Respectful maternity care in the context of COVID‐19: A human rights perspective

Short abstract

Pregnant women should receive respectful maternity care in the context of COVID‐19 and not be subject to policies and practices that violate their human rights.

1. INTRODUCTION

The novel coronavirus pandemic has triggered numerous changes to the provision of maternity care, many of which contradict the core tenants of what has come to be known as “respectful maternity care.” 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 labor and childbirth”. ¹

International bodies and civil society groups developed international recommendations related to the provision of respectful maternity care in response to a growing body of research on people’s experiences of harmful practices when accessing health services related to pregnancy, childbirth, and postpartum care. These harmful experiences can include neglect, disrespect, discrimination, and, in some cases, verbal or physical abuse, and can lead to poorer physical and mental health outcomes for pregnant women and their newborns.

Responses to the current COVID‐19 pandemic have included the adoption of policies and practices aimed at reducing risks of the disease’s spread, based on less than robust evidence. Unfortunately, many responses have exacerbated pregnant women’s experiences of harmful practices in this context. The present article examines the problematic implications of these policies and practices according to the respectful maternity care framework, which is grounded in the principles of international human rights. It considers how these policies and practices result in violations of the rights to health, information, and non‐discrimination, among others, and may have lasting consequences for pregnant women’s health, well‐being, and dignity.

2. RECENT CHANGES TO MATERNITY CARE

Alternate approaches to prenatal care, including further spacing out in‐person appointment times and reducing the number of patients’ in‐person visits, have emerged as a strategy to reduce risks of spreading COVID‐19 among patients, caregivers, and staff. ² Typically, the switch to telehealth for the majority of prenatal visits is only recommended for routine or low‐risk pregnancies. Several studies have not shown worse outcomes, even for women at high risk. ³ , ⁴ However, reliance on telehealth for prenatal care excludes people impacted by the “digital divide”—inequitable access to or use of remote communications technologies—such as those living in certain areas with low Internet connectivity, those who are poor and have no access to the hardware necessary for such visits (tablets, laptops, or computers), and those with poor technical literacy. ⁵

Restrictions against a companion being present during labor and delivery were widespread at the outset of the pandemic, depriving women of an option that has been shown to not only improve the childbirth experience and outcomes, but also prevent other forms of mistreatment during childbirth. ⁶ , ⁷ Many facilities have since rolled back these restrictions and are now in compliance with relevant WHO recommendations, which stress that a safe and positive childbirth experience in the context of COVID‐19 includes “having a companion of choice present during delivery”. ⁸

In addition, early in the pandemic, certain medical interventions were more likely to be performed on women who were positive for SARS‐CoV‐2 during labor and delivery without clear medical justification, such as induction of labor, instrumental deliveries, and cesarean deliveries. ⁶ , ⁹ All three of these interventions are not recommended for routine labor management and are associated with significant harm. According to WHO, pregnant women with suspected and confirmed SARS‐CoV‐2 infection do not necessarily need to give birth by cesarean delivery and they should only be performed when medically justified. ⁸

In the context of postpartum care, measures to reduce the risk of mother‐to‐child transmission have included temporarily separating newborns from women who test positive for SARS‐CoV‐2, discouraging skin‐to‐skin contact, and limiting breastfeeding. ⁶ Guidance on this issue is conflicting but current evidence suggests that healthy newborns are at low risk of harm from infection and that there are important benefits for both mothers and newborns associated with these interventions, ¹⁰ leading WHO to encourage safe breastfeeding, holding newborns skin‐to‐skin, and room sharing. ⁸ The American Academy of Pediatrics recently reversed their guidance, now indicating that infants of mothers infected with SARS‐Cov‐2 may room‐in, as long as precautions are taken to minimize transmission. ¹¹

In addition, the COVID‐19 pandemic has exacerbated a range of harmful practices already widespread in the context of prenatal, intrapartum, and postpartum care, including lack of information, denial or suspension of care, neglect, abandonment, and abuse. ⁶ Women have reported receiving insufficient or inadequate information about policies, interventions, referrals, and the full range of options available to them. ⁶ They have also experienced outright denial of care in emergency circumstances, as well as restricted access to emergency transport, out‐of‐hospital options for skilled care, pain relief, and various intrapartum and postpartum support services. ⁹

