This lesson focuses on care values, in particular, respectful care that involves people in their own decision making. In this lesson, we will review definitions of respectful and disrespectful maternity care, describe birth related psychological trauma and shared decision making. Discuss respect and abuse as a system level problem that can also impact care providers. And review the World Health Organization guidelines on reducing and illuminating disrespect and abuse in facility based childbirth. Respectful care continues to be a global challenge. Giving birth in a facility or being attended by a trained and licensed healthcare professional does not guarantee respectful patient centered care. 2019 study in The Lancet reported that on review of over 2,000 women in four low income countries, one in three individuals experienced mistreatment during birth in health facilities with the youngest and least educated women being at the highest risk for abuse. A similar study, also published in 2019 based on a survey of over 2,000 women in the US, echoed these results with one in six women reporting one or more types of mistreatment. In this case, rates of mistreatment and abuse were consistently higher for black women. Why is respectful responsive care important? Clearly, because it's a moral and ethical imperative, and because disrespectful and abusive care can cause lasting trauma for women and their families. Ultimately, women will not access services at all if they feel they're going to be cared for in an abusive environment. In a qualitative study conducted by Miltenburg and colleagues in 2018, women describe elements of disrespect and abuse in the care they received. These included providing emotional and physical support, such as a consistent positive attitude and undivided attention. A care provider who is responsive to physical and verbal cues given in labor or during birth. Effective communication that is providing explanations about procedures before they happen, providing opportunities to discuss care options. Proximity, I especially like this one and being physically close. For example, coming quickly when called. Encouraging individuals to ask for help, and as the clinician, physically positioning oneself at the same level or even below the person being cared for to demonstrate that you were in service to the person that you're caring for. Privacy was another component of respectful care. And these are simple things to enact like creating private spaces using curtains, drapes, positioning, and then making sure to avoid outside interruptions, turning off cell phones, things like that. Finally, consent before vaginal exams or procedures of any kind. Disrespectful care was also frequently observed. Here's how the researchers describe that. Categories of disrespect and abuse that they documented included psychological and physical abuse like discriminatory or aggressive language, slapping or hitting. Unnecessary medical invention interventions or interventions performed without adequate pain management. Another category was non support defined as inattention undermining of women's beliefs or needs, ignoring their cues, and failing to provide explanation about the care that they received. An extension of this was outright abandonment or ignoring women an leaving them unattended. And finally, of course non-consented care. Some women report ongoing post traumatic stress symptoms from this kind of treatment. This residual trauma does not necessarily arise from the complications or procedures themselves, even when they are extreme or difficult, but rather frequently arises from the way individuals are treated by their care providers. Reed and colleagues in a study published in 2017 reported that this was the case for the majority of women who were traumatized. Specifically, reports of child birth trauma clustered around four major themes. Women felt traumatized when the birth process was altered to meet the care provider's agenda rather than fitting into their own needs and priorities as care receivers. When their own embodied knowledge was ignored and the expert opinion of the care provider, It was presented as more correct or more valid. When lies and threats, especially those that related to fetal well-being were used as a type of coercion. And finally, when physical and psychological violation was experienced, an example for many was being practiced on by new practitioners or by students. The bad news here are that women reported this suffering and lasting trauma at the hands of the very people tasked with supporting and protecting them through their pregnancy and birth. But the good news is that treatment, care, interaction, communication, all of these are modifiable in a system that prioritizes an institutionalizes respect and support. One antidote to disrespect and abuse in maternity care is the practice of shared decision-making. The concept of shared decision-making is based on the idea that individuals have this right to be extensively involved in directing and managing their own care. This is probably especially true for maternity care, which is really going through a normal physiological life transition. A group of experts who described the common components of shared decision-making in maternity care came up with the following list of key characteristics. Shared decision-making needs to be an iterative process that begins and continues during antenatal care. It's dependent upon building strong and trusting relationships between the service user and the service provider. It requires anticipatory guidance to discuss decision-making situations that may hypothetically arise. What would you do if this happened? Conversations like that. It includes revisiting complex decisions more than once to let thoughts and questions evolve overtime. It prepares women for urgent and possibly unexpected decisions. It involves reviewing and debriefing after the birth. That is something that we often fall short on, especially when we work in healthcare systems that only see women six weeks after the birth. And it relies on providing evidence based information. In some successful shared decision rests on a foundation of a significant time commitment, and the process of building an ongoing substantive relationship. Time for this important work needs to be prioritized and built into work schedules if it's going to be an integral part of care. But why does disrespect and abuse happen? There's general awareness that blaming individual health care providers is a simplistic view of this issue. Those healthcare providers are also often subject to larger forces of structural racism, bias, and violence. Health care providers who are victimized themselves will intern victimized those they're caring for as they struggle to work in a dehumanizing environment. Addressing disrespect and abuse at the level of the health care system can create greater change than addressing it only as a problem of bad people behaving badly. The World Health Organization has published guidelines on the prevention and elimination of disrespect and abuse in facility based childbirth. These guidelines also address the problem as a system level issue and include the following mandates. Bring disrespect and abuse to the frontline of government and development policies. Pull back the curtain on disrespect and abuse in maternity care in other words. Initiate programs designed to improve the quality of maternal health care with a strong focus on respectful care as an essential component of quality care. Emphasize the right of women to dignified, respectful healthcare throughout pregnancy and childbirth. Generate data related to this problem of respectful and disrespectful care practices. And established systems of accountability, as well as meaningful professional support to train professionals in providing respectful care. And finally, involve all stakeholders, including women themselves. Protecting the human rights of all childbearing people is an ethical imperative. Individuals from racial, religious, or cultural minorities, those who are undocumented, incarcerated, very young, struggling with addiction or without basic resources like money, shelter, food, educational, or social support are particularly at risk of human rights violations. The rights for all childbearing people include the right to be free from harm and ill-treatment. To receive information. Informed consent and the right to refuse care. The right to privacy and confidentiality. The right to be treated with dignity and respect. The right to equality, freedom from discrimination and equitable care. The right to receive health care and to attain the highest possible level of health. And the right to liberty, autonomy, self-determination and freedom from coercion. I encourage you to use this list of the universal rights of childbearing women published by the White Ribbon Alliance as you advocate for change in your own environment. This provides a useful guide for developing services and educating women on their own basic rights.