Every woman has the right to dignified and respectful care during pregnancy and delivery. This is a recent declaration from WHO, issued in September 2014, and already endorsed by dozens of national and international organizations (1). Do you agree with that?

For the past twenty years, women have been strongly encouraged to deliver in health facilities, with skilled health staff. However, women do not always find the care they expected and were told they would get. In his blog, Mr. Rornald M Kananura described the disrespectful and negligent treatment women experience in some maternities in Uganda. Many women suffer the consequences of a non-conducive environment for quality care especially during childbirth.

The list of abuse to which women are subjected to in reproductive health care is long and is only beginning to be scientifically documented (2-4). Among those, women have reported physical and verbal abuse (including severe humiliation), coercively imposed medical procedures, lack of confidentiality, lack of informed consent, refusal to administer their drugs against pain, gross violations of women’s privacy, refusal of admission to health facilities, negligence resulting in avoidable complications ...

This happens everywhere, in countries with limited resources, as well as  in rich countries (5). I have asked my colleagues midwives in France, via their Facebook page, if they had recently witnessed abuses of pregnant women. In less than 12 hours, they reported nearly sixty different situations of shameful women disrespects. All intolerable, they describe refused painkillers administrations, a gynecologist who plays with the sex of a woman in labor, episiotomies imposed despite the refusal of women, threats to remove the child at birth if a mother does not cooperate (while she was in her rights) ... More than half of the reported cases relate to gestures medically unjustified but practiced in order to meet the comfort of caregivers.

It appears that some women are more susceptible to such abuse, as recently described by Elizabeth in her blog. These include teenage single mothers, poor women (5), women from ethnic minorities, immigrant and women who are HIV positive.

Pregnancy and childbirth are times when women are very vulnerable. It is possible that for a few hours they lose some of their discernment when they are overwhelmed by their physical feelings. Fearing for the survival of their baby, they are generally very docile and obey the orders of midwives and other health workers. They agree to stay in uncomfortable positions, not to drink during the labor... or they even suffer violations of their physical integrity as practice episiotomies without any prior information.

This violence may have long-term consequences. Some women reported that they felt deprived of their body, infantilized, and then felt they were not able to become mothers. A scientific article recently published shows the possible link between violence and postpartum depression (6).

How then do we remedy this situation of violence? There is of course no simple recipe. Two of our bloggers have already described the many barriers to changing practices. For my part, I would like to suggest three axes of possible further reflection: those of Empathy, Law and… Science.

•  Empathy: We are all women or children of a woman. Being empathetic is to try to put ourselves in the place of another. For our matter it is to ask ourselves: "Would I like this for myself?  Would I like my mother / sister / daughter facing that? " Empathy allows to reconsider our own actions.
• The Law: In some countries, there are laws on which it is possible to rely, as in France, the Charter of the patients (7). You have witnessed some questionable practices? Report them or provoke discussion by referring to the laws in force in your area. Refuse to put your patients at risk. The associations of HIV positive patients are often knowledgeable about the laws concerning the rights of patients,  it may be useful to contact them.
• Science: it brings in objective and verifiable elements which may be invoked to change the disrespectful practices on women. It may be helpful to refer to the WHO guide 1997 normal delivery (8)(in French only), in which routine care was classified into four categories according to their scientific relevance, their effectiveness and harmfulness. Science has shown that respect for women's rights to privacy, to choose a relative to care for them during childbirth, to stay mobile and choose their birthing position is beneficial to the of health mothers and their newborns. There are practices to reinforce. Among harmful or useless practices, we note the systematic use of enema before delivery, the routine pubic shaving, routine intravenous infusions or the supine position imposed during labor.

A website lists interesting documents on this topic.  Here is also is a list of useful tools for teaching and assessing respectful care to women. It would be necessary to develop mechanisms for reporting violations of women's rights, and before that, to develop practices enabling women to provide their informed consent. In Western countries, women raise their voices and advocate for the respect of their rights. But we also need   that governments, health program managers, individuals and / or professional associations to engage themselves in the spirit of the WHO statement.

Références

1.   WHO [En ligne]. WHO | Prevention and elimination of disrespect and abuse during childbirth; [cité le 3 nov 2014]. Disponible: http://www.who.int/reproductivehealth/topics/maternal_perinatal/statemen...
2. Silal SP, Penn-Kekana L, Harris B, Birch S, McIntyre D. Exploring inequalities in access to and use of maternal health services in South Africa. BMC Health Serv Res. 2012;12:120.
3. D’ Oliveira AFPL, Diniz SG, Schraiber LB. Violence against women in health-care institutions: an emerging problem. Lancet. 11 mai 2002;359(9318):1681‑5.
4. Small R, Yelland J, Lumley J, Brown S, Liamputtong P. Immigrant women’s views about care during labor and birth: an Australian study of Vietnamese, Turkish, and Filipino women. Birth Berkeley Calif. déc 2002;29(4):266‑77.
5.  Lindquist A, Kurinczuk J, Redshaw M, Knight M. Experiences, utilisation and outcomes of maternity care in England among women from different socio-economic groups: findings from the 2010 National Maternity Survey. BJOG Int J Obstet Gynaecol. 1 sept 2014;n/a ‑ n/a.
6.  Alvarez-Segura M, Garcia-Esteve L, Torres A, Plaza A, Imaz ML, Hermida-Barros L, et al. Are women with a history of abuse more vulnerable to perinatal depressive symptoms? A systematic review. Arch Womens Ment Health. oct 2014;17(5):343‑57.
7.  [En ligne]. La charte de la personne hospitalisée : des droits pour tous - www.sante.gouv.fr; [cité le 3 nov 2014]. Disponible: http://www.sante.gouv.fr/la-charte-de-la-personne-hospitalisee-des-droit...
8.  WHO [En ligne]. WHO | Les soins liés à un accouchement normal; [cité le 4 nov 2014]. Disponible: http://www.who.int/reproductivehealth/publications/maternal_perinatal_he...