How it can be responsive, respectful, person-centred
| PATIENCE AFULANI AND NADIA DIAMOND-SMITH | COVID-19 is sweeping the world, and the burden on healthcare facilities is growing. Stories have begun to emerge from higher-resource countries, mainly in the U.S. and Europe, about poor experiences for women giving birth in these circumstances. Some have been denied companions such as husbands or partners during childbirth, or have had their baby taken away from them afterwards. Some may have been neglected or not given information.
As the pandemic reaches into more low-resource settings, including African countries, it is likely that more women will face similar experiences. Often, in these settings, maternity care is already not what it should be: centred on people.
Person-centred maternity care refers to care that is respectful and responsive to women and their families’ preferences, needs and values. It includes aspects like communication and dignity. Unfortunately, disrespectful and neglectful treatment of women during childbirth, including verbal, physical and emotional abuse, is not uncommon.
The drivers of poor care are likely to be exaggerated in times of crisis. This is why person-centred care needs to be emphasised as part of provider training to respond to the pandemic.
Putting people first
Person-centred maternity care is a fundamental human right. Everyone is entitled to dignified and respectful care, and that includes during childbirth.
Negative health care experiences lead to lack of trust and poor perceptions of the quality of care in health facilities. This discourages women from seeking health care. When even a few women in a community don’t get person-centred care, it discourages others from delivering in health facilities. That may make them more likely to die of pregnancy complications.
Person-centred care also has direct effects on women and their newborn babies by improving clinical decision-making and communication between the birthing woman and the healthcare provider. Women are more likely to follow treatments and do well.
In contrast, when care is delayed, inadequate or unnecessary, mothers and babies suffer.
Despite recognition of the importance of person-centred maternity care, research has highlighted gaps worldwide. A recent study in Ghana, Guinea, Myanmar and Nigeria found that more than one-third of women experienced some form of mistreatment. Research in Kenya, Ghana and India highlighted communication gaps, lack of respect for women’s autonomy and unsupportive care. Over half of women reported that providers did not explain the purpose of exams or procedures or ask permission before performing them. About half of the women in the urban Kenya and Ghana studies didn’t have someone with them throughout their labour.
Most of the drivers of poor care are likely to be exaggerated in the pandemic, as has been seen in other pandemics, such as Ebola.
One key area is visitors and support at the facility during childbirth. There is already evidence of institutional policies limiting visitors such as birth companions.
In many low-resource settings women are routinely being denied companions because of lack of privacy in open, overcrowded wards or distrust of companions. This is even when they are needed to provide practical help to women during labour. Hearteningly, in an effort to improve person-centred care, this was beginning to change. But with COVID-19, facilities may start restricting visitors even more stringently. This may leave women unsupported and alone when they deliver, with potential adverse impacts on emotional and physical health.
Health worker shortages are already high in low-resource settings. As new COVID-19 cases continue to increase, so will the demands on health systems and the risk of infections in health workers. This will increase the chance that women will not receive the care that they need.
Providers will be more stressed, given the increased workload from potential COVID-19 infections, inadequate personal protective equipment and an overstretched health system. Stressed providers have been shown to be more likely to verbally and physically abuse women. Poor communication and stress are likely to lead to situations where providers perceive women as difficult. Difficult situations are going to be exaggerated, with verbal and physical abuse likely to increase, as providers feel helpless and resort to these reactive behaviours as a means of gaining compliance.
Prior research has highlighted that poor communication and lack of respect for women’s autonomy is widespread.
It has also been related to women’s ability to demand or command effective communication and respect for their autonomy. During a pandemic, communication may worsen because providers are even more overstretched. Women’s autonomy may be restricted to keep people “safe” from COVID-19 infections. These challenges arise at a time when clear communication is even more important, as women need to understand what is happening to and around them.
What can be done?
Person-centred maternity care is a priority for women, as highlighted by responses from nearly 1.2 million women in the “What Women Want” global campaign.
This is even more important in a pandemic when anxiety and risks are high. To prevent worsening quality of care, it needs to remain high on the agenda along with efforts to control COVID-19. Both person-centred maternity care and safety precautions are needed to prevent the spread of infection. Women are more likely to comply if they understand what is happening to them and trust that providers have their interest at heart. This can only happen if providers take time to talk to women.
Person-centred care needs to be emphasised as part of provider training to respond to the pandemic. Training needs to include self-care for providers to develop positive coping mechanisms. They also need personal protective equipment, which will reduce their anxiety and prevent them from projecting such anxiety to birthing women. Promoting person-centred maternity care should be part of institutional maternal and child health policies for pandemic response.
Patience Afulani is Assistant Professor, University of California, San Francisco & Nadia Diamond-Smith is Assistant Professor, University of California, San Francisco
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