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Every woman in the world must have respectful care during childbirth: a reflection.
Reproductive Health ( IF 3.6 ) Pub Date : 2020-01-22 , DOI: 10.1186/s12978-020-0855-x
José M Belizán 1 , Suellen Miller 2 , Caitlin Williams 3 , Verónica Pingray 1
Affiliation  

Every woman has the right to the highest attainable standard of health, which includes the right to respectful maternity care [1]. We—as pregnant and birthing individuals and the care providers, public health professionals, and researchers serving them—know instinctually what constitutes dignified treatment. Yet the systems and structures within which we birth and work are not designed to ensure respectful, evidence-based care.

To help the reader see this more clearly, we invite you to do a thought experiment. Imagine you are a woman in labour. You come to a facility in order to receive quality obstetric care. What type of treatment would you expect? Timely attention? Clear and detailed information from a caring health provider about what to expect and why? Recognition of your role as an active decision-maker and protagonist in your own birthing experience, with the choice to consent to or refuse any procedures once you understand them and their implications? Perhaps having a chosen companion with you at all times or deciding on birth position(s) based on your own comfort? Or maybe having the privacy to experience your newborn’s first hours without sharing a bed with a stranger? What other expectations would you have? Viewed in this way, conceptualizing dignified treatment is simple.

Yet such timely, respectful and consensual obstetric care is not the norm in many healthcare settings across the globe. There is a wide-spread belief that ensuring safe birth requires placing the needs and priorities of health providers over those of birthing women. This sets up and perpetuates a power imbalance, privileging providers and contributing to obstetric violence. The power imbalance between women and providers is echoed and exacerbated by similar power dynamics between providers (across cadre and seniority) that can produce counterproductive and even toxic interactions between members of the care team, undermining quality of care and contributing to provider burnout [2].

It is critical that we all reflect individually on these issues, because we—collectively as society—create the written and unwritten rules and norms that govern institutions (be they health facilities; schools of medicine, midwifery, and nursing; or safe motherhood initiatives); therefore, we can also be the driving force to change them. Clear your mind of the idea that the power dynamics in the institutions under which we live are natural. They are not; and making such a dangerous mistake misleads us into believing that we are exempt from acting.

In the Millennium Development Goal-era push to reduce maternal and newborn mortality and morbidity, strong recommendations and actions were taken to reduce home births and encourage women to instead give birth in health facilities. Unfortunately, there was a large missing element. While we have seen rates of facility delivery increase dramatically, we have not seen a concomitant improvement in women’s experience of childbirth. The shift from birthing at home to birthing in facilities helped increase access to life-saving care for complications, but also introduced new challenges, including overcrowding of facilities, an excess of procedures, and over-medicalization of birth. In fact, we now know that facility birth does not on its own lead to improved outcomes; these rely on quality, respectful, evidence-based care [3].

The foundations for the contemporary focus on respectful care were laid in Latin America in the 1970s and 1980s. The publication (in Spanish) of Physiological and Psychological Bases for the Humanized Management of Natural Birth by Roberto Caldeyro-Barcia in the Latin American Centre for Perinatology, along with the jointly-led WHO and PAHO 1985 Fortaleza Declaration foregrounded the importance of dignified treatment [4, 5]. Subsequent work focused this new global attention on centring maternal satisfaction with the birthing process, uplifting positive traditional and indigenous practices, and identifying the health system conditions that contribute to mistreatment [6,7,8].

Within the last decade, respectful care in childbirth has garnered renewed attention, this time among a broader range of global health actors. For example, in Latin America, advocates pushed for legal frameworks addressing the issue [9]. The articles published in the Respectful Care series of this Journal reflect this, documenting the lack of dignified treatment in many countries: Tunisia, Nigeria, Guinea, Brazil, Tanzania, Ethiopia, India, South Africa, the United States, and among Romani women in Europe [10,11,12,13,14,15,16,17,18,19]. Yet today we find ourselves at an inflection point: it is time for us to move from merely documenting the problem towards engaging women, their families, and communities in jointly designing and testing effective, meaningful interventions.

