The literature contains many accounts of disrespect, neglect and abuse in reproductive health services. The examples below have been selected to demonstrate the breadth of contexts and the multiple ways in which healthcare providers fail to provide respectful quality care.
In the UK, the Changing Childbirth report in 1993 recommended a major
reorganisation of maternity services that would put women at the centre of their care through choice, continuity and control (House of Commons Health
Committee 2003). Women in a qualitative study by Baker et al. (2005),
however, perceived that they had suffered from a lack of control, few choices and little influence over decision-making. The majority of the 24 women interviewed had been given inadequate information regarding what was happening to them and several talked of being coerced or bullied into
procedures against their wishes and what their bodies were telling them (Baker et al. 2005). According to the authors, over half used negative terms to describe the midwives’ attitudes, such as rude, harsh, judgemental, insensitive,
intimidating or threatening.
Abuse and neglect were the dominant features of South African women’s
narrative accounts of labour and childbirth (Jewkes et al. 1998). In their study of the health seeking practices in maternity services, women described being shouted at, beaten, threatened with beatings and ordered to clean the floor - some women gave birth on their own. Women complained that the midwives were inhuman and uncaring. The most distressing part of their experience the women said was the neglect, the perception that the staff did not care. In-depth interviews with 19 Benin women explored their experiences of pregnancy and childbirth (Grossman-Kendall et al. 2001). Women considered themselves lucky if kind midwives cared for them. Other women described their midwives as
impatient, intolerant and scornful of women who complained of the pain. They also described midwives beating those who did not comply during childbirth (Grossman-Kendall et al. 2001). The women’s testimonies described many dimensions of care that did not meet their expectations and was socially unacceptable to them. In Benin society, for example, age and having children traditionally brought respect. Grossmann-Kendall and colleagues noted that the mistreatment of older women with many children by young midwives, many without children, transgressed social mores. The older women found this particularly humiliating and barely understandable. The authors also explained that women considered caesarean sections as an act against nature, an evil of modern life and were suspicious that caesareans were performed to generate money. One woman had been forced to stay in the hospital for a month after the birth until her family paid the bill (Grossman-Kendall et al. 2001).
Swahnberg et al. (2007) interviewed and explored Swedish women’s feelings of being abused during their lifetime in the healthcare system. The women, who had attended a gynaecological clinic, described their feelings of powerlessness when the staff did not listen to their concerns, take them seriously or believe them. They felt ignored even when they tried to stand up for themselves and no one responded, and they perceived that they were being treated ‘as a thing without feelings’. One woman, for example, told the doctor to stop a procedure as the anaesthetic was not working but he did not answer and continued (Swahnberg et al. 2007). The callousness, rough, brusque or threatening treatment evoked feelings of discomfort and terror in the women. The core theoretical construct Swahnberg and colleagues (p.165) identified from these women’s feelings was one of “being nullified”, of losing autonomy and human dignity. Women reported intense current suffering even although the abusive event had, for some, occurred years earlier. Kenyan women who had their babies in Kenya’s largest public hospital described “egregious rights violations”, abuse and humiliation that endangered their lives and the lives of their babies (Center for Reproductive Rights and Federation of Women Lawyers Kenya 2007, p.7). The authors noted that women’s experiences in this healthcare facility were said to have lasting psychological and physical repercussions, which shaped their subsequent decisions regarding healthcare use.
Several studies noted the lack of information for women, and the hostile
reactions or ridicule which they received if they showed initiative or questioned the healthcare providers (Jewkes et al. 1998; Kabakian-Khasholian et al. 2000; Swahnberg et al. 2007). For women in Benin daring to ask a question was considered an act of bravery (Grossman-Kendall et al. 2001). Women in South Africa said that they were frightened of the healthcare providers and the random nature of the abuse. Midwives used fear, scolding, and punitive measures to exert control (Jewkes et al. 1998).
