Problem

Currently there is a well-documented culture of abuse and burnout within the public health maternity and labour wards. Midwives are under staffed, over worked, tired, stressed and disempowered. This has a direct impact on their ability to provide professional and compassionate care to women in labour and in the precious moments after birth where skin to skin contact and early breastfeeding need to be established for the long term health and wellbeing of the child.(1). Abuse of maternity patients in health facilities has long term and sometimes fatal psychological and physiological effects, driving women away from seeking care, leading to delayed diagnosis and treatment, and increased morbidity and mortality. (2) Growing Evidence of Disrespect and Abuse. Imagine the personal treatment you would expect from a maternity care provider entrusted to help you or a woman you love give birth. Naturally, we envision a relationship characterized by caring, empathy, support, trust, confidence, and empowerment, as well as gentle, respectful, and effective communication to enable informed decision making. Unfortunately, too many women experience care that does not match this image. A growing body of research evidence, experience, and case reports collected in maternity care systems from the wealthiest to poorest nations worldwide paints a different and disturbing picture. In fact, disrespect and abuse of women seeking maternity care is becoming an urgent problem and creating a growing community of concern that spans the domains of healthcare research, quality, and education; human rights; and civil rights advocacy. In 2010, a landscape report by Bowser and Hill, (3) summarized the available knowledge and evidence on this topic. While the review revealed a relative lack of formal research on the topic, the authors’ in?depth search of published and technical literature as well as interviews and discussions with content experts described seven major categories of disrespect and abuse that childbearing women encounter during maternity care. These categories overlap and occur along a continuum from subtle disrespect and humiliation to overt violence; they include physical abuse, non?consented clinical care, non?confidential care, non?dignified care (including verbal abuse), discrimination based on specific patient attributes, abandonment or denial of care, and detention in facilities. Interpersonal care that is disrespectful and abusive in nature to women before, during, and after birth is appalling because of the high value societies attach to motherhood and because we know the intense vulnerability of women during this time. All childbearing women need and deserve respectful care and protection of their autonomy and right to self?determination; this includes special care to protect the mother?baby pair as well as women in a context of marginalization or heightened vulnerability (e.g., adolescents, ethnic minorities, and women living with physical or mental disabilities or HIV). Furthermore, disrespect and abuse during maternity care are a violation of women’s basic human rights. (4). In sharp contrast, supportive emotional care in labour improves birth outcomes significantly. (5) Current inadequate solutions • The problem of maternity/labour ward abuse by maternity staff is widely recognized by the Department of Health in South Africa. Historically, the problem has been addressed by one of two methods: Either through disciplinary hearings, or through debriefing programmes. • Disciplinary hearings, whilst essential for instilling the correct standards of behaviour, do not address the underlying problems that cause the abuse. Often abuse goes unreported and the abusive culture becomes the norm. Disciplinary hearings, when they do occur, also increase the weight of shame, which is associated with increasingly abusive behaviour. • Debriefing, the second method for attending to abuse in the maternity/labour wards is one on one counselling between the midwife and a psychologist or social worker. Unfortunately there is some stigma amongst midwives about being assigned to debriefing. Midwives are usually individually debriefed only when they are failing to give effective care because their stressors have become overwhelming, so those who are selected for debriefing are sometimes seen as ‘failures’. As it is, as a result of the reports on abuse in South African maternity wards, a culture of shame has developed amongst all midwives, so to be identified as needing debriefing only serves to heighten this perception of being completely inadequate. • Shame’s