South Sudan: Juba Teaching Hospital Support

Photo: Participants role playing patients, family members and Midwives/Nurses.

RESPECTFUL MATERNITY CARE (RMC)

Background

Recently, maternity experts and global stakeholders have turned attention towards the presence of disrespect and abuse (D&A) by staff within health centers and hospitals as a deterrent to women seeking potentially lifesaving maternity services. Literature indicates that there is a strong correlation between how respectfully a woman is treated when receiving antenatal care and giving birth with how likely she is to utilize these services in the future. Negative experiences and perceptions of providers and health facilities also can spread across communities and deter large numbers of women from seeking care by skilled birth attendants. This is particularly alarming because the World Health Organization (WHO) recommends that a skilled attendant be present at every birth since they can prevent up to 90% of maternal deaths where they are authorized to practice their competencies and play a full role during pregnancy, childbirth and after birth.
 
D&A exists on a continuum ranging from shaming or neglecting women when they are at their most vulnerable to slapping and shouting at them and their families. As one physician from Juba Teaching Hospital that we interviewed stated, “Just like helping someone and being kind to them makes them want to return, when they wait for a long time in the hot sun and then are treated rudely, it is negative advertising for our hospital.”
 
Of particular note is the observation that women are routinely not allowed to have a family member with them during labor and delivery yet often are left alone because of understaffing. Procedures are not explained to women before they are performed, there is minimal protection of modesty, and women often have their legs forcefully separated as part of the delivery process. These behaviors can partly be attributed to the stress and burnout among staff that routinely work without the medications, supplies, and human resources they need to effectively save lives. Many also have incorrectly been taught to treat women poorly as part of their training, or because of a lack of exposure to humanized and family-centered care. Literature suggests that staff that is experiencing high stress and low job satisfaction show decreased compassion to patients.
 
Transforming maternity care into a welcoming and supportive experience through the systematic introduction of Respectful Maternity Care (RMC) will increase utilization of services, improve community and health system relationships, and improve staff morale and job satisfaction.

 
Photo: (Left) Participants discussing stress and burnout reduction in small groups before presenting their ideas, (Right) Participants practicing how to introduce themselves and put the women in labor coming to the facility for care at ease during a simulation activity

RMC is possibly one of the most significant interventions that can be introduced in order to approach the goals of Millennium Development Goal (MDG) 5. Additionally, respectful care should not be viewed as a privilege but as a human right that needs to be guaranteed for vulnerable populations such as pregnant women and their families. Addressing this problem should be a priority because if women are not willing to seek lifesaving care, then improving training, equipment, medication stocks, and financial barriers will fail to reduce the number of women dying.
 
Respectful Maternity Care Training Program – RMF Concepts
What makes RMF’s approach unique is that this training program is based on our concepts of ”Friends helping Friends helping Friends” and “Liberating Human Potential”:  Treating each other and the people we are supporting around the world with the respect and dignity you give to friends; we listen, learn and partner with the local populations, and  empower local leadership. We train, educate and employ locals, producing innovative solutions and co-creating strong communities that sustain and grow (healthcare) capacity. We believe that our innate capacity to create transcends differences of ethnicity and economic standing. By empowering the people we are trying to help, we discover visionaries and partners who are best able to solve their problems. Igniting their potential will turn aid into empowerment and victims into leaders. We believe that every life deserves the chance to realize its potential. When people are liberated from their fight for survival, they begin creating a better life for themselves and their community. We believe in the human ability to transform. We are human because of our potential to change the world. When we are at our best, we are co-creators.

What this means is that the program brings a solution-oriented approach to the community and facilitates them to create a sustainable and independent response to challenges and not dictating a preordained set of solutions from outside the community.  This mechanism of building community resilience is a cornerstone of RMF’s vision.
 
The program itself is the first to operationalize the teaching of compassion and respect to maternity workers rather than just document and define the problem of D&A in facilities. We addressed the following challenges in order to accomplish this:
 

 
The RMC training program consists of 6 modules facilitated over a 2 full day period with the following learning objectives:
 

1. Analyze caring behaviors and culturally sensitive interactions in the maternity setting
2. Discuss and practice therapeutic communication skills that lead to compassionate and humanized care
3. Examine professional role expectations and standards of practice when providing care
4. Describe key features of dignity
5. Describe the methods of collaboration with other health facility staff and community members. 

Learning Module Content

1. RMF Concept of “Friends Helping Friends Helping Friends”: welcoming patients and their families, listening to them and creating rapport and trust, concepts of body language and respectful communication, equalizing relationships between the various cadres of workers
2. RMF Concept of “Holding the Space”: creating a safe birth space by protecting modesty, privacy, and the wishes of the patient 
3. RMF Concept of “Gentle Voices, Giving Choices”: open and respectful communication with women about procedures and policies, informed consent, evidence-based maternity care and confidentiality of sensitive issues
4. RMF Concept of “Being With a Woman”: labor support basics, the role of family members, freedom to move in labor, and delivery positions
5. RMF Concept of “Calm Beginnings”: skin-to-skin and non-separation bonding of the mother and baby, promotion of breastfeeding, postpartum support and education before discharge
6. RMF Concept of “Liberating Human Potential”: creating a positive work environment, respectful leadership, open communication with colleagues – empowering healthcare staff and allowing them to tap into their full potential as human beings and as caregivers

Photo: Master Trainers discussing program design and sharing ideas

Participants

1. The RMC program was facilitated for 29 third year midwifery students from the Juba College of Nursing and Midwifery (JCONAM). The students represent both males and females from a variety of ethnic groups that came to study in Juba from different states in South Sudan.
2. 4 Master Trainers were selected by the Ministry of Health and JCONAM administration: 2 practicing physicians and 2 midwifery tutors at JCONAM.
3. The Master Trainers facilitated a 2 full day RMC training for 19 maternity staff from Juba Teaching Hospital and two local Primary Healthcare Centers (PHCCs), Munuki and Kator. The staff was comprised of: community midwives, nurse-midwives, physicians, lab technicians, and nurses.

Photo: Participants with certificates of completion of the training program