A Guide for Advocating for Respectful Maternity Care

Publication date: 2013

iHEALTH POL ICY P R O J E C T ISBN- 978-1-59560-016-5 Suggested citation: Windau-Melmer, Tamara. 2013. A Guide for Advocating for Respectful Maternity Care. Washington, DC: Futures Group, Health Policy Project. The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. It is implemented by Futures Group, in collaboration with CEDPA (a part of Plan International USA), Futures Institute, Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of the U.S. Agency for International Development. A Guide for Advocating for Respectful Maternity Care iii Table of Contents FOREWORD ACKNOWLEDGMENTS v vii Introduction CHAPTER 1 1 What is Respectful Maternity Care and why is it important? 1 What is the goal of this guide and what are the objectives? 2 Who should use this guide and how is it organized? 3 Article 1: Every woman has the right to be free from harm and ill treatment. 7 Article 2: Every woman has the right to information, informed consent and refusal, and respect for her choices and preferences, including the right to her choice of companionship during maternity care. 9 Article 3: Every woman has the right to privacy and confidentiality. 11 Article 4: Every woman has the right to be treated with dignity and respect. 13 Article 5: Every woman has the right to equality, freedom from discrimination, and equitable care. 15 Article 6: Every woman has the right to healthcare and to the highest attainable level of health. 17 Article 7: Every woman has the right to liberty, autonomy, self-determination, and freedom from coercion. 19 Conclusion 19 What are the Respectful Maternity Care Rights and What Do They Mean? 5CHAPTER 2 Distribute the Respectful Maternity Care Poster and Brochure 21 Host an Event 25 Utilize Social Media 26 Conclusion 27 How Can You Raise Awareness and Generate Demand from Civil Society for Respectful Maternity Care Rights? 21CHAPTER 3 iv Hold a Public Hearing 30 Use Community Score Cards 34 Conclusion 34 How Can You Mobilize the Community to Hold Local Leaders and Service Providers Accountable for Respectful Maternity Care? 29CHAPTER 4 How Can You Secure Commitment at the National Level to Institutionalize Respectful Maternity Care as the Standard of Care? CHAPTER 5 Develop a National Respectful Maternity Care–Focused Advocacy Strategy 40 Launch a National Campaign to Promote Respectful Maternity Care 45 Hold a Meeting 48 Facilitate Formation of a Parliamentarian Group for Respectful Maternity Care 51 Conclusion 55 39 Issue a Media Release 62 Host a Press Conference 65 Produce a Public Service Announcement 67 Hold a Media Sensitization Workshop 70 Host a Journalism Contest 70 Conclusion 70 How Do You Engage the Media in Your Respectful Maternity Care Efforts? CHAPTER 6 59 REFERENCES 73 APPENDIX Respectful Maternity Care PowerPoint Presentations Break the Silence: Respectful Maternity Care Film Respectful Maternity Care Charter Respectful Maternity Care Poster Respectful Maternity Care Brochure 74 v The White Ribbon Alliance (WRA) acknowledges and appreciates the broad group of stakeholders representing research, clinical, human rights, and advocacy perspectives that have come together in a community of concern to develop the Respectful Maternity Care campaign, made possible by support from USAID through the Health Policy Project. A special note of thanks to Rima Jolivet for her work and leadership role in the development of RMC Charter. The WRA extends its sincere gratitude to the individuals and organizations cited throughout the guide; all of whom/which provided their explicit permission to have their materials and tools used and adapted for the purpose of this guide. This guide was created with members of the RMC Advisory Council and the WRA, who generously gave their time to contribute and review content. The WRA deeply acknowledges and appreciates the author of this guide, Tamara Windau-Melmer. Crucial support was provided by Mande Limbu, Maternal Health Technical Advisor, and Megan Higdon at the White Ribbon Alliance in Washington, DC, USA. A Guide for Advocating for Respectful Maternity Care was edited by Lory A. Frenkel, and designed by Gwendolyn Stinger and Aria Gray. Acknowledgments vii Foreword “If we lose … love and self-respect and respect for each other, this is how we will finally die.” Maya Angelou, poet, author, activist What is respect? A childhood memory of being guided to “treat people as you would want to be treated: as individuals, with regard, with consideration, and with courtesy” comes to mind. Whoever we are and wherever we live the world’s 200 million childbearing women want and deserve to be treated in this manner. It’s a surprise to many that this is not