Maternity care and Human Rights: what do women think?

Sub-standard quality of care during pregnancy and childbirth is increasingly acknowledged to negatively influence subsequent care seeking and an important underlying cause for maternal morbidity and mortality [1–8]. Quality of care, however, is a complex concept often defined through an interaction of structure aspects of the health system, process of care provision including technical and interpersonal aspects and outcomes of care [9, 10]. Recent years increased attention has been given to interpersonal quality of care with concerns about maltreatment during childbirth [11]. Numerous authors report abusive language of health care workers (HCWs), rudeness, intimidation, scolding, lack of empathy, lack of privacy, uninformed decision making, physical assault and denial of services [4–6, 8, 12]. Such disrespectful treatment implies that multiple human rights principles are violated, in particular the right of every woman to be treated with respect for their dignity [13, 14].

‘The Respectful Maternity Care Charter: the Universal Rights of Childbearing Women’, launched by the White Ribbon Alliance, is a recent attempt to clearly demonstrate the link of human rights in maternal health with focus on the interpersonal aspects of care received by women seeking maternity services [15]. Applying such a human rights based approach to maternal health requires attention to the fundamental human rights principle of dignity as well as its related principles autonomy, equality and safety which are relevant in all kinds of health care settings [16]. Although these fundamental principles are incorporated into several legal and medical instruments, their implication and meaning ‘on the ground’ (for example, in the labour room) are far from clear [17–20]. Anecdotes of disrespect and abuse in health facilities, as descriptions of violations of these principles, is an attempt to operationalize human rights violations during childbirth but does not capture the complex interaction of experiences of women, characteristics of health provider behaviour and environmental factors that together influence quality of care [2, 21, 22]. At the same time, assessment of human rights violations alone is limited to what care should ‘not’ be, rather than understanding how care could be provided to ensure human rights principles are respected.

It is believed, that a lack of information about health rights during pregnancy and childbirth, influences women’s perception on maternal health services and an apparent passive acceptance of substandard quality of care [5, 6, 20, 23]. Relying on women’s experiences might therefore be limited due to assumed normalization of sub-standard care in the health system [14, 21]. Nevertheless, any attempt to understand complex quality of care concepts should start with analysis of ‘what women need and want’ [21]. Therefore the aim of this study is to understand women’s perceptions and experiences of maternal health services from a human rights perspective in a low-resource setting in Magu district, Tanzania.

Quality of care provided, and in particular the interpersonal component of quality of care, during pregnancy and childbirth should ensure that women are treated with respect for their ‘dignity’. The Universal Declaration of Human Rights (UDHR) placed dignity at the center of its description of basic human rights and as a consequence the concept of dignity has universally been adopted to be a fundamental principle of human rights [17]. Attention needs to be given to claim of critics that the vagueness of the term hinders its effective implementation [24]. Jacobsen argues this vagueness is largely attributed to lack of distinguishing ‘human dignity’ from ‘social dignity’ [24]. Where human dignity refers to a person’s ability to make moral choices [25–27], social dignity refers to a person’s position in society and social interactions with others [24, 27]. Following this distinction, it can be argued that sense of dignity is susceptible to internal and external actions [28].

Within healthcare, considerations of dignity as a concept have primarily been confined to the fields of palliative care and elderly care [25, 26]. In maternal health, dignity, as a human rights principle, has developed most fully within the context of family planning services with ‘the right to full information and freedom of choice for contraceptive method’ [29]. When dignity concepts are applied to women in labour the same rights apply but are often clouded by other priorities. Women in labour are at their most vulnerable, often fully depended on the health provider and the surrounding health system. Access to evidence-based care, provided with respect for the woman and her child’s dignity, including informed decision-making should be at the center of the provision of care. Far too often however, the technical aspects of care during labour are prioritised beyond the ways in which services are provided. Attributes of what ‘ dignity’ looks like and how it is experienced in a clinical setting remains poorly explored [13, 14].

According to other women, human rights were also perceived in the following terms ‘to be independent’, ‘not to be humiliated’ and ‘to be treated equally’.

Despite previous accounts of women valuing privacy, some women described how they preferred to give birth with multiple women in the same room if that would guarantee proximity of HCWs, which would increase chances of being helped on time.

This study explored the local, contextual meaning of human rights principles through accounts of women’s experiences and perceptions of maternity care. Women were able to convey how they thought they should be treated and how they should not be treated according to these principles when seeking maternal health services. Women explained that being treated with respect for dignity meant ‘being treated well’ regardless of any personal characteristics such as religion or economic status. Some women were fully aware that their rights were being violated.

Although most women might not know what to expect or what care should be provided during pregnancy and childbirth they are able to express if they are satisfied with the services or not and what this implies [6, 49]. Similar to previous studies in sub-Sahara Africa this research highlights women understand human rights ’to be equal’ and ‘to be received well’ by HCWs [6, 50]. In 2000 the UN committee on economic social and cultural rights adopted a general comment to the right to health to clarify the provision in article 12 of the ICESCR: ‘The right to health […] contains the following interrelated and essential elements [….] availability […] accessibility […] has four overlapping dimensions […] non discrimination […] physical accessibility […] affordability […] information accessibility […] acceptability […] quality [51]. For maternity care women in our study explained this to simply mean; to be greeted with a smile and calm words, assigned a bed if needed, being provided with basic medicines and supplies and having the ability to ask questions and be heard.

