting a Human Rights-Based Approach to Eliminate Preventable Maternal Mortality and Human Rights,' (2011) A/HRC/18/27

[5] UN Human Rights Council, "Preventable Maternal Mortality and Morbidity and Human Rights." (2012) A/HRC/RES/21/6