always the case. This issue affects women across the street or across the seas. The impact of disrespectful or even abusive maternity care has been highlighted and clarified by the White Ribbon Alliance (WRA). Through the Respectful Maternity Care campaign the WRA has amplified the voices of women who have experienced disrespect of all sorts, and provided Action Resources to address this universal issue. The WRA and the International Confederation of Midwives (ICM) share the goal of improving the standard of care that women receive. Essential Competencies for Basic Midwifery Practice (ICM, 2010) is based on knowledge, skills, and behaviors in recognition of the relationship between midwives and women in their care. I see respect as an attitude of acknowledging the feelings and interests of others and the consequences of this relationship, helping or harming the other. Or as author Jane Austen wrote, “Respect for right conduct is felt by everybody.” The importance of A Guide for Advocating for Respectful Maternity Care cannot be underestimated. Providing practical information, tools, and techniques, this comprehensive guide is valuable to individual citizens, communities, health professionals, service providers, and policy- and decisionmakers—all those for whom saving mothers’ lives is a priority. The health and survival women and their newborns is an issue for all societies. Let us be guided to advocate for all mothers to attain or regain respect. Respectful maternity care for all. Frances Day-Stirk President, International Confederation of Midwives (ICM) viii G eo rg in a G oo dw in , T he W or ld B an k 1 Introduction What is Respectful Maternity Care and why is it important? In every country and community worldwide, pregnancy and childbirth are momentous events in the lives of women and families, and represent a time of intense vulnerability. The concept of “safe motherhood” is usually restricted to physical safety, but childbearing is also an important rite of passage, with deep personal and cultural significance for a woman and her family. Issues of gender equity and gender-based violence are also at the core of maternity care, so the notion of safe motherhood must be expanded beyond the prevention of morbidity or mortality to encompass respect for women’s basic human rights. Women’s autonomy, dignity, feelings, choices, and preferences must be respected, including their choice of companionship wherever possible. Respectful maternity care (RMC) is a universal human right that is due to every childbearing woman in every health system around the world. Women’s experiences with maternity caregivers can empower and comfort them, or inflict lasting damage and emotional trauma. A woman’s positive or negative memories of childbearing experiences stay with her throughout her lifetime. While many interventions aim to improve access to skilled birth care, the quality of relationships with caregivers during maternity care has received less attention. However, evidence suggests that in countries with a high maternal mortality burden, the fear of disrespect and abuse that women often encounter in facility-based maternity care is a more powerful deterrent to use of skilled care than commonly recognized barriers such as cost or distance (Kruk et al., 2009). As the body of anecdotal and research evidence collected in maternity care systems worldwide—from the wealthiest to the poorest nations—grows, there are indications that disrespect and abuse of women seeking maternity care are becoming urgent problems (Kruk et al., 2009; Bowser and Hill, 2010). There is a growing community of concern that spans the domains of healthcare research, quality, and education; human rights; and civil rights advocacy. Many factors contribute to disrespect and abuse in facility-based childbirth, including the normalization of disrespect and abuse during childbirth, lack of community engagement and oversight, financial barriers, and lack of women’s autonomy and empowerment. Disrespect and abuse of women during maternity care are problems that have been obscured by a “veil of silence,” and they can significantly impact women’s willingness to seek out life-saving maternity care. In fact, disrespect and abuse in facilities are among the biggest barriers to women seeking maternal health services. Bowser and Hill, 2010 1 2 To build visibility and bring greater attention to this issue, the White Ribbon Alliance (WRA)—which envisions a world where the rights of all women to be safe and healthy before, during, and after childbirth are upheld—brought together concerned partners to develop collaborative strategies for addressing disrespect and abuse during maternity care. United as a growing multisectoral