It is imperative that we provide the most respectful, humane, careful, friendly, effective, evidence-based childbirth care in our health facilities. At Reproductive Health, we are eager to receive and publish manuscripts to help achieve such care. Contributions from women and their families would be greatly appreciated, such as submissions describing their vision for respectful care and experiences, as well as offering suggestions for increasing respectful care in facilities. We welcome manuscripts from health facility staff from all levels—administration, nursing, midwifery, medicine, program managers, and decision makers—as well as manuscripts from social scientists on interventions to help providers change their attitudes and practices, and to encourage communities to demand their right to respectful care. We also seek articles from human rights activists and policymakers on actions to protect the right to respectful care during childbirth. As is stated in one of the articles published in the Journal’s Respectful Care Series: “The compassion and evidence based medicine agenda in healthcare is interconnected with human rights in healthcare, feeding into the principles of decision making and patient centred care” ( [20], abstract).

As disrespect and abuse in childbirth has gained public traction, an interesting global semiotic discussion has arisen on the terminology that best defines it. For this series, we have selected the use of Respectful Care over the negative terms (“disrespect and abuse”, “mistreatment during childbirth”, or “obstetric violence”), in order to focus on the positive aspects of care and caring as a broader concept that encompasses all of what pregnant and childbearing people and their families deserve, and not just the absence of mistreatment [21]. By employing the term respectful care, we intend to set a shared goal for all actors, from lay individuals and health providers to researchers and policymakers. We expect that by joining efforts we can achieve a change in the delivery of dignified obstetric care.

The Chilean writer, Isabel Allende, thoroughly narrates in her book De Amor y de Sombra, Digna’s first experience giving birth in a hospital, after having had five home deliveries:

“Digna had gone to Los Riscos Hospital, where she felt she had been treated worse than a criminal. When she entered a numbered band was strapped around her wrist, they shaved her private parts, bathed her with cold water and antiseptic, (…) and placed her beside a woman in the same condition on a bed without sheets. After poking around, without her permission, in all her bodily orifices, they made her give birth beneath a bright lamp in full view of anyone who might happen by. She bore it all without a sigh, but when she left that place carrying a baby that was not hers in her arms and with her unmentionable places painted red like a flag, she swore that for the rest of her life she would never again set foot in a hospital.” (Translation by Margaret Sayer Peden) ( [22], p., 20).

In order to continue efforts to improve maternal and newborn health, it is our responsibility to ensure that no woman in the world leaves a health facility feeling like Digna. We call on all readers to work together to achieve universal respectful care for every woman, everywhere.

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We wish to thank writer Isabel Allende, for her kind provision of the translation of the paragraph of her book.

Affiliations

  1. Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires, Argentina
    • José M. Belizán
    •  & Verónica Pingray
  2. Safe Motherhood Program, University of California, San Francisco, USA
    • Suellen Miller
  3. Department of Maternal & Child Health Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
    • Caitlin Williams
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All authors read and approved the final manuscript.

Corresponding author

Correspondence to José M. Belizán.

Competing interests

The authors declare that they have no competing interests.

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Belizán, J.M., Miller, S., Williams, C. et al. Every woman in the world must have respectful care during childbirth: a reflection. Reprod Health 17, 7 (2020) doi:10.1186/s12978-020-0855-x

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中文翻译：

世界上每一位女性在分娩期间都必须得到尊重的护理：反思。


每个妇女都有权享有可达到的最高健康标准，其中包括获得尊重的产妇护理的权利[1]。作为孕妇和分娩者以及为他们服务的护理人员、公共卫生专业人员和研究人员，我们本能地知道什么是有尊严的治疗。然而，我们出生和工作的系统和结构并不是为了确保尊重、基于证据的护理而设计的。


