Some thoughts on disrespect and abuse in childbirth in response to FIGO’s Mother–Baby Friendly Birthing Facilities Initiative

Women everywhere deserve respectful, affordable, quality maternal care. The guidelines for mother–baby friendly birthing facilities recently developed by the International Federation of Gynecology and Obstetrics (FIGO) Safe Motherhood and Newborn Health Committee [1], which propose certification of health facilities that meet 10 essential criteria, are an important contribution to that end. Like FIGO, Pathfinder International has observed that facility delivery/skilled birth attendance does not guarantee qualityofcareorareductioninmaternalmorbidityandmortality. Quality of care can still be absent in facilities, thus countering the usual health benefits of skilled birth attendance over home birth. Pathfinder salutes FIGO’ sM other–Baby Friendly Birthing Facilities Initiative as an important step toward eliminating disrespectful treatment within maternity care, as well as improving quality of care during pregnancy, birth, and the postpartum period more generally, which is so sorely needed given the greater-than-expected and unacceptable remaining burden of maternal and newborn mortality in the post-Millennium Development Goals context. The guidelines also prompted renewed discussion among Pathfinder staff about respectful care, specifically with regard to government accountability, community engagement, and a rights-based approach. The guidelines are both appropriate and comprehensive. But what will it take for them to be embraced and implemented universally? It will first require, of course, a combination of persuasion and improved conditions—for the mothers and babies, but also for the providers and staff charged with caring for and safeguarding them. Several measures will be necessary—e.g. provider education and staff training that infuses a rights-based approach to maternity care; high-quality mentoring that continually promotes the same; integrated supervision whereby providers are trained and motivated to ensure continuous quality improvement themselves through collective responsibility and true provider-client partnership; and communities that are capacitated to continually intervene around quality and rights, particularly respectful care (e.g. community-facility co-management committees). FIGO’s guidance spells out enabling measures, but how can we guarantee that the necessary changes are made and sustained within countries? Currently, there are no consequencesfor noncompliance to ensure accountability by governments—either national or local—that are ultimately responsible for providing the necessary resources and other support to make the needed changes by allocating more of their budgets to maternity care and health in general. FIGO’s suggested solution lies largely in the hands of the professional associations within countries and entities like the White Ribbon Alliance, International Pediatricians Association, and WHO to push governments to comply. There must be real consequences for governments who do not vigorously and successfully address this current unacceptable abuse of fundamental human rights and the resulting loss of life and health. As implementers, we must also determine how we will help health workers and health systems respond to the needs of communities and clients, which will require more than adoption of static clinical policies. Dynamic feedback mechanisms that allow individual clients to report cases of abuse or poor treatment (and positive experiences too) are an important part of identifying problems and holding providers accountable. To be effective, feedback mechanisms must be accompanied by education for clients on their rights so that they know that demeaning care is not acceptable, and by an administrative system capable of acting on the reports of bad (and good) service experiences to provide censure, recognition, or support in response to client feedback. Furthermore, broader community feedback on the quality of maternal and newborn health services should occur through co-management structures (e.g. health committees) and requires both that communities become aware of their right to respectful care and an administrative commitment by the health system to respect community preferences, including traditional birthing practices, when they do not put the mother or baby at risk. Finally, theguidelinesframedisrespectandabuse asarightsissue—a position Pathfinder agrees with wholeheartedly. Unfortunately, in debates and literature on disrespect and abuse in childbirth, the bulk of the responsibility for demanding and ensuring that these rights are fulfilled is often placed on individual women themselves. What is really needed is for communities to rally in support of women and hold the system accountable. Since so many of the causes of disrespect and abuse—such as prejudices related to gender, class, education, ethnic origin, and age—are socially rooted, it is absolutely essential that the community be fully engaged in preventing disrespect and abuse and demanding respectful care. A rights-based approach to respectful care has to be about meaningful community mobilization and social change. Pathfinder would like to reiterate its appreciation for FIGO’ sc ontribution to this critical issue and looks forward to continued discussion and collaboration on ways forward.