community of concern to share information, jointly strategize, and harmonize efforts in pursuit of the common goal, the RMC advisory committee aims to advance respectful maternity care as the standard embedded at all levels of all maternal health systems around the globe. This multisectoral collaboration produced a groundbreaking consensus document, the Respectful Maternity Care Charter: The Universal Rights of Childbearing Women, which demonstrates the legitimate place of maternal health rights in the broader context of human rights. Seven rights were drawn from the categories of disrespect and abuse identified in Exploring Evidence for Disrespect and Abuse in Facility-Based Childbirth (2010) by Diana Bowser and Kathleen Hill. All these rights are based on international or multinational human rights declarations and conventions—the Universal Declaration of Human Rights and the Convention on the Elimination of Violence Against Women, among others—that affirm women’s rights to respectful maternity care. Disrespect and abuse during maternity care are violations of a woman’s basic human rights. The WRA is working to persuade key stakeholders to endorse the Respectful Maternity Care Charter and build national, regional, and global awareness of RMC. Your involvement and efforts to promote and advocate for RMC are crucial, because when we speak out and demand RMC, we make it safe for women everywhere to do so. What is the goal of this guide and what are the objectives? The WRA envisions a world in which a woman’s right to RMC is embedded at all levels of all maternal health systems worldwide, and where these rights are reflected in a sense of entitlement among women. The overall goal of this guide is to equip national-level advocates with the appropriate information, tools, and techniques to generate demand for, increase social accountability for, and secure commitments on the issue of RMC. The guide also aims to strengthen national-level advocates’ capacity to use the Respectful Maternity Care Charter effectively and • Raise awareness and generate demand for respectful maternity care rights from civil society; • Mobilize communities to hold local leaders and Childbirth can be a very frightening experience for many women, but it should be a joyous occasion—and every woman should feel valued, respected, and appreciated by all those who aid her in her journey of bringing new life into the world. Liv in g W at er In tl. 3 service providers accountable for respectful maternity care rights; and • Secure a national-level commitment to institutionalize respectful maternity care as the standard of care. Who should use this guide and how is it organized? This guide is designed to assist advocates undertaking a variety of activities, from raising awareness among civil society organizations to working with members of Parliament. In addition to background information and case examples, it includes various tools and techniques to enhance your work promoting social accountability and advocating for RMC in your community and country. The guide is divided into six chapters. You are strongly encouraged to read through Chapters 1 and 2 in their entirety, and refer to Chapters 3–5 for information that is relevant to your specific advocacy interests. You are also encouraged to read through Chapter 6 in its entirety because it provides information on and tools for engaging the media in your efforts. Chapter 1 introduces RMC with a brief background of the issue and the guide itself. Chapter 2 discusses the development of the seven RMC rights in detail and highlights them individually. Each article is accompanied by quotes and stories from women who experienced disrespect or abuse during childbirth. These testimonies are meant to illustrate what it might look like when a woman’s rights are violated. Chapters 3, 4, and 5 present tips, tools and techniques for three levels of approach to 1. Raising awareness and generating demand from civil society for RMC rights; 2. Mobilizing communities to hold local leaders and service providers accountable for upholding RMC rights; and 3. Securing commitment at the national level to institutionalize RMC as the standard of care. For example, Chapter 3, on raising awareness and generating demand from civil society for RMC rights, includes ideas about and descriptions of using social media and holding events to increase people’s understanding of RMC and the rights of childbearing women. Chapter 4 focuses on mobilizing communities, providing simple explanations of various social accountability approaches and guidelines on conducting public hearings and using Community Score Cards. Chapter 5 discusses securing commitment at the national level, and contains in-depth