3. HUMAN RIGHTS IMPLICATIONS

These policies and practices result in the violation of various international human rights that, in addition to others, make up the normative foundation of the respectful maternity care framework. They infringe upon not only individuals’ right to health, but also their rights to information, non‐discrimination, the benefits of scientific progress, and participation, given the indivisible and interdependent nature of human rights. ¹²

The right to health establishes that maternal healthcare services must be available in adequate numbers, accessible without discrimination and free from barriers, respectful of different cultures and sensitive to gender, age, and life‐cycle requirements, and be evidence‐based, scientifically and medically appropriate, and up‐to‐date. ¹² , ¹³ It also prohibits the adoption of policies and practices that harm women’s physical and mental integrity or undermine their full enjoyment of the right to maternal health. ¹² While some of the policies and practices referenced above restrict or prohibit access to a range of critical services and interventions that have the potential to improve the health outcomes for pregnant women and newborns, others have the potential to harm their physical and mental health status.

The right to information requires the provision of evidence‐based information on all aspects of sexual and reproductive health, including maternity care services. ¹² Access to information allows women to make informed, free, and responsible decisions about the care they receive. ¹² , ¹³ Not all pregnant women will choose to take advantage of the interventions referenced above in the context of COVID‐19. However, respectful maternity care requires effective communication between patients and providers, ¹ ensuring that patients understand that they have options and are supported in their decision‐making. Without clear communication about the full range of options available to them and support for their decisions, women may be dissuaded from accessing prenatal and postpartum services and in‐hospital deliveries, even when medically indicated. ¹⁴

The right to equality and non‐discrimination demands equal access to the same range, quality, and standard of maternity care services and special measures to overcome the discrimination that disproportionately affects women of color and women who are poor, ¹⁵ , ¹⁶ among other already marginalized and underserved groups. ¹² , ¹³ These women are more likely to experience not only worse maternal health outcomes and pre‐existing health conditions that are associated with COVID‐19‐ and pregnancy‐related complications, but also the potential harms associated with the abovementioned policies and practices. ¹⁷ Restrictions on companions during labor and delivery, especially doulas, ¹⁸ , ¹⁹ are particularly burdensome for women of color, as they are more likely to experience mistreatment or discrimination by providers. ²⁰

The right to the benefits of scientific progress establishes that all people, including pregnant women, must be able to participate in scientific progress and benefit from its applications, which includes both the material results of and the scientific knowledge and information deriving from scientific research. ²¹ Women are subject to special protections in this context, given that they tend to be underrepresented in scientific activity and that scientific research tends to be gender‐biased and not sensitive to their particular needs. ²¹ Accordingly, efforts should be made to ensure that women are able to safely participate in and benefit from research related to the development of treatments and vaccines for COVID‐19. ²²

Finally, the right to participate in political and public life encompasses participation in the formulation and implementation of policy at international, regional, national, and local levels. ²³ Participation by those most affected in such policy‐making processes helps to promote public trust, ensure accountability, and prevent against further discrimination against historically underrepresented groups. ²¹ Given that eliminating harmful practices during maternity care can only be achieved through an inclusive process, involving the participation of women, ²⁴ they should also be active participants in the formulation and adoption of related policies and practices in the context of COVID‐19.

4. CONCLUSION

Actors—whether they be governments, health profession associations, international bodies, or individual health facilities—should rely on international human rights standards, best clinical practices, and the latest scientific evidence available to inform their development of policies, practices, and guidelines related to the provision of maternity care in the context of COVID‐19. ⁹ Only then can the provision of maternity care truly be in service of pregnant women’s health, well‐being, and dignity.

Pregnant women have the right to receive respectful maternity care and not be subject to policies and practices that result in the violation of their human rights. While the COVID‐19 pandemic may justify some changes to the provision of prenatal, intrapartum, and postpartum care, they should be “strictly necessary, proportionate, reasonable, and the least restrictive” measures available. ⁹

CONFLICTS OF INTEREST

The authors have no conflicts of interest.