Respectful and Dignified Care: Learning Lessons from Tanzania
Evidence spanning geographic contexts in industrialized as well as low- and middle-income countries indicates women who give birth in health facilities can face humiliating and undignified conditions, which can hinder timely seeking of institutional care and ultimately put women and newborns’ lives at risk. For this reason, the need to address experiences of care, for example how women and their families are treated when giving birth at a health facility, is a central tenant of the WHO Quality of Care Framework and accompanying standards.
During opening welcome remarks as host delegation for the Quality Equity and Dignity (QED) workshop, Tanzania’s Director of Preventive Services, Dr. Neema Rusibamayila, underscored the need to address respectful maternity care as central to improving quality of care. Her emphasis on respectful care is no surprise, given East Africa is home to some of the first attempts to measure and address clients’ negative experiences of institutional childbirth care (often referred to as mistreatment or disrespect and abuse).
The Tanzania delegation was given the opportunity to present their experience related to one of the workshop themes: “Systems and mechanisms to ensure that health workers are enabled to deliver respectful and empathetic care.” Dr. Mary Mwanyika-Sando, CEO of Africa Academy for Public Health and member of Tanzania’s Respectful Maternity Care Taskforce, oriented the audience on what contributes to disrespect and abuse. A growing body of literature indicates that treatment results from a combination of factors such as weak infrastructure, the policy environment, human resource shortages and/or low competency, poor client-provider interactions, disempowered clients and socio-cultural norms.
Some of the approaches to advancing respectful care tested in Tanzania were processes such as adapting the Client Service Charter, Values Clarification, and Attitude Transformation exercises for health workers. Additional approaches included hosting Open Birth Days to allow families to explore and engage with the health services prior to childbirth, and implementation of companion of choice interventions. Accountability mechanisms, e.g., community score cards, were also found to be effective for soliciting client feedback and fostering community engagement. Promising health worker interventions included the provision of emotional/psycho-social support, mentorship, and on the job training.
Efforts of global and regional institutions have also helped push for respect and dignity to be reflected in policies, strategies and resolutions. For example, the East, Central and Southern Africa Health Community includes the need to address respectful maternity care in the latest resolutions from their Best Practices Forum and Health Minister’s Conference. In addition, respectful maternity care is explicitly mentioned in the Addis Declaration coming out of the Acting on the Call to End Preventable Maternal and Child Deaths consultation. Experiences to date demonstrate the importance of multi-faceted and multi-level participatory processes to address the complex issue of mistreatment, as no one simple solution will serve as a “quick fix.”
The presentations sparked lively debate as QED country delegations considered what would constitute their proposed “change packages” for their country plans of action. Further, the delegations considered how to routinely measure progress (e.g., which indicators to use) and began exploring how to incorporate evaluations and implementation science in conjunction with rolling out their change packages. Since this is new territory to forge, capturing and sharing experiences will prove critically important. As such, the establishment of a learning network among the countries emerged as another key objective of the process.
The challenges appear daunting, as the global community’s collective efforts to confront issues related to experiences of care remain in their early stages. Dr. Hussein Kidanto of Tanzania’s Ministry of Health, Community Development, Gender, Elderly and Children reminded participants during his closing workshop remarks that we ‘cannot be afraid’ and we should not use ‘health system excuses and lack of money’ as reasons for failing to advance respectful maternity care. Rather, we can and should act now.