Nagpal et al.
Global maternal health: from women’s survival to respectful care BREGJE DE KOK, LECTURER, INSTITUTE FOR INTERNATIONAL HEALTH AND DEVELOPMENT, QUEEN MARGARET UNIVERSITY, UK
..................................................................................................................................................................
M
aternal and neonatal health advocates increasingly call for respectful maternal care that addresses women’s needs (http:// whiteribbonalliance.org/campaigns/ respectful-maternity-care/). The importance of this agenda is underscored by my recent research on loss in childbearing (maternal and perinatal deaths, miscarriage) in Malawi. Four Malawian researchers (Priscilla Matinga, Blessings Kaunda, Caro Mbeya, Fryness Phiri) and I conducted focus groups and interviews with community members and practitioners, and unstructured, ethnographic observations of antenatal, postnatal and intrapartum care in three health centres and two referral hospitals in an urban, semi-urban and rural area. The body is an important tool when conducting observations; feelings and emotions direct attention and enable noticing (cf. Coffey, 1999 The Ethnographic Self: Fieldwork and the Representation of Identity. London: Sage.). Hence, I could see the rows of women waiting and felt fatigue and hunger myself as the clinic continued, uninterrupted, for hours. This increased my understanding of the rather hurried and disinterested nature of the interactions. Once, I witnessed a stillbirth. A woman was rolled into the middle of a hectic labour ward of a district hospital, with a nurse on her side, trying to deliver a lifeless baby. This was an upsetting experience for me.
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I tried but failed to restrain my tears and had a strong urge to leave. My emotional response drew my attention to the apparent absence of reaction among staff—most went on with business as usual. The nurse involved concentrated on clinical procedures; I could not discern expression of emotion or acts of compassion towards the woman. The nurse in charge jumped up, asked what was going on, looked at the client and the lifeless baby, sat down again and continued her administration at a desk 2 m away from the scene. Three people responded differently. A student nurse and patient attendant watched, looking worried. The client’s guardian held one hand over her mouth, looking shocked. Yet, she stood back and did not touch or communicate with the woman, who was staring ahead and slowly and quietly undressed herself, without anybody assisting her.
would lead to a formal audit, but quality of interpersonal care was not monitored. Accountability mechanisms that focus on providers’ accountability for survival may inadvertently distract from quality of interpersonal care and push nurses to focus on women’s physical rather than emotional needs. Yet, these must be acknowledged, especially given the social significance of loss (de Kok et al. Social Sci Med. 2010;71:1703–10). How to develop training, systems and cultures of practice that enable provision of compassionate, respectful care and avoid nurses’ de-sensitisation are important questions to be answered.
These observations highlighted to me the absence of compassionate care, noted more often during my fieldwork. However, it is important to understand rather than merely condemn. The observed differential reactions suggest that exposure informs professionals’ behaviours. Unlike the student nurse and guardian, the nurse will have seen many stillbirths before. Responses will also be informed by what is considered one’s professional responsibility. In the study sites, birth outcomes were recorded, maternal deaths
Disclosure of interest
Acknowledgements
Priscilla Matinga and Blessings Kaunda contributed to research design and data collection; Caro Mbeya and Fyness Phiri contributed to data collection.
The author declares that there is no conflict of interest. Details of ethics approval
Ethical permission was obtained from the Queen Margaret University ethics committee and the National Health Sciences Research Committee in Malawi. Funding
Funding was received from the Independent Social Research Foundation. &
ª 2014 Royal College of Obstetricians and Gynaecologists
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Global maternal health: from women’s survival to respectful care BREGJE DE KOK, LECTURER, INSTITUTE FOR INTERNATIONAL HEALTH AND DEVELOPMENT, QUEEN MARGARET UNIVERSITY, UK
..................................................................................................................................................................
M
aternal and neonatal health advocates increasingly call for respectful maternal care that addresses women’s needs (http:// whiteribbonalliance.org/campaigns/ respectful-maternity-care/). The importance of this agenda is underscored by my recent research on loss in childbearing (maternal and perinatal deaths, miscarriage) in Malawi. Four Malawian researchers (Priscilla Matinga, Blessings Kaunda, Caro Mbeya, Fryness Phiri) and I conducted focus groups and interviews with community members and practitioners, and unstructured, ethnographic observations of antenatal, postnatal and intrapartum care in three health centres and two referral hospitals in an urban, semi-urban and rural area. The body is an important tool when conducting observations; feelings and emotions direct attention and enable noticing (cf. Coffey, 1999 The Ethnographic Self: Fieldwork and the Representation of Identity. London: Sage.). Hence, I could see the rows of women waiting and felt fatigue and hunger myself as the clinic continued, uninterrupted, for hours. This increased my understanding of the rather hurried and disinterested nature of the interactions. Once, I witnessed a stillbirth. A woman was rolled into the middle of a hectic labour ward of a district hospital, with a nurse on her side, trying to deliver a lifeless baby. This was an upsetting experience for me.
248
I tried but failed to restrain my tears and had a strong urge to leave. My emotional response drew my attention to the apparent absence of reaction among staff—most went on with business as usual. The nurse involved concentrated on clinical procedures; I could not discern expression of emotion or acts of compassion towards the woman. The nurse in charge jumped up, asked what was going on, looked at the client and the lifeless baby, sat down again and continued her administration at a desk 2 m away from the scene. Three people responded differently. A student nurse and patient attendant watched, looking worried. The client’s guardian held one hand over her mouth, looking shocked. Yet, she stood back and did not touch or communicate with the woman, who was staring ahead and slowly and quietly undressed herself, without anybody assisting her.
would lead to a formal audit, but quality of interpersonal care was not monitored. Accountability mechanisms that focus on providers’ accountability for survival may inadvertently distract from quality of interpersonal care and push nurses to focus on women’s physical rather than emotional needs. Yet, these must be acknowledged, especially given the social significance of loss (de Kok et al. Social Sci Med. 2010;71:1703–10). How to develop training, systems and cultures of practice that enable provision of compassionate, respectful care and avoid nurses’ de-sensitisation are important questions to be answered.
These observations highlighted to me the absence of compassionate care, noted more often during my fieldwork. However, it is important to understand rather than merely condemn. The observed differential reactions suggest that exposure informs professionals’ behaviours. Unlike the student nurse and guardian, the nurse will have seen many stillbirths before. Responses will also be informed by what is considered one’s professional responsibility. In the study sites, birth outcomes were recorded, maternal deaths
Disclosure of interest
Acknowledgements
Priscilla Matinga and Blessings Kaunda contributed to research design and data collection; Caro Mbeya and Fyness Phiri contributed to data collection.
The author declares that there is no conflict of interest. Details of ethics approval
Ethical permission was obtained from the Queen Margaret University ethics committee and the National Health Sciences Research Committee in Malawi. Funding
Funding was received from the Independent Social Research Foundation. &
ª 2014 Royal College of Obstetricians and Gynaecologists
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
