Why India needs respectful maternal care

Respectful maternal care assumes great significance in times of a pandemic. Many cases have been reported by the media about pregnant women being denied admissions to hospitals, of being referred from one facility to another, with some even delivering by the roadside.

Currently, women may shy away from accessing facilities due to fear of COVID-19 infections, and this may be compounded by fear of disrespect, discrimination and abuse, which is a more powerful deterrent to the use of skilled care than geographic and financial obstacles. It has taken years for India to get to the point where women from all socio-economic sections of society decide and opt for institutional deliveries instead of home births, and these gains must not be lost.

Women’s experiences with maternity caregivers can empower and comfort them, or inflict lasting damage and emotional trauma. A woman’s positive or negative memories of childbearing experiences stay with her throughout her lifetime. Studies shows that violating women’s rights during childbirth leads women to distrust health care providers and facilities. Such women are not only less likely to seek out maternity care— such as postnatal and emergency obstetric care—but other health services as well, such as family planning.

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Successful efforts to promote respectful maternity care must consider and address the systems, structures, attitudes, and behaviors that are generating disrespect and abuse within a given environment. Combating disrespect and abuse requires concentrated effort across sectors. Most importantly, all such approaches must involve women themselves – they should be involved in the definition of their needs and preferences in maternity care, as well as in setting up systems to facilitate their ongoing feedback and participation. Women and their families should be enabled to overcome normalization of disrespect and abuse and demand for respectful maternity care(RMC) as their basic right.

Aruna, a young mother was forced to do the cleaner’s job after her delivery: “I had just given birth and the pain was still too much to bear. They forced me to clean the floor of the labor room. I feel there is nothing worse than being a woman”. Contrary to common perception, even the wealthy and advantaged are sometimes not immune to being denied timely care and choice of a companion during labour and delivery, both essential components of respectful maternity care. Television actress Chhavi Mittal has gone on record to say that she was denied a birth companion during her delivery, which, as per the guidelines of Government of India, should be ensured to a woman in labour. Other women have shared that “…When I could tolerate the pain, I asked for my mother, but I was refused and asked me to try on my own. I was not even allowed to hold my mom's hand”.

WHO’s “Quality of Care Framework” for maternal and child health includes both the provision of care, and the experience of care as equal determinants of quality of care. This is significant as it situates RMC as a critical quality of care issue and not exclusively a human rights issue. The White Ribbon Alliance’s Charter for Respectful Maternal Care lists seven such rights: the right to dignity, respect, information, confidentiality, protection from discrimination and abuse, as well as the right to give explicit consent on every aspect of their treatment. In fact, the process of birth and post-natal care should be a collaborative process between mothers and the healthcare professionals – there should be mutual support, both emotionally and medically.

At the policy level, it is recognized that respectful maternity care is a critical aspect of the maternal and newborn health agenda. In 2017, the Ministry of Health and Family Welfare, GoI, launched the LAQSHYA Guidelines - or the Labor Room Quality Initiative – which detailed a set of guidelines stipulating the measures that public health facilities should follow to ensure quality and respectful maternity care, thus ensuring a positive birthing experience. Similarly, the Government’s SurakshitMaatritvaAashwasan (SUMAN), is an initiative to tackle maternal mortality by assuring maternal and newborn healthcare services to all women, giving wider access to cost-effective quality care services, zero tolerance for denial of services, and focuses on respecting women's autonomy, dignity, choices and preferences.

In addition to policy-level changes, what also needs to be dealt with are deep-rooted biases that regards respectful maternity care as a concept that is secondary to the main issue of providing care in India’s often over-crowded, over stretched and overwhelmed health facilities. One such bias is bias against women from low socio-economic strata of society. A senior gynecologist captured the gist of this bias, “Patients who expect high standards of care should be of high quality themselves”. What is frightening about such blatant prejudice is that it assumes dignity and basic human rights need be “given” only to those who can pay for it.

Disrespect and abuse must be addressed at multiple levels. Successful responses must cross sectors, including legal cases, social accountability, provider values clarification training, health systems strengthening, and grassroots education to empower women as rights bearers.

In every family and community, childbirth are momentous events in the lives of women and families, and represent a time of intense vulnerability. The concept of “safe motherhood” is usually restricted to physical safety, but childbearing is also an important rite of passage, with deep personal and cultural significance for a woman and her family. The notion of safe motherhood must be expanded beyond the prevention of morbidity or mortality to encompass respect for women’s basic human rights. Women’s autonomy, dignity, feelings, choices, and preferences must be respected, including their choice of companionship wherever possible.

(The author is the National Coordinator & Executive director of White Ribbon Alliance of India (WRAI), Center for Catalyzing change.)