information and guidance on developing a national RMC-focused advocacy strategy and campaign. This chapter will help you define your advocacy priorities; assess the environment you are working in; map out your strategy and campaign; and monitor, document, and report impact. You will also find tips and tools for sensitizing leaders and engaging members of Parliament. The information in Chapters 3 and 4 will also be helpful if you are developing a national campaign and want to use some of the techniques presented there. If you are interested in launching a nationwide RMC nationwide campaign, that’s great! But you can still effectively advocate for RMC and make a real difference even if you don’t have the resources to develop a full- fledged campaign at this time. Before you embark on any specific RMC activities, you need to clarify what you are doing, why you are doing it, and how you are going to do it. This guide is intended to be flexible and adaptable to your needs. You can read straight through Chapters 3, 4, and 5, or go directly to the chapter that is relevant to your RMC advocacy interests and goals. Chapter 6 presents tips, tools, and techniques for engaging with the media. Involving or partnering with the popular press is a central component of advocacy that should be woven into your RMC efforts no matter what approach you take or at what level you wish to work. The Appendix contains all of the RMC-related tools that have been developed to date. Feel free to copy these and use them. Some chapters include lists of additional resources sorted by topic if you are interested in learning more about a particular issue or technique. There are references and links throughout the guide to the many wonderful tools and publications that were used and adapted in its preparation. The WRA acknowledges and recognizes these individuals and organizations for their work and appreciates their granting permission to use and adapt their materials. 4 Ph ot og ra ph y by E lin 5 What are the Respectful Maternity Care Rights and What Do They Mean? Human rights are fundamental entitlements due to all people that are recognized by societies and governments and enshrined in international declarations and conventions. All childbearing women need and deserve respectful care and protection; this includes special care to protect the mother-baby pair and women who are in a context of marginalization or heightened vulnerability (e.g., adolescents, ethnic minorities, and women living with physical or mental disabilities or HIV). Disrespect and abuse during maternity care are violations of women’s basic human rights. Until recently, no instrument has specifically delineated the role of human rights in childbirth or affirmed their application as basic, inalienable rights to women giving birth. To promote RMC, the WRA facilitated the development of a rights charter with broad input from project partners, representatives from the WRA National Alliances network, and international NGOs around the globe. The seven rights in this consensus document are drawn from the categories of disrespect and abuse that have been identified by researchers Bowser and Hill (2010). It is understood, however, that disrespect and abuse often fall into more than one category, so the categories are not intended to be mutually exclusive—they should be seen as overlapping along a continuum. All of these rights are based on international or multinational human rights instruments. The Charter solidifies the legitimate position of maternal health rights within the broader context of human rights. The Charter can be used to address the problems of disrespect and abuse during maternity care within a positive, rights-based framework. In addition to defining maternal health rights as basic human rights grounded in international declarations, the Charter: • Raises awareness of the issue in a way that avoids blaming and shaming; • Shows that the rights of childbearing women have al- ready been recognized in guarantees of human rights; • Provides a tool for advocacy at all levels and a basis for accountability; and • Provides a platform to build childbearing women’s sense of entitlement to high-quality maternity care by aligning it with international human rights. You can find the Charter in the Appendix of this guide. The remainder of this chapter explains each of the seven articles in detail and provides real-life examples of violations of these rights. 