inherently egocentric focus on the “bad self” (as opposed to the bad behavior) derails the empathic process. Individuals in the throes of shame turn tightly inward, and are thus less able to focus cognitive and emotional resources on the harmed other (Tangney et al. 1994). There is a shame-rage spiral described by Lewis (1971) and Scheff (1987) where shame and anger go hand in hand. (6) Desperate to escape painful feelings of shame, shamed individuals are apt to turn the tables defensively, externalizing blame and anger outward onto a convenient scapegoat. • The evidence for group debriefing as a means to resolve ongoing trauma, such as that experienced in maternity wards, is not good. The trauma experienced by one individual often just rekindles trauma in others. • Carolyn Hastie left the midwifery profession because of disillusionment with the lack of change in the status quo. Horizontal violence (hostile and aggressive behavior by individual or group members towards another member or groups of members) occurs among health care workers, especially midwives, at an alarming rate. “The more research I did into bullying the more I realized that the health care system has done a good job of imposing the status quo on us and we in turn impose the destructive behavior of oppression on one another.” (7) Oppression, as Hastie defines it, is a manifestation of "subtle forms of self-hatred such as divisiveness, lack of cohesion, lack of participation in professional groups, back-biting, destructive gossiping, fault-finding and other forms of violence and contradictory behavior…." (8). Horizontal violence is non physical inter group conflict and is manifested in overt and covert behaviours of hostility (Freire 1972; Duffy 1995). It is behaviour associated with oppressed groups and can occur in any arena where there are unequal power relations, and one group's self expression and autonomy is controlled by forces with greater prestige, power and status than themselves (Harcombe 1999). It may be conscious or unconscious behaviour (Taylor 1996). It is, generally, psychologically, emotionally and spiritually damaging behaviour and can have devastating long term effects on the recipients (Wilkie 1996). It may be overt or covert. It is generally non physical, but may involve shoving, hitting or throwing objects. It is one arm of the submissive/aggressive syndrome that results from an internalised self-hatred and low self esteem as a result of being part of an oppressed group (Glass 1997; Roberts 1996; MCCall 1995). It is the inappropriate way oppressed people release built up tension when they are unable to address and solve issues with the oppressor. • Nothing that has been done so far to address this problem has made a significant enough difference. Footnotes: 1. (Harcombe, J. 1999, "Power and political power positions in maternity care". Roberts, S.J. 1996, "Breaking the Cycle of Oppression: Lessons for Nurse Practitioners?" Journal of the American Academy of Nurse Practitioners, Vol 8. No. 5. May p. 209 - 214. The Lamp, 1999, "Those that can do, those that can't bully", The Lamp, Newsletter of the NSWNA, Vol. 56, No. 9. October). Footnote: 2. Human Rights Watch. “Stop Making Excuses”. Accountability for Maternal Health Care in South Africa ISBN: 1-56432-798-1 Jewkes R, Abrahams N, Mvo Z. Why do Nurses Abuse Patients? Reflections from South African Obstetric Soc. Sci. Med. Vol. 47, No. 11, pp. 1781±1795, 1998 Vivian, L, Naidu, C, Keikelame, MJ and Irlam, J. Medical Students’ Experiences of Professional Lapses and Patient Rights Abuses in a South African Health Sciences Faculty. Academic Medicine, Vol. 86, No. 10 / October 2011 Footnote: 3. Bowser and Hill, Exploring Evidence for Disrespect and Abuse in Facility?based Childbirth Footnote: 4. Respectful Maternity Care: The Universal Rights of Childbearing Women - White Ribbon Alliance. i. Bowser, D., and K. Hill. 2010. Exploring Evidence for Disrespect and Abuse in Facility?based Childbirth: Report of a Landscape Analysis. Bethesda, MD: USAID?TRAction Project, University Research Corporation, LLC, and Harvard School of Public Health. Footnote: 5. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub3 Footnote: 6. June Price Tangney, Jeff Stuewig, and Debra J. Mashek. Moral Emotions and Moral Behavior Footnote: 7. Hastie, CR 2001, 'Horizontal violence in the workplace', Birth International) writes about bullying among midwives and notes how many midwives (and other health care workers Footnote: 8. Marinah Valenzuela Farrell, LM, CPM, Midwifery Today. July 2006

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