As a mother and director of porn for women I have wanted to address this for a long time and I’m happy to announce that I have released an explicit sex documentary about sex and pregnancy featuring adult performer Tiffany Doll & her husband Bruno. In the upcoming weeks, the Erika Lust Blog will host a number of highly experienced women’s health and sexuality professionals to discuss everything around the topic of Pregnancy & Sexuality.
Respectful Maternity Care (RMC) is a public health response to the disrespect and abuse many women experience in the setting of healthcare during childbearing. This phenomenon is largely a function of gender inequality in society at large and how it translates to healthcare when women are most vulnerable. This is experienced to a greater degree by women with limited resources and barriers to accessing basic care. Cindy’s article addresses the causes and impact of disrespect and abuse in maternity care and is based on her years of clinical experience and research in this area.
Pregnancy and childbirth are quintessential cultural experiences shaped by many different local beliefs and practices depending on the setting. Across cultures, this is a time when women can find themselves at their most powerful and their most vulnerable both physically and psychologically. These experiences can be transformative for women and their partners, forging a path for empowerment, happiness, and deep satisfaction in their lives. The health care that women receive during this time is critical to how the experience will be perceived and integrated by the woman and her family as well as the health outcome of the pregnancy itself.
While most women in high income countries can expect a healthy outcome for themselves and their babies, this is not the case in many low and middle-income countries. Maternal mortality (defined by the World Health Organization as the death of a woman during pregnancy or within 42 days of the end of the pregnancy) is a much more common occurrence in certain parts of the world. Although there has been a great decline in maternal mortality globally in the last 30 years, parts of Sub-Saharan Africa and South Asia experience much higher rates of maternal mortality than average as can be seen in this data from UNICEF.
Social and cultural factors play a large role in maternal health disparities and access to safe maternity care. In addition to many women not having access to the supplies, equipment, and skilled care of professional health workers, many women also delay or avoid seeking care in health facilities because of how they are treated by those entrusted to care for them during pregnancy and birth. Despite a growing movement to eliminate exploitation in the care of pregnant and birthing women, many women are still obligated to abandon their autonomy when entering a maternity ward to give birth, just as they often do in the bedroom. The message that safe pregnancy, healthy sexuality, and reproductive choice are human rights has not reached all healthcare settings with examples of disrespect and abuse by health workers permeating the process of childbearing in many parts of the world.
Expanding access to high quality maternity care has been a top priority in global health for decades. There is now a growing recognition that achieving improvements in pregnancy and birth outcomes is not just a matter of preventing death and disability, but is inextricably linked with women having their feelings, choices, and preferences respected in the course of receiving care. Disrespectful or undignified care can result in negative outcomes for women, their babies, and entire communities. This is not only because the trauma of a negative birth experience disempowers the individual, but it can also impact her decision as to whether she will delay or entirely avoid seeking potentially lifesaving care in the future. Entire communities may also be deterred upon hearing stories of disrespect and abuse that family or friends experienced leading to high risk situations being managed without a skilled birth attendant or without the necessary supplies or equipment to save lives.
Common experiences of women globally include being forced or coerced to undergo unnecessary medical procedures such as labor induction, cesarean section, or episiotomy (incision made to widen the vaginal opening) that can have emotionally and physically altering consequences. Women may also be separated from their chosen labor support person and left alone, ignored, verbally abused or threatened if they don’t comply with a health worker’s demands. Other forms of disrespectful care include not allowing women to participate in their care and voice their preferences or not explaining the plan of care to them, which should include answering their questions about procedures, medications, their body, health, or baby’s well-being.
I have witnessed this to some degree in almost every place I have practiced as a midwife whether it was Hawai’i or New York City, Israel, South Sudan, or Nepal. Verbal abuse or coercion tactics are common and vary along a continuum. For example, in one African country, I routinely saw providers and nurses forcefully spreading women’s legs during birth and shaming them into pushing harder so the babies delivered faster. In many parts of the United States, I have heard women be told that if they did not comply with a procedure that was being recommended (such as a cesarean delivery) that their baby may die so that the doctor did not have to stay late and wait for a woman to deliver vaginally.