2 6 The operating room was chilly on a grey morning in Bihar, Northern India. Tile floors did nothing to insulate from the thick, damp cold seeping through the blankets on rickety hospital beds. Sugia Devi was spread on the operating table like a martyr, arms wide. But Devi wasn’t dead; she was active and flailing in pain. Throughout her cesarean section she responded to each incision, each stitch, jerking her face away and moaning ghoulishly. The doctors working on her abdomen, distracted by pulling out the baby and answering a phone call, ignored her cries. But the junior doctor standing next to her face, heard. He held down the thin gauze strip covering her eyes, pressing so strongly he indented the mounds of her cheeks. SUGIA DEVI’S STORY The cover was ineffective; beneath the thin cloth her eyes were visible, darting in fear. The doctor pumped Devi full of pain medications during the surgery, and he said that after that she was moaning out of fear. Devi, however, blatantly disagreed: “I remember that I was shouting out of pain.” When she moaned Kumar shook her, then jerked her, and finally hit her, over and over during the surgery. His lip snarled and he looked angry at the disturbance. There was no concept of her cries representing a physical need or something wrong with her pain control. They were only annoying. Devi, abdomen still open, half anesthetized, uterus exposed, had no choice but to weather the health worker’s blows. Sugia Devi’s Story was originally published in The Atlantic, “The Everyday Violence Against Pregnant Women in India,” on February 12, 2013. Written by Allyn Gaestel and photographed by Allison Shelley. The full article can be found here: http://www.theatlantic.com/health/archive/ 2013/02/the-everyday-violence-against-pregnant-women-in-india/273045/. A lli so n Sh el le y 7 Article 1 Every woman has the right to be free from harm and ill treatment. No one can physically abuse you. All physical contact with pregnant women should be as gentle, comforting, and reassuring as possible. Even though freedom from physical abuse is the right of each patient, many stories of physical abuse during childbirth have been reported. Examples of physical abuse during childbirth range from service providers pinching women to outright sexual assault and abuse (Bowser and Hill, 2010). Other examples of physical abuse include • Being slapped; • Being restrained or tied down during labor; • Undergoing unnecessary and extensive episiotomies (sometimes for financial gain), or postpartum sutur- ing of vaginal tears or episiotomy cuts without the use of anesthesia; and • Being subjected to pushing on the abdomen to force the baby out, or excessive physical force to pull the baby out. A woman from Peru reported that during labor, “A nurse who was helping me told me that I should help, that I should push. At that moment I couldn’t. I cried out. The nurse slapped me. I felt ashamed. They treated me like a child with bad manners.” d’Oliveria et al., 2002; CLADEM/CRLP, 1998 8 MAMA WAILI’S STORY By 37 weeks into her pregnancy, it was difficult to recognize Mama Waili. Pregnant with twins, she developed edema of the limbs that spread to her whole body, including her face, lips, tongue, and fingers. Valleria Mushi, a nurse and family friend, knew immediately that Mama must get medical help. Mama was receiving antenatal care at a private clinic in Dar es Salaam, and had repeatedly requested that she be referred to a government facility where equipment and specialists would be more readily available. The doctor in the clinic ignored her wishes and she did not have the confidence to insist on a referral. Mama soon developed severe preeclampsia and was admitted to the hospital. The hospital building was still under construction; it had dust all over, no reliable power, no neonatal unit, and no lift. The rooms were small, noisy, and congested. The doctor informed Mama that he would operate, with little or no plan of how to manage her care. He once again ignored pleas from Mama, her family, and Valleria for a referral that would offer both Mama and her children a greater chance of survival. The doctor implied that there were no complications, became furious, and threatened to write a referral in such a way that Mama would not get help. One morning Valleria was ready to take Mama to an appointment she had secured at a different hospital. The nurses hid the clinic card and the referral note said nothing about the patient’s condition or what treatment had been given. Mama’s mother started crying with anger, “You are forcing my daughter to remain here even if she will die, as long as you will get money!” Eventually, Valleria transferred Mama to a different hospital, where she gave birth to beautiful twin girls. After some initial complications, for which Mama and the children received care in and out of the hospital, all are healthy and doing well thanks to the strength, foresight, and determination of one health worker. Without Valleria’s courage and