The quality of the relationship between pregnant women, newborns, and healthcare workers is a critical factor that affects the use of maternal and newborn health services. Since 2011, the Population Council has been at the forefront in promoting respectful care for women and newborns globally. However, additional focus is required to achieve global consensus on respectful newborn care—including beyond childbirth. The Council and other partners have been working with the World Health Organization (WHO) on compiling a respectful maternal and newborn care (RMNC) companion guide, which will provide information and interventions to promote RMNC.
Key Takeaways
- Women and newborns have universal rights.
- A participatory and consultative process is essential.
- Community involvement and consensus building are critical to success.
- Respectful care workshops with health workers and communities improved outcomes.
- Global frameworks are needed to support implementation.
Respectful Maternal Care
In Kenya, Population Council led the groundbreaking Heshima project (USAID 2011–2016) in partnership with the Federation of Women Lawyers-Kenya (FIDA-Kenya), the National Nurses Association of Kenya (Midwifery Chapter), and the Ministry of Health. This was one of the first studies to measure the prevalence of disrespect and abuse of women during labor and delivery in healthcare facilities. Council research found that one in five (20 percent) of postnatal women interviewed felt they had been mistreated during facility-based childbirth (over 600 women in 13 facilities). This included verbal and physical abuse from maternal healthcare workers, failure to meet professional standards (e.g., lack of informed consent and confidentiality), and health system challenges (e.g., lack of equipment, supplies, and inadequate provision for privacy).
To address these issues, an adaptable, multifaceted approach was co-developed with women, communities, health workers, and policy makers to disrupt low-quality care. The co-designed approach included health worker mentorship; values clarification workshops; strengthening quality improvement teams; counseling for health workers; maternity open days; community workshops—including promoting male involvement; and mediation activities to restore positive relationships between communities and health facilities. This endeavor proved fruitful as the mistreatment of women in labor during facility-based childbirth fell by 40 percent (Abuya 2015).
Key to this success was readiness for change at multiple levels as well as continuous, participatory reviews from stakeholders. Considering facility organizational cultures and community norms helped contextualize interventions. Necessary input was provided at the policy, facility, and community levels (Warren et al. 2017).
Respectful Maternity Care (RMC) gained momentum through the Universal Rights of Childbearing Women. This publication (White Ribbon Alliance 2011) was developed and disseminated through the ever-expanding Global RMC Council—coordinated by the White Ribbon Alliance. Increasing evidence from Kenya, and other places, led to more widespread acceptance.
This was most vividly seen in the WHO statement calling attention to the promotion of dignity and access to maternity care and reduction in mistreatment of women (World Health Organization 2014). WHO spearheaded systematic reviews and further research and also developed the Maternal and Newborn Health (MNH) Quality of Care Framework. The framework includes respect and preservation of dignity, effective communication, and emotional support for women and newborns receiving care. However, it was not until 2018 that newborns were explicitly included in the revised charter on RMC for women and newborns (White Ribbon Alliance 2018).
Between 2019 and 2022, the Council—through the Breakthrough RESEARCH project—adapted components of Heshima to deploy in Madagascar and Malawi as part of the Advancing Postpartum Hemorrhage Care (APPHC) Initiative, in collaboration with the HEARD Project at University Research Co., LLC (URC); Kamuzu University of Health Sciences, Malawi; and Ministries of Health, with funding from USAID. The adaptation incorporated RMC questions in surveys with maternal healthcare workers to develop context-specific facility improvements to address high postpartum hemorrhage (PPH)—including the introduction of companions during childbirth. Council findings suggest that when healthcare workers feel supported by their managers, they are less likely to mistreat women during childbirth and therefore be more attentive to any danger signs—such as bleeding after birth (Burnett-Zieman et al. 2023).
More recently in India (2022–2025), the Council has been leading research on the introduction of a maternal health chatbot, which sends gestationally appropriate information through WhatsApp. It includes reminders of when to attend antenatal and postnatal care. Women are also asked RMC questions after each engagement with a health facility. Funded by MSD for Mothers, partners include, Nivi Inc., Sitaram Bhartia Institute of Science and Research, and the State of Assam.
Respectful Newborn Care
While the respectful care movement initially focused on women, newborns soon became a globally recognized priority. Enhancing respectful, responsive, integrative, and nurturing care for hospitalized newborns is an urgent need, however, it is under-researched in low- and middle-income countries. From 2019 through 2023, the Council—through Breakthrough RESEARCH—conducted a study on newborns and very young children in Kenya using a mixed-methods evaluation. Council researchers led a formative study to understand mistreatment of newborns documented through their parents’ perceptions (Abuya et al. 2022; Okondo 2022).
Subsequently, the Council engaged in a participatory co-creation process with parents, healthcare workers, and newborn health stakeholders to develop a comprehensive, heath worker behavior-change intervention and implemented it across five hospitals in two counties in Kenya. The multifaceted intervention included a seven-module orientation, feedback meetings, job aids, and psychosocial support for healthcare workers in newborn units. There were significant post-intervention improvements in healthcare worker knowledge on safeguarding sleep, positioning and handling, and protecting skin. However, improvements are still required in assessing a baby’s pain, supporting parental stress, and environmental stress experienced by a newborn (e.g., noise, bright lights). Among parents who received coaching from healthcare workers, there were higher levels of interpersonal communication between parent and healthcare worker; parental empowerment; and an improved ability to provide integrated, responsive care to their child (Warren 2023).
Despite these promising studies and interventions, progress on reducing maternal and newborn deaths has stagnated in 133 countries and increased in 17 countries (van den Akker 2024). There are over 4.5 million pregnancy related deaths that occur every year: 0.29 million maternal deaths; 1.9 million stillbirths; and 2.3 million newborn deaths, and the majority occur in sub-Saharan Africa and Southeast Asia (World Health Organization 2023). Renewed effort is essential, and more emphasis is required for respectful maternal newborn care.