Power Asymmetry at the Point of Childbirth Care: A Potential Driver of Disrespect and Abuse

Session: Differentials in the Utilization and Quality of Maternal and Newborn Care: Uncovering Inequities

Presenter: Kate Ramsey, Columbia University AMDD
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Background: It is increasingly recognized that improving interpersonal care is a fundamental component of ensuring maternal and newborn survival. Pregnant women often experience alienation and abuse when seeking healthcare, while maternity providers simultaneously feel demotivated and disempowered by the system. Exposing the root causes of these experiences is essential for ensuring sustained high quality services.

Methodology: In a Tanzanian district, we conducted 11 focus group discussions (FGDs) with women and men who had a child under one year old, three FGDs with maternity providers, and key informant interviews with nine health system managers and nine community leaders exploring the nature and drivers of disrespect and abuse around childbirth. Transcripts were coded thematically by two researchers in Nvivo10.0.

Results: Layers of bureaucratic and professional hierarchy contributed to a facility environment that was experienced as abusive and disempowering by maternity providers. At the frontline, these providers, typically women, also bore the brunt of user’s expression of dissatisfaction with the health system. For their part, women and their families perceived providers as lacking humility and providing superior care for those with higher status. In these interactions, providers exercised the discretionary power which they lack in other spheres, resulting in disrespectful behaviors. These were sustained in part due to the infrequent enforcement of accountability mechanisms, as well as organizational norms.

Conclusion: The power asymmetry in health facilities reflects the broader health systems and social context. Although change in the facility level environment is possible, ultimately the power dynamics embedded in the broader structures and culture of the health system must be tackled to ensure respectful childbirth services. Similarly, mechanisms to fill the breach between women and providers can contribute to change from the ground up. All approaches need to be responsive to women’s social and emotional needs as well as providers’ motivational needs.