ability to combat negligence, corruption, and malpractice, this would likely have been a very different story. This story was contributed to the WRA’s “Stories of Mothers Saved” project by Valleria Mushi. Also see the film Stories of Mothers Saved. Dir. Bridget McConville. White Ribbon Alliance, 2010, available at https://www.youtube.com/ watch?v=tMnbLlYDW4I&list=PL35425219238BD0EC. Va lle ria M us hi 9 Article 2 Every woman has the right to information, informed consent and refusal, and respect for her choices and preferences, including companionship during maternity care. No one can force you or do things to you without your knowledge and consent. All patients need a careful explanation of proposed procedures in a language and at a level they can understand so they can knowingly consent to or refuse a procedure (informed consent). When informed consent isn’t granted, it may be due to a patient’s lack of understanding, language difficulties, level of education, or cultural background. Examples of non-consented care include • Healthcare providers not giving women the proper information about medical procedures; • Healthcare providers not asking for women’s permission to conduct medical procedures such as • Cesarean sections • Episiotomies • Hysterectomies • Blood transfusions • Sterilization • Augmentation of labor; and • Women feeling coerced into a medical procedure, such as a cesarean section. A woman from Kenya reported that during her first birth, she was “really scared,” and did not know what to expect or what the doctor was supposed to do, and nobody was telling her what was happening during the process of delivery. Center for Reproductive Rights and FIDA, 2007 10 A YOUNG TANZANIAN WOMAN’S STORY This story describes a woman’s experience in a maternity ward in Tanzania. Although every woman’s right to privacy and confidentiality during maternity care should be upheld, overcrowding and a lack of privacy are part of childbirth for many women in Africa. I witnessed a young woman giving birth in a labor ward in Tanzania. She must have been 20 years old, and she was giving birth for the first time. The labor ward was like a hall where each woman could see what was happening to her peers in the next bed or at the far end of the ward. The people cleaning the ward could see the deliveries. Senior doctors, nurses, students, laboratory technicians, and others filled this open hall and the young woman knew they would all see her naked. The medical attendant instructed the woman to open her legs because she was due to push. But the young woman held her legs closed tightly. In a panic, the medical attendant shouted, “Open your legs just as you did when you were conceiving!” In tears, the woman closed her legs even tighter, and the attendant reacted with an “obstetric slap” on the thigh. This made things worse, because the young woman would not let her privacy be violated. She closed her legs tighter still. She and the baby were getting tired. A senior midwife was consulted and spoke to the young woman in a more polite and professional way. The baby was finally delivered through a vacuum extraction. In Tanzania husbands or partners are not allowed in labor wards because of the overcrowding and lack of privacy. This lack of privacy is a violation of women’s basic rights as human beings, because no woman would like to be seen naked or be exposed to another’s nakedness when she goes to a labor ward for maternity care. This story was contributed by Rose Mlay, National Alliance Coordinator for WRA Tanzania, for the WRA blog. Accessed June 12, 2013, from http://www.whiteribbonalliance.org/index.cfm/news-blogs/wra-blogs/blog-respectful- care-during-labor-and-childbirth/. W hi te R ib bo n A lli an ce 11 Article 3 Every woman has the right to privacy and confidentiality. No one can expose you or your personal information. Healthcare providers must do everything possible to protect the privacy and confidentiality of patients and their information. This includes privacy and confidentiality during counseling, physical examinations, clinical procedures, and when handling patients’ medical records and other personal information. Violations of privacy and confidentiality for women who give birth in facilities can include • Having to labor and deliver in view of others (without privacy barriers such as curtains); and • Having healthcare workers share sensitive information, such as a patient’s HIV status, age, marital status, and medical history, in a way that other people can hear. A rural clinic in northern Ghana was described as having “no dividers to provide privacy. Case histories were taken in the midst of other [patients] waiting in the reception area. The privacy was compounded by the