为了帮助读者更清楚地看到这一点，我们邀请您做一个思想实验。想象一下您是一名临产妇女。您来到医疗机构是为了接受优质的产科护理。您希望接受什么类型的治疗？及时关注？来自充满关爱的医疗服务提供者提供的清晰详细的信息说明了预期结果以及原因？认识到您在自己的分娩经历中作为积极决策者和主角的角色，一旦您了解了任何程序及其影响，就可以选择同意或拒绝任何程序？也许有一个选定的伴侣随时陪伴您，或者根据您自己的舒适度决定出生位置？或者也许可以拥有隐私来体验新生儿的最初几个小时而不与陌生人同床共枕？您还有什么其他期望？从这个角度来看，尊严待遇的概念很简单。


然而，这种及时、尊重和协商一致的产科护理在全球许多医疗机构中并不常见。人们普遍认为，确保安全分娩需要将卫生服务提供者的需求和优先事项置于分娩妇女的需求和优先事项之上。这造成并延续了权力失衡，使服务提供者享有特权，并助长了产科暴力。女性和提供者之间的权力不平衡因提供者之间（跨干部和资历）类似的权力动态而得到呼应和加剧，这可能会在护理团队成员之间产生适得其反甚至有毒的相互作用，从而损害护理质量并导致提供者倦怠[2] 。


至关重要的是，我们所有人都必须单独反思这些问题，因为我们作为社会集体，制定了管理机构的成文和不成文规则和规范（无论是医疗机构；医学院、助产士和护理学院；还是安全孕产倡议） ;因此，我们也可以成为改变它们的驱动力。清除你的想法，即我们所生活的机构中的权力动态是自然的。他们不是；犯下如此危险的错误会误导我们相信我们可以免于采取行动。


在千年发展目标时代推动降低孕产妇和新生儿死亡率和发病率的过程中，采取了强有力的建议和行动来减少在家分娩，并鼓励妇女在卫生机构分娩。不幸的是，有一个很大的缺失元素。虽然我们看到设施分娩率急剧上升，但我们并没有看到女性分娩经历随之改善。从在家分娩到在设施分娩的转变有助于增加获得并发症救生护理的机会，但也带来了新的挑战，包括设施过度拥挤、程序过多和分娩过度医疗化。事实上，我们现在知道，设施分娩本身并不能改善结局；相反，它可以改善分娩结果。这些依赖于优质、尊重、循证的护理 [3]。


当代对尊重护理的关注奠定了 20 世纪 70 年代和 80 年代拉丁美洲的基础。拉丁美洲围产期中心罗伯托·卡尔代罗-巴西亚 (Roberto Caldeyro-Barcia) 出版的《自然分娩人性化管理的生理和心理基础》（西班牙语），以及世界卫生组织和泛美卫生组织联合领导的 1985 年福塔雷萨宣言，强调了有尊严的治疗的重要性。 4、5]。随后的工作将这一新的全球注意力集中在母亲对分娩过程的满意度、提升积极的传统和本土做法以及确定导致虐待的卫生系统条件上[6,7,8]。


在过去的十年中，尊重分娩的护理再次引起了更广泛的全球卫生行为者的关注。例如，在拉丁美洲，倡导者推动建立解决该问题的法律框架[9]。本杂志“尊重关怀”系列发表的文章反映了这一点，记录了许多国家缺乏有尊严的待遇：突尼斯、尼日利亚、几内亚、巴西、坦桑尼亚、埃塞俄比亚、印度、南非、美国以及罗姆族妇女欧洲[10,11,12,13,14,15,16,17,18,19]。然而今天，我们发现自己正处于一个转折点：现在是我们从仅仅记录问题转向让妇女、她们的家庭和社区共同设计和测试有效、有意义的干预措施的时候了。


我们必须在我们的医疗机构中提供最尊重、人道、细心、友好、有效、循证的分娩护理。在生殖健康，我们渴望收到和出版手稿来帮助实现这种护理。我们将非常感谢妇女及其家人的贡献，例如描述她们对尊重护理和体验的愿景的提交材料，以及为在设施中增加尊重护理提供的建议。我们欢迎来自各级卫生机构工作人员（行政、护理、助产、医学、项目经理和决策者）的手稿，以及社会科学家关于干预措施的手稿，以帮助提供者改变他们的态度和做法，并鼓励社区提出要求他们获得尊重照顾的权利。我们还寻求人权活动家和政策制定者发表关于采取行动保护分娩期间受到尊重的护理的权利的文章。正如该杂志尊重护理系列中发表的一篇文章所述： “医疗保健中的同情心和循证医学议程与医疗保健中的人权相互关联，融入了决策和以患者为中心的护理原则” （[20] ， 抽象的）.


