Respectful maternity care: the problem and suggested solutions

Guest  post by Donna Walls, RN, BSN, CLC, ANLC with intro by jess fedenia, clc

 

Donna Walls’s, RN, BSN, ICCE, IBCLC, ANLC unmedicated births were sort of a fluke.

“I remember being horribly afraid of someone sticking a needle in my back,” she recalls.

The “glorious” feelings of confidence and joy were unexpected consequences, but thinking back, Donna says, “Boy, I am sure glad I [gave birth that way.]”

In all other aspects of parenting, Walls credits growing up in the 1960s for becoming a self-described Granola Mom.

“When everything went ‘back to nature’, that was a big influencer for me,” she says.

As a nurse, Walls was always drawn to maternity care and supporting breastfeeding as the natural progression after giving birth.

It felt thorny to her when babies were taken to the transition nursery immediately after birth and later given back to their mothers.

This ritual sent the message that “We (as in the staff) can take better care of your baby than you (as in the mother) can.” That never sat right with Walls.

Then, one pivotal moment in particular, Walls on duty in the transition nursery, walked by a baby only a couple of hours old.

“He was frightened,” Walls begins. “His lip was quivering and he was splayed out underneath the warmer. He was so frightened. It just affected me.”

After that, Walls galvanized to change the culture in this hospital. She worked very hard alongside a physician colleague to open a birth center within the hospital. In 1995, Family Beginnings at Miami Valley Hospital in Dayton, Ohio was unveiled, offering families an option where birth wasn’t pathologized and where mothers and babies were honored as dyads. (Birthing at Family Beginnings remains an option for those in the Dayton area today.)

The center was designed to look like a home. There was no nursery for babies to be separated from their parents. When mothers came in to labor, the staff would pop in bread to bake, a special touch of aromatherapy.

Freshly baked bread, though enticing, wasn’t the number one reason families signed up to birth here. Instead, they chose Family Beginnings because they didn’t want their babies taken away from them, Walls reports.

Walls has since retired from her work in the hospital, but respectful maternity care remains forward in her mind and in her advocacy.

She graces us with reflections on respectful maternity care in her guest post this week on Our Milky Way. Read on!

******

As a nurse in maternity for over 40 years, I have too often witnessed what I refer to as the “empty vessel theory”. Women are regarded as merely a container for the fetus and care providers merely the technician to remove it, usually as quickly as possible. I have often been saddened when the emotions and spirituality of birthing are disregarded or even mocked. This miraculous process is a rite of passage with all the inherent pain, joy, lessons and connections needed to begin the journey into parenting. My hope is that through discussions and activism, we can reach a point where the birthing family is honored and all newborns are brought into the world with love and respect.

Photo by João Paulo de Souza Oliveira: https://www.pexels.com/photo/gray-scale-photo-of-a-pregnant-woman-3737150/

Respect is “showing regard for the feelings, wishes, rights or traditions of others”. Concerningly, there is an abundance of anecdotes from patients and caregivers that demonstrate how maternity care practices are often disrespectful, sometimes even abusive.

Disrespectful care encompasses racial inequity, lack of confidentiality, physical and/or emotional abuse, denial of care or provision of substandard care, lack of informed consent or coercion or condescending communications. This type of care occurs in all countries around the world, to all demographics of women and their families. Fortunately, disrespectful care has drawn the attention of many health organizations, including the World Health Organization, and steps are being taken to stop disrespectful, abusive care practices.

Examining the intersection of maternity care and human rights has been a recent topic in many maternal and infant care advocacy groups as well. We cannot assume that hospital admission for an appendectomy is equal to admission for the birth of a baby. This is because  the scope of the process of birthing impacts a person, a family, a community and a nation which is not so of a surgical procedure.

Most women and families expect they will receive safe, inclusive, compassionate care and trust their caregivers to provide prenatal, intrapartum and postnatal care with honest communication and respect for their needs and choices. Provision of safe care should look beyond the basics of preventing maternal, fetal or neonatal morbidity or mortality and consider how to support the family’s human rights– rights inherent to all people, without discrimination, regardless of age, nationality, place of residence, sex, national or ethnic origin, color, religion, language or any other status. (White Ribbon Alliance, 2020)

Photo by Dipu Shahin DS: https://www.pexels.com/photo/baby-in-pink-and-white-blanket-4050647/

The first stated right is to be free from harm and mistreatment, yet we find continuing cases of physically and emotionally abusive treatment of pregnant and birthing women. Secondly is the right to competent, culturally sensitive care for both mother and newborn.  Next is  the right to companionship and support, and lastly the right to meet the basic life-sustaining needs of the dyad, including breastfeeding support for the newborn.

The first step toward respectful care is choosing  healthcare providers who value open, honest communication and who will discuss options and listen to the family’s needs and concerns. WHO defines respectful communication as communication which  “aims to put women at the centre of care, enhancing their experience of pregnancy and ensuring that babies have the best possible start in life.” (WHO, 2018)

Other components of respectful communication include the use of positive body language, active listening, the use of non-judgmental language, assuring patient privacy and honoring physical and emotional needs.  Respectful communication can begin with simply referring to the person by the name they prefer. If it is not documented, ask.

Another important step is selecting the birthing place. (Niles, 2023) Most care providers practice at one to two hospitals or birth centers. Choosing the birthing environment is an important decision in creating a birth experience which is in line with the family’s expectations and goals. Research and discussions with childbirth educators, lactation care providers and other families can give insights into common or routine practices at that institution. Will the family’s requests be honored? Will questions be answered with open and honest informed consent? Will the birthing and breastfeeding practices support their goals? These are all questions that need to be answered before a birthing place decision is made.

