From Global Rights to Local Relationships: Exploring Disconnects in Respectful Maternity Care in Malawi

Abstract

Widespread reports of “disrespect and abuse” in maternity wards in low- and middle-income countries have triggered the development of rights-based respectful maternity care (RMC) standards and initiatives. To explore how international standards translate into local realities, we conducted a team ethnography, involving observations in labor wards in government facilities in central Malawi, and interviews and focus groups with midwives, women, and guardians. We identified a dual disconnect between, first, universal RMC principles and local notions of good care and, second, between midwives and women and guardians. The latter disconnect pertains to fraught relationships, reproduced by and manifested in mechanistic care, mutual responsibilization for trouble, and misunderstandings and distrust. RMC initiatives should be tailored to local contexts and midwife-client relationships. In a hierarchical, resource-strapped context like Malawi, promoting mutual love, understanding, and collaboration may be a more productive way to stimulate “respectful” care than the current emphasis on formal rights and respect.

Epistemic injustice in academic global health

“…Such instances of bias implicitly deny marginalised people and groups the space to interpret their own reality. This form of interpretive marginalisation can be found in interventions and recommendations in the literature that prioritise the universal conceptions of, for example, "respectful maternal care principles" over "local notions of good care", 40 or if actors default to or prioritise globally defined measures of health-system performance (eg, maternal mortality) over locally defined framing of performance. 41 This form of interpretive marginalisation could further lead to credibility deficit if western (located or oriented) voices are allowed to speak for the universal, but others can only speak of local (thereby being undervalued).…”

“Even though they insult us, the delivery they give us is the greatest thing”: a qualitative study contextualizing women’s experiences with facility-based maternal health care in Ethiopia

“…There is, however, healthcare provider consensus that provider communication and perceived experience of care are important dimensions of high-quality care delivery, and more work is needed by care workers themselves to better implement holistically respectful care [ 49 ]. Indeed, Ethiopia has targeted compassionate and respectful care as a core pillar of their Health Sector Transformation Plan, and respectful maternal care trainings are being tested and implemented nationwide with some success [ 45 ], as have other interventions in Tanzania [ 50 ] and Kenya [ 51 ], thought important challenges remain in practice [ 52 , 53 ]. Mothers in our study noted special quality of care when birth attendants provided them continuous accompaniment, attention, privacy, and support.…”

Are midwives ready to provide quality evidence-based care after pre-service training? Curricula assessment in four countries - Benin, Malawi, Tanzania, and Uganda

“…Our findings indicate that gaps in pre-service training curricula were consistent across the study countries, with a lack of focus on woman centered care, information sharing and shared decision making, care related to women who experience physical and sexual violence and abuse as well as aspects concerning fundamental human rights when providing midwifery care. These aspects of respectful care have been described as missing in a number of studies despite being seen as very critical in relation to women’s experiences during the pregnancy, childbirth and postnatal continuum, as well as important in promoting the use of facility-based maternity care [27-31]. The curricula also reflect the legal status of abortion in the study countries [32] and competencies related to the provision of care to women with unintended or mistimed pregnancy were only partly included in five pre-service training curricula.…”