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This post was originally published on the Triangle Global Health Consortium blog in support of the 16 Days of Activism Against Gender Violence Campaign.
The nature of health service providers is different than other civil servants—[health service providers] are life savers. Pregnant women deserve care, protection, affection, and respect. The service provider can be friendly and talk like a family member. Service providers need to understand it is not just medical care.
—Male community member and health facility service user in Ethiopia
When I had my son 18 years ago this week, I made some unusual choices for the time. I chose to have him in a free-standing birthing center—a renovated house actually—with the services of a nurse midwife. I decided this was best for me because I wanted to give birth in the safest way, of course, but I also wanted my choices to be respected. I wanted to birth in a position of my choosing, in a non-medical setting with the care and active support of my husband. I wanted as natural a birth as possible, and I did not want any unnecessary procedures or drugs. I wanted a place that would be safe, supportive, and above all, respectful of my choices, my family, and our health.
So I found myself profoundly empathetic with the women who participated in discussions in the IntraHealth gender assessment in Ethiopia earlier this year. Ethiopia has one of the world’s highest rates of maternal deaths and disabilities in the world—673 for every 100,000 live births. Overall, the proportion of deliveries assisted by skilled birth attendants in Ethiopia is 18.4%.1
There has been progress in Ethiopia, and the government is to be commended for establishing a policy to provide free delivery services for all women. Many of the facilities that IntraHealth supports deliver more babies than the national average for health facilities but still lag behind where we would like to see them.
The purpose of our gender assessment was to identify why more women do not give birth in health facilities. We carried out 25 focus group discussions in two regions and six sites with female and male health service and non-service users, as well as with providers and local religious leaders.
We found a lot of good things: Most of the men and women in the groups knew and could discuss the benefits of facility-based delivery. The women came for antenatal care (including vaccinations and HIV testing) even if they did not deliver in the facility. And many wanted to deliver in health facilities so they could avoid transmitting HIV to their children.
The latter was, as you might expect, expressed mostly by HIV-positive members of mothers’ support groups. Even though some of these support group members were not satisfied with the services at the facilities, the possibility of having HIV-negative babies far outweighed their dissatisfaction. And many of these mothers attended the discussions with their healthy, HIV-negative babies on their laps.
So why, despite the risks of home birth and the benefits of institutional delivery, are most women in Ethiopia still giving birth at home?
Across the board, the number-one barrier identified by all of the focus groups was disrespect and abuse of pregnant women in health facilities. Or, more accurately, gender-based violence against pregnant women in health facilities (more on that later). Group members mentioned this barrier far more often than either geographic or financial barriers.
A gender-based violence framework developed under the United States Agency for International Development-supported Translating Research into Action (TRAction) Project2 was particularly useful in analyzing the data we collected. The framework identifies seven categories of disrespect and abuse of pregnant women by providers: physical abuse, non-consented clinical care, non-confidential care, non-dignified care (including verbal abuse), discrimination based on specific patient attributes, abandonment of care, and detention in facilities. We heard examples fitting into each of these categories in our discussions in Ethiopia.
Here are a few examples3:
“Her suffering is my suffering. Sometimes they beat women at the hospital.” —Male service user
“I send women here, and they complain that the providers don’t tell them what they are doing. They say that the providers treat them but give them no information on what they are doing.” —Urban health extension professional
“There is mistreatment in the facility. They shout at us, and we don’t like it.” —Female service user
“One of the problems is we don’t have special waiting rooms and [patients] are exposed to [seen naked by] people.” —Health facility provider
“They judge us on our physical appearance. If we look poor, they treat us differently.” —Female service non-user
“I think that there is unequal treatment between the health facilities. People mistreat you because you are HIV-positive.” —Female service user
“We took a family member to the hospital at night. They said she wasn’t in labor. She was left in the delivery room and came to us and said she didn’t want to be alone. The service providers were sleeping.” —Male service user
“She delivered at 2 a.m., and when we went to bring her home they asked for 400 br. They said we can’t take her unless we pay the 400 br. We raised the money from the community. But those without family suffer in these cases.” —Male service user
Many of the women who participated in the focus group discussions expressed the same desire I had for my birth so many years ago: to have their wishes for their births be treated with respect. At a minimum, they wanted not to be abused—physically or verbally. Beyond that, they wanted to be accompanied and supported by family members. To have some privacy before, during, and after delivery. To bring the best of home-based and traditional births into the facility setting. To deliver in positions other than lying flat on their backs on delivery “couches.” And to have beds to stay in both before and after giving birth.
Contrast some of the comments above with this next comment from a woman (a service non-user) who gave birth at home:
The neighbors and my friends were there. They are there to give me care and support. People arrange everything. They warm the house. They get charcoal. I told my husband I would be okay with their support. You don’t suffer when you deliver at home. There is no stretcher or couch. You don’t need to move. There is no problem especially if you have a TBA [traditional birth attendant]. At the health center there is a process: register, get your card. You go from room to room. Home is the safest place to deliver. You have warm drinks and massage. Your mother is there with you and Saint Mary. I had all three children at home. If the TBA can bring a blade to cut the umbilical cord, if she can bring gloves to prevent HIV, then home delivery is preferable.
When we talked to health care providers, it was clear that most want to provide—and believe they are providing—high-quality services, citing their women-friendly approach and their caring and friendly manner. These providers’ efforts are to be commended, especially given the limitations within which they work. Many facilities have poor ambulance services, or none at all. Many providers work in facilities that lack sufficient space and supplies—one facility had no water, another had no toilets, and yet another had problems with electricity. The providers also pointed out that as more women start delivering in their facilities, their staffs struggle to keep up with the increased demand.
But do these limitations excuse disrespect and abuse of pregnant women? I don’t think so. The root of the problems is not material—it is attitude. And now we are back to why this constitutes gender-based violence. Although you may not immediately think of abusive care during delivery as gender-based violence, this abuse is directed at women’s sexuality, their reproductive role, and their capacity to make decisions regarding their own bodies. It targets women when they are least powerful and most vulnerable, and negates their autonomy over their bodies.
In order to effectively eradicate this problem we need to clearly label it for what it is and begin to address the underlying power imbalances. Until we do, pregnant women may choose to stay home and hope for the best.
Analysis. Bethesda, MD: USAID‐TRAction Project, University Research Corporation, LLC, and Harvard School of Public Health.
3. Not all of the stories group members shared were about the local clinics—some were about other public hospitals or nongovernmental organization-supported clinics, and some were a few years old and did not reflect subsequent improvements.
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