A comment piece by Duncan Fisher of The Family Initiative.
After the Second World War, birth in western countries was gradually moved out of the home and into hospitals. Infant and maternal mortality rates decreased substantially, but with the removal of mothers from their natural place of support and safety came a wide range of problems, not least inhuman treatment on occasions.
This change of birth environment drove one of the major social changes of the 20th century: the presence of fathers during labour and childbirth. Mothers, mostly living in small family units, took their immediate family with them at this time of great vulnerability.
All the best maternity units strive to “be like home”. In some countries “midwife led care” is a way of reducing the medicalization of birth and its removal from a family environment. But there remains much ambivalence – because hospitals are not homes. Where do fathers and/or other birth partners fit in a hospital setting? They are not patients, but they are not visitors either. The confusion remains to this day and leaves partners in an undefined space when accompanying the woman (Steen et al 2012).
The health facility based birth model has been exported globally to provide maternal and newborn health services. Wherever it goes, similar health benefits have been realized, but the same problems have followed. Placing women in a highly vulnerable state into an unfamiliar place where there is no familial support, care or love opens up risks. Disrespect and sometimes abuse inevitably take place.
The recognition of abuse happening to vulnerable women in maternal health facilities has generated the respectful maternal care movement and most recently, a fledgling family inclusion campaign. Both seek the same thing: the protection of women by directly challenging standards of care in maternal health units and by allowing women to have family support with them.
Research indicates that fathers and families play a key protective role in advocating for respect and by simply being a witness.
A study in Lucknow, India, found that women with more support from a husband, a mother/mother-in-law or a health worker were less likely to report mistreatment. Support from friends, neighbours and other family members did not reduce mistreatment (Diamond-Smith 2016). These researchers concluded: “interventions aiming to reduce mistreatment of women during childbirth should consider the important role of increasing support for women”. A Kenyan study found that women with a family member present or who are married are less likely to experience disrespect (Abuya et al 2015a). These researchers implemented a campaign to reduce abuse, which included specific outreach to men to become advocates for respectful care. The overall campaign achieved a 7% reduction in reported abuse (Abuya et al 2015b).
In 2014 a study undertaken in Tanzania showed that men are more likely than women to be assertive in the face of abuse, requesting better care and filing complaints (McMahon et al 2014). One man in this Tanzanian study reported assaulting a staff member – this is clearly a very bad idea, but the anger at witnessing a loved one being abused in such a vulnerable condition can trigger enormous anger.
It is surprising that those who have exported maternal new health models to developing countries have not done more to insist that the women using these health facilities have the same privileges to have family present as women have carved out in developed countries. Saying that local culture prevents it is not an excuse: when women in developed countries brought men into the labour room, they were challenging and changing a culture that disadvantaged women and the culture changed rapidly and profoundly.
The good news is that the World Health Organisation has just declared that having a birth companion during labour and childbirth is a fundamental standard for all maternal healthcare, along with the privacy that such attendance requires (WHO 2016).
The campaign for respectful care, the campaign to expand the midwifery profession, the campaign for family inclusive care: all these are reactions to the problems that occur when birth is taken out of the home and put into a medical environment. We cannot turn the clock back on the advances in maternal and newborn health that have come with this change, but we can continue to campaign for a reconciliation between home and hospital, knowing perhaps that it will never be complete.
Abuya T et al (2015a), Exploring the prevalence of disrespect and abuse during childbirth in Kenya, PLOS One
Abuya T et al (2015b), The effect of a multi-component intervention on disrespect and abuse during childbirth in Kenya, BMC Pregnancy and Childbirth
Diamond-Smith N, Sudhinaraset M, Melo J & Murthy N (2016), The relationship between women’s experiences of mistreatment at facilities during childbirth, types of support received and person providing the support in Lucknow, India, Midwifery 40
McMahon SA et al (2014), Experiences of and responses to disrespectful maternity care and abuse during childbirth; a qualitative study with women and men in Morogoro Region, Tanzania, BMC Pregnancy and Childbirth
Steen M et al (2012), Not-patient and not-visitor: a metasynthesis fathers’ encounters with pregnancy, birth and maternity care, Midwifery
Photo: Sandor Weisz. Creative Commons.