The anticipation, the excitement, the unknown and the unrelenting desperation to deliver a healthy baby are shared by every woman in pregnancy. Respect and the opportunity to participate in one’s own decisions in childbirth are likely assumed as
automatic. But according to the World Health Organization (WHO), that is not necessarily so.
In 2017, the organization published standards for quality of maternal and newborn care that included prioritizing respect and patient-led decision-making. A prior WHO review across 34 countries outlined numerous instances of human-rights abuses in childbirth—including physical, sexual and verbal abuse, as well as the loss of autonomy and lack of supportive care. The report concluded there was no consensus on how to measure disrespect in maternity care. However the work of Dr. Saraswathi Vedam, principal of the University of B.C.’s Birth Place Lab and associate professor of midwifery at BC Women’s, is changing that.
“All the major health organizations realized they didn’t reach the millennium development goals for mothers and babies,” explains Vedam from her BC Women’s Hospital research office. “They thought the answer was to institutionalize birth and incentivize people to come to the hospital, but they didn’t increase the amount of resources in the hospital. Many women who come to the hospital from the village in India, sub-Saharan Africa or the Philippines, for example, face overcrowded, understaffed units, a lack of privacy and frustrated providers. We know that their experience of mistreatment leads them to delay coming in or seeking help when needed, which is clearly not safer.”
Throughout her 30-year career as a midwife and researcher, Vedam has focused on respect and autonomy in childbirth. Her unyielding commitment to being a leader in patient-centred care resonates deeply at BC Women’s, which is proud to be the first hospital in B.C. to have credentialed midwife attendants at birth. In that pioneering tradition, Vedam is also breaking new ground in addressing the challenges outlined by the WHO through creating the first quality measures to assess provider-patient relationships and maternal access to person-centred maternity care.
Funding from partners at the Vancouver Foundation, BC Womens Hospital and the Michael Smith Foundation for Health Research enabled Changing Childbirth in BC, a community-led research project, and led to the development of the MADM (Mother’s Autonomy in Decision Making) scale and MORi (Mothers on Respect index). These tools recently received an Innovation award from the National Quality Forum. With new tools in place to quantify a patient’s experience, this data could now be used to measure current practices and inform new ones.
More than 4,000 women across B.C. were surveyed about their childbirth experiences and reported variations in respect and autonomy during pregnancy depending on their health status and preferences for care, as well as where and how they gave birth. Overseen by Vedam, the project is run through a steering group of women from different cultural and socio-economic backgrounds. Despite the diversity of the participants, Vedam says they all raised similar concerns.
“Ninety-five percent of women said it was ‘very important’ or ‘important’ that they lead decisions about their care,” Vedam notes. “But very few said they were able to.” Women who were dissatisfied with their role in decision-making had very low MADM scores, indicating a lack of autonomy. Vedam’s research also found women with higher medical or social risks during pregnancy were four times as likely to have low MORi scores, indicating they felt less respected by their care providers. Recent immigrants and refugees, or women with a history of substance use, incarceration, poverty and/or homelessness were twice as likely to have low MORi scores. Women with midwifery care reported higher MADM and MORi scores compared to women with just physician care.
“We found that overall in B.C., women felt a good level of respect, but there were big differences in how much autonomy they felt,” explains Vedam. “Both respect and autonomy were linked to how much pressure they felt to accept a certain intervention.”
Vedam’s hope is that MADM and MORi will inform efforts to deliver the highest levels of maternal care. “We have very good outcomes for people here, unlike in the global south,” she points out. “Where we haven’t improved is in the experience of care, and that’s where this kind of work that is patient-directed and informed will help…. The whole world is talking about respectful maternity care and respectful standards. Now is our chance to make it better.”
Written by Jessica Werb
Photography by Claudette Carracedo