Reports over the past decade have drawn global attention to shocking abuses some women have been subjected to during childbirth in developed and developing countries.
The maltreatment has ranged from lack of privacy and neglect to forced sterilization, sexual and physical assault, and refusal to release a mother or child from a birth facility without payment. The problems are especially acute in sub-Saharan Africa, which accounts for 66 percent of all maternal deaths per year worldwide, according to a February report from UNICEF, the U.N. Children's Fund.
A four-year study by researchers in the United States and Tanzania looked at ways to reduce abuse of mothers-to-be. Keys included gathering community stakeholders and health care workers to define standards of care and identifying barriers to change.
Previous efforts to reduce mortality of women giving birth focused on getting them into health care facilities to deliver their children. Despite dramatic increases in facility-based childbirth, however, decreases in mortality remained modest. Even when facilities are equipped to save a mother's life, reports of abuse can keep women from seeking medical treatment during birth.
Site is no guarantee
"It doesn't matter where you give birth — just because it's a building doesn't mean you survive," Lynn Freedman of Columbia University's Mailman School of Public Health told VOA.
With colleagues from Columbia, the Ifakara Health Institute in Tanzania and Harvard University, Freedman designed one of the first attempts to show how abuse could be reduced. The researchers followed facilities in the Tanga Region of Tanzania for their study and randomly selected one to receive the intervention. They called their project Staha, which means "respect" in Swahili.
They first gathered stakeholders in the community and asked them to develop a set of standards for what appropriate care during childbirth should be. The residents were able to provide a unique local perspective. In this case, stakeholders felt it was important to foster a mutual respect between patients and health providers.
Freedman agreed, saying, "Patients can blame the health workers, who are more an expression of systemic problems and not the sole cause of them."
Researchers then distributed the standards in the facility and convened a quality-improvement team made up of its employees. The team determined drivers of abuse and implemented changes to correct them. Changes included continuous patient surveys, increased oversight by management and educators, and tea for the staff to show appreciation on difficult days.
A year after they finished working with the facility, the researchers went back to see whether there had been changes in reported abuse and if progress had been sustained. They found that there was a 66 percent decrease in levels of reported abuse. The sharpest decreases were seen in reports of neglect and physical assault.
But Freedman warned against immediately recommending that others implement these changes. Getting the community involved is most important, she said.
It's not, " 'Here's the best practice. Do this,' " she said. It's vital "that people themselves analyze the situation and develop the intervention."
While attention has been growing, Freedman hopes for more. This is an issue that "everyone who actually lives with and works in the system knows is there, but has been so not the priority of policymakers and donors — almost like a silent emergency."