tendency of nurses to interview women in loud voices, making it easy for those who were waiting to hear their concerns.” Center for Reproductive Rights and FIDA, 2007; Yakong, 2010 A team observing deliveries in the Dominican Republic described a delivery with the following words, “Low- and high-risk women labored together in one large, brightly lit and noisy room. Some women were naked, most were lying on bare plastic mattresses, the one sheet having been soiled with urine, feces, or drenched in amniotic fluid. There was no privacy, no dignity.” Miller et al., 2002 12 UMM ANAS’ STORY Umm Anas is 35 years old and lives in Sana’a, the capital of Yemen. She completed her undergraduate studies with distinction and has a master’s degree. “I joined one of the capital’s schools as a teacher, where I performed remarkably well. I am married and have three children. This did not deter me from carrying out my professional responsibilities. Unfortunately, my resolve and strength were tested during my third pregnancy. “I visited my doctor every two months for checkups and I was fine until the time of delivery. When I started labor, I went to the center in the neighborhood next to ours, where I was told that I was late for that day and that I would have to come back the next day. The pain increased on the second day and when I went to the hospital, the doctors told me that I would give birth within two hours. I was also asked to walk the corridors of the hospital to facilitate the process of childbirth. As I was leaving the delivery room, a second doctor came in and asked to examine me. I told her that I had just been examined, but she insisted. I submitted and allowed her to examine me. I walked around the hospital corridors for two hours and returned to the first doctor, who examined me again. I was now told that I would give birth at noon and that I needed to walk some more. When I came back, I was examined yet another time and told that I would only give birth in the afternoon. “I decided to return to my house, but was confronted by the first doctor, who screamed at me. I was in pain—not just the pain of childbirth, but the pain of the various tests and examinations. The doctor also screamed at another woman in the delivery room, who was bleeding and crying and trying to tell the doctor about her situation. I could not bear what I saw and decided that I could not trust the doctors in the hospital any longer. I ran from the hospital to my home with tears streaming down my face. “I was totally exhausted and fatigued by this time. I contacted a midwife, Hedaidah, who lives in the same street that I do. She came in the afternoon and said that I would give birth at night, since my cervix was not sufficiently dilated. As my labor pains increased over the course of the night, I contacted her and she attended to me right away. I cannot help but compare her kind treatment with the cold, disinterested treatment I had received in the hospital. The midwife provided me with emotional support and took a genuine interest in me. She did not leave me alone and ignore me, unlike the doctors in the hospital. She was kind and patient with me, even when I was screaming during the final stages of delivery.” This story was contributed to the WRA’s “Stories of Mothers Saved” project by the National Safe Motherhood Associ- ation of Yemen. Also see the film Stories of Mothers Saved. Dir. Bridget McConville. White Ribbon Alliance, 2010, available at https://www.youtube.com/watch?v=tMnbLlYDW4I&list=PL35425219238BD0EC. N at io na l S af e M ot he rh oo d A ss oc ia tio n of Y em en 13 Article 4 Every woman has the right to be treated with dignity and respect. No one can humiliate or verbally abuse you. Service providers must ensure that patients are as comfortable as possible during procedures. Every woman seeking care is a person of value and has the right to be treated with respect and consideration. Patients should be encouraged to express their views freely, even when they differ from service providers’ views. Service providers also need to ask patients for feedback. Cases have been reported of midwives scolding their patients and telling them they were stupid. There are also reports of women being told to stop pretending they were in pain and to stop crying. Other examples of non-dignified care during child- birth can include intentional humiliation, blaming, rough treatment, scolding, and shouting. It is important to remember that a woman’s descrip- tion and perception of non-dignified care may be very context specific. This means that an example from one country may not be relevant in others. For example, a woman may perceive eye contact, a smile, and a handshake from a male provider as polite