A recent report by Every Mother Counts looking at maternity care samples in the US, found that 1 in 6 women report experiencing negative treatment in childbirth. This number increased dramatically among minority women and those with less financial resources. This number is overwhelmingly larger in much of sub Saharan Africa where maternal mortality is highest so efforts to make lifesaving maternity care accessible to women should clearly be prioritized. Part of the way to do this is through improving the birth environment. The global attempt to repair this problem has been termed Respectful Maternity Care (RMC) and encompasses a group of attitudes and behaviors for everyone to adopt in the maternity setting so that women have the autonomy and empowerment that is rightfully ours.
However, there are two main barriers to accomplishing the full integration of RMC. The first is that gender inequality is a fact of life in much of the world and despite our best efforts to train health workers in how to behave respectfully, they are, after all, people who live within the context of the inequities of the society they exist in. Discrimination, oppression, and abuse are all things women may be routinely exposed to and so it is often normalized. Normalization means if you are a woman from these circumstances, you may not even realize that it is your right to demand or expect better treatment. You may not know how or where to turn for help when it happens. Worse still, there may be laws or societal rules which condone or encourage the disempowerment of women. In settings where gender inequality is normalized, the health workers who experience the negative consequences of these circumstances bring that to the bedside when they care for women, whether they are women themselves or men.
The second barrier to implementing RMC is that the concept of respect is heavily influenced by environmental, cultural, ethical, and socio-economic factors. Therefore, the definition is abstract and will always be variable between individuals making it difficult to explain, create policies for, and translate into actions deemed ‘respectful.’ My own research focuses on this factor in that it is devoted to finding a somewhat standardized definition of respect that can contribute to creating RMC programs and policies in order to improve maternal health for all women. It involves interviewing women in various settings in the US, Sub-Saharan Africa, and Asia about their experiences and perceptions in childbearing.
I am grateful to the women I have served for the last 25 years in my role as a midwife, and to those I was able to interview in the course of my research for sharing their stories with me. These stories gave me greater insight into what makes women feel valued, respected, disempowered, and what elements of women’s experiences were so important that they could influence their future decision-making regarding how and when they seek care. Despite the variation in culture, socio-economic level, education, religion and age, there are some identifiable themes that crosscut all of these influencing factors. Namely, what women all seem to want is to have their needs met in a timely manner, feel listened to, have things explained to them by people who are kind, knowledgeable, experienced, and empathetic. They want to be in an environment that is clean, safe, comfortable, and affords them the level of privacy they prefer. In a sense, isn’t this what we should all expect and demand within the context of healthcare, as well as life in general?
Guidelines for how to begin to address and integrate RMC were created by The White Ribbon Alliance, a consortium of individuals and organizations that are committed to improving maternal health. It outlines the human rights that should be guaranteed to all women while giving birth and how to advocate for them, and features stories from women in various parts of the world who describe their experiences. Until we can standardize the definition for respect and begin to overhaul healthcare and how it is delivered, address gender inequality, and allow women to be the strongest voice in the room, women will not be able to enjoy the transformation that childbirth can offer. We should all begin by advocating for this right by using our own voices.
About the author:
Cindy Stein PhD, MPH,CNM has been a midwife, global health professional, and researcher for over 20 years, providing clinical care, training, program design and implementation and data collection for projects in over 18 countries. Her specialties include: Respectful Health Care, Maternal Health, mHealth tool development, and qualitative research. She holds a PhD in Nursing, a Master’s in Public Health with as specialty in Forced Migration, and a Master’s in Midwifery. She currently works as an independent health consultant, a midwife at Sutter in Santa Cruz, California, and as a lecturer at California State University at Monterey Bay. She is also the mother of four children.