For those of us working in the trenches of global maternal health, it’s easy to forget that amazing progress has been made. In Kenya during the five years from 2009 to 2014, the percent of women who delivered their babies in health facilities increased from 44% to 61%. This matters because women still die in labor from preventable causes like bleeding and hypertension at unacceptably high rates: their chances for survival are much better in health facilities with trained staff, than they are at home on their own or with traditional birth attendants. Kenyan women from all backgrounds are becoming increasingly aware of this fact, and their health seeking behavior is changing. A change like this is a victory for everyone.
But an increased demand for facility-based services leads to a corresponding need to increase the amount and the quality of these services. This part of the equation has been less successful.
Researchers, policy makers and health system managers in Kenya and around the world are understanding a painful reality: women are disrespected and abused by health workers during childbirth. Sometimes this treatment is physical – women are slapped, pinched, or physically restrained. Other times a woman’s privacy or her confidentiality is violated – her HIV status is disclosed to other patients, or she delivers in an open space without any curtains. And sometimes women are neglected, left alone in labor for long periods of time without a health care worker coming to check on her progress. Early programme data in Kenya indicates that poor and uneducated women bear a disproportionate brunt of this mistreatment.
As a mother myself, I know that childbirth is one of the most intense, painful, beautiful and powerful journeys of the human experience. It is incomprehensible to me to imagine the additional pain and indignity of being mistreated during that experience by the very people I trusted my life – and my baby’s life – to. If something like that happened to me, I would most surely have my next baby at home with a traditional attendant, and I would encourage all of my friends to do the same.
But as a nurse, I also know that most health workers are very good people. Kenyan nurses and other health professionals don’t graduate from university with an intention to abuse their patients. A complex web of things happens along the way that leads to these outcomes, which we are only beginning to understand.
We know that health care workers in the public sector are often over worked and under paid. Good performance frequently goes unrecognized, service standards are not monitored, and supervision is sporadic and unstructured. Health care workers are also deeply and personally affected by the loss of their patients – especially by the loss of a mother during childbirth. They silently blame themselves, and become progressively demotivated working in a system where death is normative. Their skin thickens over time as they learn to protect themselves from this environment.
These are not excuses to justify abuse. But they are realities that contribute to a culture that normalizes health care workers’ mistreatment of their clients – not just during childbirth, but across the entire health system. Our interventions to change health worker behavior must recognize that this behavior is often the product of a failing system. The solution must lie, in part, with addressing the system itself.
The DFID-funded Maternal and Newborn Improvement (MANI) project is implementing a range of activities to improve respectful maternity care, including health care worker training and professional debriefing. Wrapped around this are a range of related interventions, including facility-based quality committees and the use of performance based financing to improve quality; the use of community scorecards to promote social accountability; HR support to improve the appropriate number and distribution of health care workers; and broader health system approaches to strengthen management and leadership at the county level. We hope to see notable changes from these approaches, which can be shared to deepen the knowledge and enhance the debate in this complex area.
I believe that the future is bright. If in just five years, the skilled birth attendance rate can rise by 17%, our efforts are not in vain. By 2020 we can improve respectful maternity care in Kenya, and ensure that all women experience their right to childbirth with dignity. We can do it by talking honestly about why this is happening, and building work environments that support health care workers to succeed.