Guest post by Susan Bradley, School of Health Sciences, City, University of London, UK

Last year we published a systematic review exploring women’s experiences of maternal health and looked at the issue of respectful care. We examined the larger factors driving disrespect and abuse during facility-based delivery in sub-Saharan Africa.

Efforts to reduce maternal mortality in low-income contexts have largely focused on technical care. There has been a blind spot to respectful maternal care and little attention to women’s needs for emotional support and safety during labour and delivery. Unsurprisingly, women often experience maternity care as medicalised and dehumanised.

Midwives and women are caught between medical and social models of care

The medical model situates birth as a technical event, carried out and controlled by a skilled expert. In many parts of sub-Saharan Africa birth’s social aspects, such as comforting and encouraging women, are frequently not considered part of the midwife’s role. Women reported being alone during labour, with midwives often only appearing when women started pushing or the baby’s head was out.

Even when midwives want to support women during the first stage of labour, they may be blocked by health systems that can make this impossible, such as unmanageable midwife to women ratios or policies that exclude family members from the labour ward. I have been carrying out research on respectful maternity care in Malawi, where just two midwives cover the night shift at one of the central hospitals. It was not uncommon for me to arrive at morning handover and hear that overnight those two midwives had delivered 20-25 babies. In contexts where there are too few staff or where midwives only carry out technical care, far too many women can be left to labour alone and some even deliver alone too.

Barriers to birth companions

The right to have a companion during childbirth is a key element of respectful care. It seems obvious that leaving a woman to labour alone in unfamiliar and sometimes frightening surroundings is disrespectful and inhumane. Further, it makes no sense to prevent fathers or other family members from providing the social care that midwives may be either unable or unwilling to carry out.

Two main factors make this a challenge in resource-poor contexts, such as Malawi. Firstly, midwives in many health facilities face serious infrastructural challenges, such as open wards with no/flimsy curtains offering extremely limited privacy.

The 2016 photo above of the labour ward in one of Malawi’s central hospitals gives an idea of the physical layout – one that is replicated in most facilities across the country. In facilities with open wards, midwives can only permit a companion (often at their own discretion) if there is only one woman in the labour ward; her companion would be forced to leave if another labouring woman arrived. Alternatively, companions can be brought in briefly to reassure or encourage a woman who is struggling, but this is fraught with difficulty in terms of the privacy of other women. One result of this is that access to a companion is only guaranteed for women who can afford to birth in private facilities, further discriminating against poor and marginalised women.

Some hospitals are working hard to accommodate companions. Initiatives include providing separate rooms for delivery, or building ‘cubes’ (3/4 height walls around a bed with a curtained entrance). However, this is not possible everywhere due to financial or space constraints.

The second issue is the attitude of midwives. I heard mixed views about whether partners or family members should be present in the labour ward. Many staff clearly think it is a good idea. They are aware of the positive impacts companionship has on the labour process itself and on women’s psychological well-being. Others worry that companions would put staff under pressure to provide better care – which can be a source of conflict and demoralisation when local constraints (e.g. staff, resources, drugs) are not conducive to it. A worrying finding that is relevant to familial support is a strong discourse among Malawian midwives of the ‘uncooperative woman’ and blaming disrespectful care on the woman’s behaviour. One mechanism proposed to ‘control’ a labouring woman is to bring her relatives (including her in-laws) to the bedside to shout at her, to ‘persuade’ her to cooperate with the midwife’s instructions. Other midwives express a reluctance to have companions present as the woman would then be free to do as she wants, not as she is told.

Malawi ban on traditional birth attendants

In many places around the world woman are under pressure to have their babies in health facilities. This often forces them to swap the psycho-emotional care they would receive at home from traditional birth attendants for the technical care that professional midwives are currently offering. In Malawi, this pressure includes a country-wide ban on traditional birth attendants, effectively coercing women to endure a birth experience that may not match their need for compassion, presence and safety. An urgent policy change is needed to realise women’s rights to have a companion and to find creative ways to bring the family into the labour ward to support and protect women.

Bradley S, McCourt C, Rayment J & Parmar D (2016), Disrespectful intrapartum care during facility-based delivery in sub-Saharan Africa: A qualitative systematic review and thematic synthesis of women’s perceptions and experiences, Social Science & Medicine 169

Van Lerberghe W, Matthews Z, Achadi E, Ancona C, Campbell J, Channon A, de Bernis L, De Brouwere V, Fauveau V, Fogstad H, Koblinsky M, Liljestrand J, Mechbal A, Murray SF, Rathavay T, Rehr H, Richard F, Ten Hoope-Bender P & Turkmani S (2014),  Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality, Lancet 384(9949)

Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP & Gülmezoglu AM (2014), Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis, Reproductive Health 11:71

White Ribbon Alliance (2011), Respectful Maternity Care: The Universal Rights of Childbearing Women

Photo provided by the author.