Professor Pius Okong on providing respectful care for women and newborns

Bo Jacobsson and Pius Okong

Professor Pius Okong, Past-Chair of the Committee on Respectful Care, was the Health Systems Strengthening Theme Leader of the FIGO World Congress Scientific Programme Committee. He examines the importance of delivering quality and respectful care for women and newborns wherever they are in the world.  

What are the key points to highlight about the quality of care in childbirth for women and newborns?  

Respectful care is a practice of love. It is a human right of every woman and her baby to be treated with care, respect, dignity and freedom from harm and being accorded liberty and autonomy. 

FIGO puts respectful care at the core of its functions and expects health professionals to adhere to ethical practice. There are five key principles that we should all follow: 

  1. Recognise the rights and wishes of individuals wherever they seek care. Obstetricians and other health workers should collaborate closely on this.     
  2. The principle of beneficence, which is to provide value-based, evidence-based and beneficial care to all women and their children wherever and whenever healthcare professionals interact with them.  
  3. No maleficence, this ethical principle addresses the issue of avoiding harmful practices, disrespect and abuse of women when they come for prenatal care, checkups, childbirth and postpartum care.  
  4. The principle of justice, which requires us, as healthcare professionals, to provide dignity, respect, and free choice. 
  5. Autonomy, which require Healthcare professionals to fully inform and communicate with the woman and family and respect her autonomy (this in the Bill of Rights for women in childbirth). 

How has care evolved in recent years? 

We need to consider how  care has evolved in relation to women's wishes, consent and autonomy. I would emphasise that, historically, the issue of respecting women's wishes and consent started with the Baby Friendly Hospital Initiative. This was a global initiative launched in 1991 by the World Health Organization and Unicef in response to the 1990 scientific declaration on the promotion, protection and support of breastfeeding. 

The initiative was launched in Uganda in 1992 and the first global efforts following this were derived from the International Conference on Population and Development (ICPD) in 1994 in Cairo, Egypt. The Cairo conference moved away from population policy and programmes that were focused on numbers. At that time, people were largely concerned about population explosion. Specifically, this conference put emphasis where it should be: on improving the lives of individuals and increasing respect for human rights. This respect touched on the issues of respecting women’s wishes, consent and autonomy.  

Following ICPD 10, we had the Beijing Conference of Women in 1995 which brought a huge interest on the gender issues, gender equality and on the issues of maternal health. The Beijing declaration and plan of action of bringing gender on board was unanimously adopted by 189 countries. It was an agenda of women's empowerment and gender equality, which then touched on issues of maternal health, access, their protection and rights. 

In 2018, the WHO then advocated strongly for respect in maternity care, an approach centered on the individual based on the principle of ethics and respect for human rights. It also included calls for maternity services that recognise women's preferences and women's and newborn’s needs. We recognise that the human right of every woman and her baby is to be treated with care, respect, and dignity, free from harm, and to maintain liberty and autonomy. 

FIGO’s project, the International Child Initiative, expounds on the principles of providing respectful care through a 12 steps programme. These 12 steps address the issue of equity and advocates timely effective and respectful care. To date, more than 20 health facilities in 14 countries that have adopted this concept of respectful care in childbirth, and many other health facilities and countries are initiating implementation.  

What cultural differences are there in respectful care from one region of the world to another? 

There are cultural differences with regard to respectful care from one region to another, and even within the same country. 

All women seeking childcare services should expect to be respected, listened to and be given the opportunity to ask questions But there are different cultural practices and expectations based on location, ethnic origin, level of education and their capacity to be able to pay for services. These differences exist in Uganda for example, and in and many sub-Saharan African countries where they see large rural populations.  

Expectations for respectful care in these regions vary from urban areas to rural areas. Women in rural areas may have low education, they tend to be shy and do not ask many questions. Women in formal employment have also different expectations from those who are unemployed or work in the informal sector. Many women in sub-Saharan Africa working in the informal sector rarely ask for clear explanations or for the the opportunity to make informed choices.  In Uganda, women do not traditionally ask health workers questions as this may be perceived as disrespectful to health care workers. However, this is beginning to change now. The educated elite and women living in the urban areas have more access to information and know their rights. They are increasingly assertive and demanding quality and respectful care. 

There is a growing trend in low and middle-income countries for men to come to their wives’ antenatal care - something that is taken for granted in many high-income. This practice is slowly picking up in low and middle-income countries because of the integration of HIV care in antenatal care.  However, in many rural areas in sub-Saharan Africa, spouses are not present during the delivery and postpartum care. Some studies show that many women in rural areas and those with low education have negative feelings towards men seeing them naked, especially in labor and childbirth. They are also reluctant for men to be present when they discuss their concerns with the midwife in the clinic.  

How can we mitigate these differences and facilitate the delivery of respectful care? 

We need to do more to educate all women, change their attitudes and expanding their knowledge and confidence - and that is a cultural issue. It is important to remember that health system structural challenges do exist in trying to address cultural differences and try to overcome them. However, if health systems are weak, you often find that human resources are a significant factor. There is a severe understaffing in the health sector. The WHO recommends 2.28 health workers for every 1,000 population in order to achieve 80% of skilled birth attendance. The reality on the ground is a much lower figure and this severely constrains service delivery. When you are understaffed, the few health workers are stretched and overworked and have no opportunity to provide respectful care.  

Secondly, the health workers need to be trained to give respectful care. Poor infrastructure in the health facilities, especially in low-income countries, further aggravates the situation. It reduces capacity of health workers to provide privacy and to be able to talk to the women with confidence and maintain confidentiality.  

Inadequate supplies and lack of equipment are also constraining health workers from providing evidence-based care that women deserve, as they often have to improvise to address the gaps. Lack of health insurance is also another key factor to address, as some women have to spend out of pocket to pay for and access health services. This poses a risk for poor women who may not be able to access and afford the kind of care that they rightfully deserve. 

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