Over the last decade or so my work has extensively allowed me to be situated in Government health facilities (Primary Health Centres, Referral Hospitals and Teaching Hospitals) for a variety of reasons. One of the main ones however has been to observe the process of women “Birthing” babies and the practices around the event. Personally, some of the visuals I have witnessed have not only made me deliberate whether I would like to have my own but has constantly made me ask the primary question, Why do women choose/are pushed to choose to deliver at an institution (by their families, by the government health policies etc)? The straightforward answer to that is to ensure women get access to skilled health personnel and referral facilities when needed, thus keeping them safe and ensuring healthy birth outcomes. The nagging thought cannot be pushed aside, what is the payback?
Recently, I was faced with a birth event at a Maternity Referral hospital that left me wondering about a concept that is being widely discussed in the current times, “Respectful Maternity care”. However, before I bring to you the definition of the term and discuss some aspects related to it, I am keen to describe what I was an eye-witness to.
It was a three bedded labor room, where the steel beds were placed one after the other in a line fashion. They were cold steel beds that did not have a mattress or a lining of any sort. All the beds were occupied and there were no dividers or curtains between the women. I wondered if the women were comfortable with this situation or whether they longed for privacy?
Of the three women present, one of them seemed to be progressing quite quickly, (she was kicking her legs up in the air and screaming) which made the nurse want to examine her. On examination, the nurse called out that she was about 7–8 cm dilated and instructed another nurse to administer oxytocin to the woman. The Ayah (labor room helper) was standing beside the woman and gently asking her to calm down. The woman had her hand around the Ayah’s waist, almost in a manner that she trusted her completely. She pooped during the PV, but the nurse nor the Ayah seemed to mind and did not say anything. In addition, the woman was allowed to scream as much as she wanted without being reprimanded.
In about 15 mins after the administration, the nurse decided (not based on any clinical reports) it was time for the woman to deliver. She put on her gown, took her seat on the stool and asked the woman to start pushing. It reminded me of a soldier getting ready to go to war. Two ayahs on either side of the woman were holding her legs down while the nurse gave her an episiotomy (a surgical cut made at the opening of the vagina during childbirth). In about a minute after that the ayahs started applying fundal pressure (pushing on the mother’s abdomen in the direction of the birth canal). One hand per ayah on either side, I decided we could call it, “Each one, use one”. As if this was not enough a nurse got onto the table and decided to give the woman more fundal pressure. So, at this point it was essentially about 3- 4 hands applying pressure on the woman’s abdomen. A few minutes later, they wanted to make sure the fetal heart rate was alright, so they monitored it really quickly. In about 2 minutes after that, the nurse decided a further episiotomy was needed (at this point, I was absolutely sure that the woman’s body could not have been abused more). The head was born almost instantly after that deep cut and so was the baby shortly thereafter.
The baby cried very little immediately, but after a bit of suction, the baby was fine. I did recall that the nurses wanted a paediatrician to be present when the baby was born but had they forgotten to inform the specialist? What if the baby had not cried, not breathed, not been able to be resuscitated by the nurses? Would it have been all too late?
The placenta was delivered shortly after the birth by tugging on the cord. The suturing was not something I wish to describe. Let me just say, the episiotomy was deep and not straight. I watched it nevertheless. I watched it while the woman moaned in pain, while she probably could feel every layer being stitched up. I wonder if she was even thinking about how her body had been treated, what it had been through and how she would heal? Is the cry of the baby all the woman needs to hear or is she at all aware and concerned about the practices that are carried out as part of the childbearing process. However, the larger question here is, what percentage of women know what to expect when they access services at a larger facility? This area of knowledge transfer between the relative- woman at home and/or provider- woman at an institution needs to be explored in a manner that would help us understand how aware and empowered women feel during the most important event of their lives.
The WHO defines Respectful maternity care as care organized for and provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth
In this context, the level of mismatch between the gold standard and what actually happens behind the closed doors of a loosely supervised facility is shocking. A couple of inferences can be made and questions raised from having observed this birth:
- A seemingly healthy primi was exposed to unnecessary medical interventions such as labor augmentation, episiotomy and fundal pressure. These obstetric practices that are not recommended unless the clinical benefits are clear did well interfere with the physiological process of childbirth. Do women recognise these as a violation of their rights and does it then act as a barrier to seeking intrapartum services in the future?
- Despite the gentle tones and the decent amount of emotional support provided by the Ayahs, there was a larger quotient of disrespect seen in the setting presented by the absence of privacy and confidentiality. Is this sort of behaviour limited to the underprivileged and marginalised population?
- The birthing process was not guided by but completely controlled by the health provider. This sort of practice is most often seen in settings that are understaffed and resource poor where providers just need to tackle the line. However, this facility did not fit the criteria and it would be intriguing to understand the motivations behind the various actions that were taken.
Often as researchers we allow ourselves to ask all these important questions and be drowned in the various explanations that might be. However, it is time we go back to these women and allow them to tell us how incidents such as the above impact their lives. It is time we let communities talk while we listen.