随着分娩中的不尊重和虐待行为受到公众的关注，一场有趣的全球符号学讨论开始围绕最能定义它的术语进行。在本系列中，我们选择使用尊重性护理而不是负面术语（“不尊重和虐待”、“分娩期间的虐待”或“产科暴力”），以便重点关注护理和护理作为一种积极的方面。更广泛的概念，涵盖孕妇和育儿者及其家人应得的一切，而不仅仅是不存在虐待[21]。通过使用“尊重护理”一词，我们打算为所有参与者（从非专业人士和卫生服务提供者到研究人员和政策制定者）​​设定一个共同目标。我们期望通过共同努力，我们能够改变提供有尊严的产科护理的方式。


智利作家伊莎贝尔·阿连德在她的《De Amor y de Sombra 》一书中详尽地叙述了迪格纳在经历了五次家庭分娩后第一次在医院分娩的经历：


“迪格娜去了洛斯里斯科斯医院，她觉得自己在那里受到的待遇比罪犯还要糟糕。当她进入时，她的手腕上绑着一条编号带，他们剃掉了她的私处，用冷水和消毒剂给她洗澡，（……）并将她放在一张没有床单的床上，旁边是一名情况相同的妇女。在未经她允许的情况下，他们在她身体的所有孔穴中进行了探查，然后让她在一盏明亮的灯下分娩，任何可能经过的人都可以看到。她默默地承受了这一切，但当她怀里抱着一个不属于自己的婴儿离开那个地方，那些不可告人的地方都被涂成了旗帜般的红色时，她发誓这辈子再也不会踏足了。在医院里。” （Margaret Sayer Peden 翻译）（[22]，第 20 页）。


为了继续努力改善孕产妇和新生儿健康，我们有责任确保世界上没有任何女性在离开医疗机构时有像 Digna 这样的感觉。我们呼吁所有读者共同努力，实现对世界各地每一位女性的普遍尊重。

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 下载参考资料


我们要感谢作家伊莎贝尔·阿连德（Isabel Allende）慷慨地提供了书中段落的翻译。

 隶属关系


  1. 母婴健康研究部，临床有效性和健康政策研究所 (IECS-CONICET)，阿根廷布宜诺斯艾利斯
    •  何塞·M·贝利桑
    •  维罗尼卡·平格雷

  2. 安全孕产计划，加利福尼亚大学，旧金山，美国
    •  苏伦·米勒

  3. 北卡罗来纳大学教堂山分校吉林斯全球公共卫生学院母婴健康系，美国教堂山
    •  凯特琳·威廉姆斯
 作者

  1. 在以下位置搜索 José M. Belizán：

    • 考研医学•
    •  谷歌学术

  2. 在以下位置搜索 Suellen Miller：

    • 考研医学•
    •  谷歌学术

  3. 在以下位置搜索凯特琳·威廉姆斯：

    • 考研医学•
    •  谷歌学术

  4. 在以下位置搜索维罗妮卡·平格雷：

    • 考研医学•
    •  谷歌学术

 贡献


所有作者阅读并认可的终稿。

 通讯作者


通讯作者：José M. Belizán。

 利益争夺


作者声明他们没有利益冲突。

 出版商备注


施普林格·自然对于已出版的地图和机构隶属关系中的管辖权主张保持中立。


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 转载和许可

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 引用这篇文章


Belizán, JM、Miller, S.、Williams, C.等人。世界上每个女性在分娩期间都必须得到尊重的护理：反思。生殖健康17, 7 (2020) doi:10.1186/s12978-020-0855-x

 下载引文


  • 发布日期：


  • DOI ： https://doi.org/10.1186/s12978-020-0855-x

更新日期：2020-04-22
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