Creating an environment of respectful care in the birthing place is foundational. It is care that assures women and their families will be regarded as capable of making decisions. Making decisions which respect the values and unique needs of the birthing woman can only be made when patient autonomy– the right of patients to make decisions about their medical care without their health care provider trying to influence the decision–  is recognized.

Photo by Rebekah Vos on Unsplash

Individuals often comment on birthing in the hospital as a time when you lose all modesty; however, it is possible to follow protocols that set a standard for assuring privacy and modesty which can positively impact the birth experience. Simple steps like not discussing patient history or current conditions in front of others (without the patient’s permission), being mindful of covering intimate body parts (or culturally sensitive covering) whenever possible, asking permission before touching or knocking (and waiting for a response) before entering the room are a huge part of maintaining patient dignity. It cannot be overstated that any cultural requirements for modesty must be respected at all times.

More on respect in health care on Our Milky Way here, here and here.

Other recommended resources 

The International MotherBaby Childbirth Initiative (IMBCI) A Human Rights Approach to Optimal Maternity Care

Inclusive, supportive and dignified maternity care (SDMC)-Development and feasibility assessment of an intervention package for public health systems: A study protocol.

The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States.

Exploring Evidence for Disrespect and Abuse in Facility‐based Childbirth: Report of a Landscape Analysis

 

Exploring language among gender nonconforming individuals and nontraditional partners

 June is notoriously known as Pride Month, but October features other observances that bring awareness to a variety of health issues and topics that impact LGBTQIA youth. October 11 was National Coming Out Day, October 20 was International Pronouns Day and last week, individuals and organizations recognized Intersex Awareness Day

In Breastfeeding Priorities: Safe Sleep, Bias, Gender Equitable Norms, and Paid Leave— Q&A with Internationally and Nationally Recognized Breastfeeding Expert, Lori Feldman Winter, MD, MPH, NICHQ poses the questions: How can we acknowledge the need to be inclusive of all types of parents and caregivers?  How do we promote gender-equitable social norms to better support breastfeeding?”

Photo by Karolina Grabowska

Feldman Winter offers, “… We need to ask, ‘how do we better support breastfeeding among gender nonconforming individuals and nontraditional partners?’ so we don’t alienate anyone when it comes to breastfeeding. It starts with being more inclusive and acknowledging that the benefits of breastfeeding aren’t all tied to the concept of the ‘breast’ itself. Breastfeeding is a complex compilation of systems including biological benefits from skin-to-skin touching and nurturing; nutrients from human milk that can be breast- or bottle-fed; and benefits that come directly from the flora on a lactating/nursing breast.

There are multiple ways to look at breastfeeding and understand its benefits, Feldman Winter continues. 

For instance “a chest that may not be able to produce milk can still nurture babies through the benefits of skin-to-skin contact,” she’s quoted in the NICHQ piece. “People who don’t produce breastmilk can still provide human milk through donor milk and bottle feeding. Transgender men and gender nonconforming parents and caregivers may still breastfeed safely if they choose to, and may prefer the term chestfeeding over breastfeeding because it respects their identity. All kinds of arrangements can be made to truly provide an equitable support system. As clinicians and scientists, we need to keep an open mind as we look at breastfeeding and explore how to optimize the health and well-being of all babies and families.” 

The authors of Effective Communication About Pregnancy, Birth, Lactation, Breastfeeding and Newborn Care: The Importance of Sexed Language present their thoughts about the risks of using desexed language in perinatal care.

Photo credit: PNW Production

The authors acknowledge that “Desexing the language of female reproduction has been done with a view to being sensitive to individual needs and as beneficial, kind, and inclusive.” 

They go on, “Yet, this kindness has delivered unintended consequences that have serious implications for women and children. These include: decreasing overall inclusivity; dehumanizing; including people who should be excluded; being imprecise, inaccurate or misleading; and disembodying and undermining breastfeeding. In addition, avoidance of the term ‘mother’ in its sexed sense, risks reducing recognition and the right to protection of the mother-infant dyad.”  

As part of this discussion, NICHQ has released statements in regard to the use of its language.

Photo by Mikhail Nilov

Heidi Brooks, Chief Operating Officer at NICHQ writes,  “NICHQ is not abandoning the traditional use of the terms ‘mother’ and ‘maternal.’ We are embracing the inclusive language of ‘birthing person/people’ across our work. A move toward inclusive language does not force us to stop using language that so many people identify with; at its core, inclusion is about creating more space for one another. We are taking care to expand the use of these terms in our communications, on our website, in our resources, and eventually, in all our projects. This evolution is another aspect of NICHQ’s commitment to equity in all forms, including race, nationality, gender identity, sexual orientation, and ability.” 

The Academy of Breastfeeding Medicine (ABM) put out its Clinical Protocol #33: Lactation Care for Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Plus Patients in May 2020 to help guide lactation care providers through items like language, creating a respectful health care environment, through the effects of transition-related health care on pregnancy and breast/chestfeeding, fertility options, induced lactation and colactation and milk sharing, as well as put out a call out for future research to better inform practice.

Photo courtesy of Glenis Decuir

Check out past Our Milky Way coverage on LGBTQIA health

Uplifting transgender and non binary parents 

On becoming transliterate 

Working to close the gaps in LGBTQ care 

Blurring the binary 

Skin to skin image goes viral 

Wives co-breastfeed son for two-and-a-half years

Explore youth.gov’s page for other past and upcoming events celebrating Sexual Orientation and Gender Identity, Expression, and Well-Being.