With the increasing reports of non-respectful, non-dignified care of women in facility-based childbirth the notion of safe motherhood has been expanded beyond maternal mortality and morbidity to promote the human rights of women. Advocacy groups such as the White Ribbon Alliance, for example, produced a Charter linking human rights with the needs of childbearing women and providing a platform for improvement (The White Ribbon Alliance 2011). Human rights groups have conducted many large-scale investigations into the reasons behind high maternal mortality and morbidity ratios in some hospitals, including the neglect, abuse and discrimination experienced by women and girls having their babies in healthcare facilities.
In South Africa, a Human Rights Watch report (2011) documented negligent and abusive behaviour by healthcare providers in healthcare facilities where maternal mortality rates had risen. Family members reported an apparent lack of concern by doctors and nurses in examining or treating relatives admitted with complications. The delays of several hours or days contributed to the deaths of babies and mothers. There was evidence of discrimination by individual healthcare providers against women who were HIV positive or foreigners, such as Somali women. Poor communication and a lack of
translation for refugees meant that medical procedures were performed without informed consent, and women complained that they had received no
In nineteen years, (1987-2006) the maternal mortality ratio in the United States of America was reported to have doubled. In addition, because there were no federal requirements to report maternal deaths, the authorities conceded that maternal deaths might be twice as high as reported (Amnesty International 2010). Ethnicity and economic status were found to have affected women’s access to healthcare and the quality of care received. Amnesty International reported that African American, Latina, Native American and Alaskan Native women were at particularly high risk of discrimination, poor care, death or
complications. An absence of translation services further disadvantaged women with limited or no English, resulting in difficulties accessing care and exclusion from decisions regarding their care.
A 10-month Human Rights Watch investigation in Uttar Pradesh, India, between 2008-2009, examined the reasons behind the continuing high maternal mortality ratio in that state, despite government initiatives to improve the quality and uptake of facility-based childbirth (Human Rights Watch 2009). The
investigation found that many Comprehensive Emergency Obstetric Care
facilities lacked the skilled personnel and essential supplies to manage obstetric complications. Women were therefore transferred between several facilities, often dying before effective treatment could be accessed. Despite government guarantees of free childbirth care, Human Rights Watch found that women faced unlawful demands for money from hospital workers for routine care such as cutting the baby’s cord and for emergency treatment, such as blood
transfusions, or an emergency ambulance. This imposed a severe burden on poor families and was a barrier to accessing care. Although hospital authorities denied that bribery occurred, the families of women in South Africa said they had to provide money, ‘a cold drink’ (bribe) or food for the nurses in exchange for medicines and treatment (Human Rights Watch 2011). Giving birth alone, verbal, physical and sexual abuse, and cases of detention in facilities for inability to pay have been documented in Kenya (Center for Reproductive Rights and Federation of Women Lawyers Kenya 2007).
Several articles and studies have sought to categorise the different types of suboptimal care. D’Oliveira and colleagues (2002) discussed four forms of violence: neglect; verbal violence including threats, scolding and intentional humiliation; physical violence including denial of pain relief; and sexual abuse. These forms of violence, the authors argue, support assertions regarding the dehumanisation of care and are a serious violation of human rights. As part of the USAID-TRAction Project, 2010, Bowser and Hill (2010) reviewed the evidence of disrespect and abuse in facility-based childbirth in low, middle and high-income countries. They examined the scope, contributors and impact of disrespect and abuse. They also included promising interventions. Their report revealed the multifaceted nature of non-respectful care. Seven categories of disrespect and abuse were identified: physical abuse, non-consented clinical care, non-confidential care, non-dignified care (including verbal abuse), discrimination based on specific client attributes, abandonment of care, and detention in facilities.
It was clear from the literature that disrespect, neglect and abuse was
widespread and diverse. Furthermore, the varied forms of suboptimal care put women and their babies at risk, caused distress to women, deterred them from seeking professional help during pregnancy and childbirth or when faced with complications, and could result in the preventable deaths of women or their babies. In the next section I examine the root causes of suboptimal care.