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A health care worker handing baby to mother. Source: Jhpiego.
Greater than one third of all women experience mistreatment during facility-based childbirth. Mistreatment, particularly in humanitarian settings, may include verbal or physical abuse, poor patient-provider rapport, a lack of information about maternal and newborn health (MNH) services for both pregnant women and providers, lack of privacy within facilities, challenges with receiving informed consent from women for medical procedures due to language and cultural barriers, and denied or delayed care. Such mistreatment can stem from historical tensions between populations seeking care and health workers (both foreign and local) as well as systemic mistreatment of providers who are burned out and possibly carry their own biases. Evidence shows that some women delay seeking care, or avoid care entirely because of social fears stemming from negative stigma or negative perceptions of their situation.
In humanitarian settings, MNH services are often interrupted or strained because of health infrastructure destruction, access constraints, reduced quality management, and attacks on service providers. Given the highly stressful environment, access to respectful maternity care is subsequently challenged, and inequitable. Respectful maternity care (RMC) is a term that’s emerged from regional and global maternal and newborn health (MNH) movements. RMC includes humanizing childbirth and overcoming obstetric violence, is rooted in human rights, and relates to the provision and experience of high quality MNH care.
While addressing mistreatment of women during facility-based childbirth is recognized as critical by the World Health Organization (WHO), and there is a growing body of evidence on mistreatment and RMC in stable settings, there has been less investigation and understanding of how to implement RMC in humanitarian contexts. Lessons learned from operationalizing RMC interventions in stable settings show that the first step is to create a shared awareness amongst varied actors by exploring the RMC issues and plausible solutions that seem most applicable to the context.
Building on the momentum of previous global discussions focused on RMC, the Maternal and Newborn Health Sub-working group of the Inter-agency Working Group on Reproductive Health in Crises (IAWG) is exploring promising strategies and interventions for the promotion and incorporation of RMC in humanitarian settings. In November 2021, we hosted a technical consultation which included 20 MNH providers and program managers with experience delivering RMC focused services in fragile or conflict-affected settings. This built off considerations from a 2018 IAWG technical consultation, and endeavored to understand the feasibility of applying previously successful RMC methods in humanitarian contexts.
The findings from the 2021 consultation were incorporated into a brief targeting healthcare providers who work in these contexts: Approaching Implementation of Respectful Maternity Care in Humanitarian Settings. The brief outlines interventions implemented in stable settings that MNH providers and program managers have identified as promising strategies for crisis-affected settings. The interventions are organized into three targeted areas: communities and women; health care providers – midwives, clinical support staff, doctors/consultants; and health systems – governance, infrastructure and commodities, human resource policies and management, and adaptive learning. The brief provides entry points for addressing RMC in humanitarian contexts. However, like all humanitarian action, intervention strategies must be selected using a participatory approach that engages policy, program implementers, and research partners during an emergency response. Involving the relevant stakeholders at the intervention selection stage will ensure that strategies are tailored to the phase of emergency and acceptable to the local context.
While RMC is being incorporated in some humanitarian and fragile settings, more evidence around the implementation and effectiveness of these interventions for diverse populations including host communities, refugees, internally displaced persons, young mothers, and other vulnerable groups is needed. The Newborn Working Group of the Global Respectful Maternity Care Council (GRMCC) recently completed a modified Delphi exercise that developed a rank-prioritized list of research questions that focus on respectful care for newborns, identifying parents and newborns in humanitarian crises settings as priority populations. This study offers the first consensus of global experts around a working definition of respectful care for newborns and develops a ranked list of research questions focusing exclusively on respectful care for newborns.
Together, the RMC technical brief and the Delphi study, make a strong case for accelerating progress of RMC in humanitarian and fragile settings. The RMC technical brief offers explanation of both why and how to increase RMC in humanitarian settings and the Delphi study provides key research priorities focused on increasing respectful newborn care.
Conducting implementation research would help to better understand the feasibility and effectiveness of integrating RMC-promoting program/interventions into humanitarian health programs. We encourage humanitarian agencies to conduct a review of their services for RMC –noting gaps and areas for improvement, select at least one RMC intervention to integrate into their response strategy, evaluate the intervention – in partnership with research partners as needed, and share learnings with the broader humanitarian community.
While implementing RMC in humanitarian settings may be a challenge, it cannot be ignored with the increasing number of crises around the world and growing potential for increased mistreatment in childbirth. It is time to draw on our collective knowledge of existing strategies, implement and test them, and translate our learning into actionable, quality, and accountability in MNH-care for all.
This post first appeared on New Security Beat.