Women often talked about human rights principles in terms of violations caused by the attitudes of HCWs. This suggests that HCWs’ behaviour such as abusive language and practices is a major contributor to women’s perceptions of care, similar to previous findings [5, 6, 22, 49, 50, 52, 53]. Women described that although HCWs could sometimes show a disrespectful attitude this could also be the result of the patients own behaviour, and therefore should not be seen as intentionally humiliating. Additionally, disrespectful behaviour can be attributed to organizational issues in the health facility such as lack of staff, underpayment of staff, insufficient space and poor resource allocation [54]. The interpretation of slapping women during labour as a form of quality care has been supported in a previous study by Brown who states, “I do not mean to belittle patients’ complaints, nor to excuse malpractice and cruelty, but rather to underline convergences between caring relationships … that elucidate more complex understandings of what constitutes care in this setting [55]”. One understanding elucidated in that study was that for some HCWs to sympathise or pamper labouring women would result in them ‘relaxing’ and in doing so would hinder the progression of labour and endanger both mother and baby. Women are admonished if they make “too much noise” or if they don’t comply with health workers instructions when it is time to push. Firm actions become socially approved as failure to comply might result in death of the child [56]. Context is therefor important to understand how dignity encounters evolve and how they give meaning to individuals.

Acceptance of negative attitudes and practices of health professionals also reflect the institutional and hierarchical organisation of health facilities as well as the general social construction of gender and power imbalances [5, 57]. From a social norms perspective pregnant women from rural areas could act submissive or normalize how they are treated based on perceived expectations of the society or out of fear that failure to act according to these expectations will lead to social sanctions [58]. Having the ‘HCW role’ gives HCWs power over pregnant women with expectations of authority and knowledge, consequently women are heavily dependant on these HCWs and willingly trust and comply with their practices. Lacking reference as to what to expect during labour and being alone and dependent on the available HCWs, hardly facilitates opportunities for women to make an informed choice. HCWs that perform harmful behaviour, knowingly or unknowingly, provide women with the impression that they know what they are doing and that it is ‘correct behaviour in their given situation’ or there was nothing else they could have done.

As many women remain silent about their dissatisfaction with the sub-standard quality of care, or do not have a clear idea about what to expect, it is reasonable to assume they submit to the situation they are in. A number of studies have portrayed women as submissive in relation to the care they receive and ignorant of their rights [3, 5, 6, 52]. However, this research found that women do not easily submit themselves to sub-standard treatment. In particular when they are confronted with undignified and unequal treatment, they appear resilient, find ways to cope or adapt and are patient. Although they don’t demand better services they voice their disapproval of how services are currently being provided when asked directly, like in this study. However, it goes without saying, this is when looking back at childbirth experiences, and not during birth. Kabakian-Khasholian et al. [52] argued that women from rural areas are less demanding because of their low educational level and knowledge of other kinds of treatment. Kumbani et al. [52] stated that most women are unaware of the respectful care that they should receive because they do not know their rights and this in turn limits access to maternal health services. However, women have vast experience and expectations of social conduct, appropriate behaviour, politeness and cultural ways of dealing with others [6]. In this study it is possible women’s limited choice of alternatives for seeking maternal health services contributes to their silence. Women cope with the sub-standard treatment because of limited alternatives and the idea that some care is better than no care at all, rather than because of ‘limited understanding’ [6]. They are however hindered in claiming their rights and lack agency in demanding better care.

Several groups and organizations are currently underway to develop and test interventions to reduce incidences of disrespect and abuse during childbirth [59]. This research can inform current efforts to promote respectful maternity care and illustrates how women’s views of health services can be instrumental in conceptualizing complex quality of care concepts. Interventions should be adapted to included contextual understanding of what constitutes both respectful and disrespectful care, according to women and health workers [60]. This study also shows, that while it appears easier to reflect on human rights principles in terms of violations, it is important that promotion of respectful care includes conceptualization and understanding of lived experiences of dignified and respectful care, beyond focus on harmful practices only. Besides experiences of violations, women presented examples of how health workers provided them with good and respectful services or showed appreciation of health workers’ technical skills to save their lives and that of their newborns. Health workers can sing a song to labouring women for comfort, while at the same time violating women’s privacy by leaving them unnecessarily uncovered. Dichotomous quality categories cannot capture the complexity of health worker behaviour and interaction with their patients [61]. Qualitative social studies therefor remain essential to contribute to the continuous efforts to measure quality of care in particular with regards to the interpersonal quality of care [14, 62]. Further research regarding health workers views and perceptions of how human rights principles can be incorporated in their daily work practices, within their complex environment is essential for further understanding of the occurrence of substandard care and to ensure interventions to promote respectful maternity care will have the desired effects.

All people are entitled to a full set of human rights and its inherent principles, with dignity as the core principle. However, the substantive meanings of human rights principles (i.e. dignity, autonomy, safety, and equality) are often far from clear and are strongly interrelated. This research took a step toward understanding these principles by studying women’s experiences and perceptions, which resulted in numerous exemplified situations. Women experienced or witnessed a variety of situations in which human rights principles were either respected or violated. Women are able to assess the provided maternal health services and appear to be well aware how they should and should not be treated according to their own understanding of human rights. Although women strongly condemn abusive behaviour of health workers, they appear to understand this to be in their best interest or endure it in order to adhere to social expectations or out of lack of alternatives.

HCWs, heath care workers; ICESCR, The International Covenant on Economic, Social and Cultural Rights; UDHR, United Declaration of Human Rights