By Dr. Bushra Al-Makaleh, Yemeni Board for Medical Specializations; Heather M.B. Howard, American Refugee Committee & Elena Ateva, White Ribbon Alliance
“Their words kill more than bullets,” said Amal, a 17-year- old girl from Yemen, about why she did not want to deliver her baby at the nearest health facility. When she delivered her last child, the health providers told her not to cry, scream, or call them when she feels pain. It was her fault having a child in this situation, they continued, she should be grateful that she found a place which provides her a free service. If she wants to express her pain, they said, she should go to a private hospital and pay for someone to put up with her screaming and be there whenever she needs to be spoiled.
Amal says the indignity she faced that day is worse than the strikes and explosions she faces every day with her family since the crisis in Yemen started two years ago. She, like many others, will deliver her next baby at home, knowing the risks, instead of going to a well-equipped and staffed hospital funded by a humanitarian NGO.
The humanitarian mandate is to assure life-saving services for people affected by man-made emergencies or natural disasters. In addition to acute and curative health care, this includes labor and delivery services. As defined in the Minimum Initial Service Package (MISP)—an international standard—emergency obstetric and newborn care services must be available, referral services operational around the clock, and clean delivery kits provided to birth attendants and visibly pregnant women.
During a humanitarian crisis, when health systems and infrastructure are broken, the primary emphasis is to quickly re-establish health care services and ensure people affected by the crisis can reach them. Of course, we want these health services to be good, but when the urgency is having any health services at all, often very little attention is given to the quality of care. Instead, “quality of care” is typically thought of as something to be addressed in more stable settings with longer funding cycles. That’s how the respectful maternity care movement first took root in developing countries.
In 2011, amidst growing evidence of disrespect and abuse in childbirth, White Ribbon Alliance led a group of global organizations to develop a ground breaking consensus document, the Respectful Maternity Care (RMC) Charter. This document demonstrates the legitimate place of maternal health rights in the broader context of human rights. It asserts that in seeking and receiving maternity care before, during, and after childbirth, every woman has the right to:
- Be free from harm and ill treatment
- Information, informed consent and refusal, and respect for her choices and preferences, including the right to companionship of choice wherever possible
- Confidentiality & privacy
- Dignity & respect
- Equality, freedom from discrimination, equitable care
- Timely health care and to the highest attainable level of health
- Liberty, autonomy, self-determination, and freedom from coercion
The impossible choice: Mistreatment or homebirth
If women find themselves mistreated, they have two options: seek health services elsewhere or don’t seek care at all. People in crisis settings typically don’t have the choice to change their health providers. If a woman in a humanitarian emergency experiences abuse or feels disrespected in childbirth, she is much more likely to stay home the next time she gives birth (and recommend her family and neighbors stay home too, lest they wish the same poor treatment). In these situations, the care that is supposed to save lives instead becomes a barrier. Thus, ensuring access to health services that are safe, timely, respectful, and culturally appropriate is not only a right for all humans, but it is imperative to realize the life-saving mandate of humanitarian missions.
Women’s experiences with maternal and newborn health services can empower and comfort them, or they can inflict lasting damage and emotional trauma. Childbirth is already a time of intense vulnerability for women. This is magnified in situations of instability and conflict where women may see and experience violence every day. As sexual violence is often a tool of war, it is possible they have been raped, and abuse in childbirth might trigger past experiences. Furthermore, in the chaos of humanitarian emergencies, there are not always functioning accountability mechanisms for women to report abuse.
Midwives also face disrespect
Women in labor are not the only ones who need special attention in humanitarian settings. Health providers such as midwives who deliver babies, also experience the daily stress and violence of crisis settings. Many of these midwives are women, who report being treated badly because of discrimination and gender inequality. They describe harassment at work, a lack of security, and fear of violence. Hammeda, a midwife who works in a public health facility in Yemen, paints a graphic picture. “What respect you are talking about? Who respects us when we are working without salaries for almost nine months now, our children starving, and we face death every day coming to here?” she asks. “We leave our children at home while we do not know if we will find them when we come back or not. Under all the stress we face, do you want us to spoil women and pat their backs whenever they feel pain? This is a luxury which is not an essential lifesaving practice that we should focus on in the crisis.”
RMC furthers the mission of lifesaving humanitarian services
Respectful maternity care is not a luxury, and it is not more expensive. Respectful maternity care is a universal human right that is due to every childbearing woman in every health system and setting—especially in humanitarian crises. It’s important that the community doesn’t refuse life-saving humanitarian assistance because of disrespect and abuse. Equally important, the power hierarchies, stress and environments in which midwives work also need to be addressed to facilitate respectful, dignified maternity care.
Respectful maternity care needs to be incorporated into the training health providers receive in emergency obstetric and newborn care, as well as training for community health workers who distribute clean delivery kits and educate the community about the importance of facility deliveries. It is equally important to establish compliance mechanisms for women to be able to anonymously report any abuse.
Childbirth should be a safe zone. Indeed, it may be the only safe zone for some. But it’s a safe zone women need, deserve and are entitled to when they bring life into the world, even when everything else around them is collapsing. As humanitarians, we must ensure a safe, respectful and dignified childbirth experience for every woman, everywhere.