Abuse and disrespect during maternity care has been documented and observed globally. In response, USAID’s flagship Maternal and Child Health Integrated Program (MCHIP) is launching the Respectful Maternity Care (RMC) Toolkit. This package of materials is designed to provide clinicians, trainers, managers and other stakeholders involved in the provision of maternity care with the tools necessary to begin implementing RMC in their area of work or influence. This toolkit contains program learning documents, such as: surveys and briefs on country experiences; training materials; tools to assess and improve RMC within programs and services; job aids; and a resource list.

Women who chose to give birth at home without a skilled health care provider, as well as their newborns, are more likely to suffer complications and die. In less developed countries, there may be many reasons women chose not to give birth in a health facility, such as distance, and lack of transport or money to pay for health services. However, all too often a lack of respectful care from frontline health workers—such as doctors and midwives—cause women and their families to distrust the health care system and opt for more risky homebirths, with unskilled traditional birth attendants (TBAs). Women often choose to deliver with TBAs not only because their services cost less, but also because they provide RMC and follow up care, and are trusted and known within their communities.

Mozambican mother holds her newborn. Photo credit: Jhpiego

Multiple factors may contribute to disrespect and abuse within healthcare services. Health systems may be underequipped, and healthcare workers may be overwhelmed due to inadequate pay, lack of infrastructure, or insufficient staff and supplies. An attitude of disrespect for clients and patients may permeate the healthcare system, and healthcare workers may not receive any guidance or supportive supervision related to RMC or their work in general.

The goal of this toolkit is to empower frontline health workers to provide RMC, allowing women and their families to experience better maternity care and to choose to deliver with a skilled provider at home or, preferably, in a health facility. The ultimate impact of more women using skilled birth services during child birth will be reduced newborn and maternal deaths.

RMC in Mozambique                                    
 ”Giving birth is such a special time for a woman, but it is also filled with stress and fear,” said MCHIP Senior Technical Advisor Veronica Reis. She often wondered during her more than 20 years of clinical practice in Brazil why ensuring women’s comfort and preferences during childbirth was almost never discussed at medical school: “Most of the training in medical school was technically focused, about diagnostic treatment and clinical procedures.”

Therefore, Dr. Reis was pleased to hear about a movement known as Humanization of Childbirth, which centers on putting women and their families at the center of care, especially during childbirth. This movement began in Brazil and has increasingly gained prominence in Latin America and elsewhere. Grounded in respect for human rights, this movement has evolved into what is known as Respectful Maternity Care, which promotes the idea of the client as a person with values and expectations that should be respected during the provision of health care.

Therefore, when asked in 2003 to help promote RMC at the Ministry of Health’s National Maternal Health Program in Brazil, Veronica jumped at the chance, convinced this was a worthwhile initiative that was long overdue. There she learned that the presence of a companion at birth, usually a family member or loved one, is an important part of RMC. She was amazed that in all the hospitals where she had worked, policies never permitted family members to accompany the woman in labor; they were always forced to stay outside and/or not be present. Nor did policies allow women to make many other choices in their care, including the right to choose their birth position.

Importantly, Veronica was able to take the skills and knowledge she developed in RMC and successfully help apply them in Mozambique, where she supported USAID’s Jhpiego-led maternal and newborn health program (ACCESS) starting in 2006.  At a large stakeholders meeting in 2007, attendees learned that one important reason women were not giving birth in hospitals—and therefore more often suffering from complications of and dying in childbirth—was fear of not being treated well.  ”Women were afraid of being treated badly and dying alone in the hospital,” Veronica explained.

With continued advocacy by Veronica and her colleagues, the Minister began to prioritize RMC through on-going health programs, most notably through MCHIP’s Model Maternity Initiative (MMI), starting in 2009.  This initiative, carried out in the largest 34 hospitals in the country, supports birthing practices that recognize women’s preferences and needs.  Not only are these hospitals continually evaluated on the quality of care they provide, but also on their ability to provide RMC. Some RMC behaviors include: respect for beliefs, traditions and culture; the right to information and privacy; the choice of a companion during birth; freedom of movement and position; keeping mother and baby together after birth; and the prevention of violence and disrespectful care.

Thanks in large part to strong commitment from the country’s key decision makers and local communities, and with financial backing from USAID through MCHIP, RMC is becoming more widespread in Mozambique. The influence of RMC can be seen increasingly in training institutions, professional associations, and civil society. In fact, the MOH, with the support of USAID and other partners, has now scaled up RMC to more than 80 facilities, and is working to scale up the MMI to more than 122 health facilities by 2014. Significantly, this figure covers about half of all facility births in the country. The MOH and its partners are taking action so that women won’t have to fear that they will be treated poorly during one of the most beautiful—and challenging—times of their lives.

The Toolkit includes:

  • “RMC: Country Experiences” survey offering an RMC overview from 19 countries
  • RMC Program Review Instrument to be used for country-level RMC self-assessment
  • “RMC: General Concepts and Considerations” presentation for guidance on the promotion of RMC
  • Learning Resource Package for RMC with all materials needed to conduct a one-day RMC workshop for clinicians
  • Operational Standards for RMC for antenatal care, childbirth care and postnatal care, which establish objective guidance to gauge health care workers’ clinical performance promoting RMC
  • Resource List for RMC with related references and links
  • Program Briefs detailing examples of RMC being implemented at the field level
  • Monitoring Indicators for RMC to measure the success of RMC interventions
  • Job Aids to serve as on-the-job reminders of the importance of maintaining RMC

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