in one culture but disrespectful in another. Indigenous women feel disrespected and report that when they go to the hospital to deliver they are told “these Indian women who come here smell, ‘Go and bathe yourself first.’” Ministerio de Salud Publica del Ecuador, 2007 Nurses “put fear in me and threatened that they would take me to the theatre [for a cesarean section] if I dared push again.” d’Ambruoso, Abbey, and Hussein, 2005 Indigenous women from Bolivia expressed fear of being examined repeatedly and unnecessarily by both physicians and students in training: “In [the] hospital as well, there are lots of student doctors all around us, and we have to lie there in front of them with our legs open. Some young girls arrive there and don’t know about it, and just don’t want to open their legs. But the doctors say, ‘Open your legs!’ and force them apart.” Bradby, 1998 14 Pr ud en ce C um in g A ss oc ia te s Ltd . Nzako moved to Kinshasa to pursue her education. She got married and became pregnant. Her husband was unemployed, so Nzako could not afford antenatal healthcare. When her baby was due, Nzako went to the closest health center and spoke with the nurse at the door. “Did you have [antenatal] visits here?” asked the nurse. “No,” answered Nzako. “How much money do you have?” asked the nurse. “Two thousand Congolese francs (approximately £2). I used the extra I had to come here,” replied Nzako. “Your case cannot be treated here,” continued the nurse. “Go to Hôpital Général de Référence in Kinshasa.” Nzako went to the hospital with her older sister, but was again asked how much money she had and turned away. Nzako was told to go Bondeko Hospital, which was five kilometers away. Despite Nzako’s pleas for help, she had to make her own way to Bondeko Hospital, where she died at the door. This story and artwork was contributed to the WRA’s “Stories of Mothers Lost” initiative by Maternité Sans Risque from the Democratic Republic of the Congo and included in: McConville, Bridget, John Shearlaw, Catharine Taylor, and Tamara Windau, eds. 2008. Stories of Mothers Lost: Created by the White Ribbon Alliance. Cambridge: Cambridge University Press. Kim (not her real name) told Amnesty International she wanted a home birth but ended up having a c-section. She said, “I could have been able to better handle the situation if they gave me some medical reason for why I needed to have a cesarean. But there was no explanation as to why I could not have a vaginal birth. It was cesarean and that’s it. All other options were taken off the table.” One doctor reportedly took Kim aside after the delivery and told her, “We don’t get many black patients. They’re just not used to your personality, asking the questions that you’re asking, saying what you’re saying. Challenging and holding them to their diagnoses.” Kim noted, “I was quite aware of their perceptions of me. There’s that assumption—I’m a young black girl so obviously I’m poor and uneducated… [but] I was asking questions every step of the way. And the more I asked, the more animosity the doctors built up towards me. After my c-section, they had a representative from Medicaid come talk to me. I said, ‘You haven’t even asked me if I even qualify! I make US$60,000 a year.’ … On my daughter’s birth certificate they checked that I was not college educated. But I have an advanced degree. It was devastating. I asked that they change this. They said, ‘No. We can’t change it. It’s already been sent out. Nobody is going to see it so it doesn’t really matter.’” Interview courtesy of Amnesty International, from Deadly Delivery: The Maternal Health Care Crisis in the USA. The full report is available from: http://www.amnestyusa.org/sites/default/files/pdfs/deadlydelivery.pdf. 15 Article 5 Every woman has the right to equality, freedom from discrimination, and equitable care. No one can discriminate because of something they do not like about you. All women are equal and must be treated with respectful care regardless of their ethnic background, culture, social standing, educational level, or economic status. For example, in some areas of Sierra Leone it is believed that obstructed labor is caused by infidelity, which may result in caregivers blaming the condition on a woman‘s past behavior, insisting that she confess, and address- ing the “immoral behavior” instead of focusing on the health situation at hand. Examples of discrimination during childbirth may be based on a woman’s race, ethnicity, age, language, HIV status, traditional beliefs and preferences, economic status, or educational level. A Native American woman from Wisconsin, USA, shared her story with Amnesty International in 2008: “Everything that came out of her mouth was the color of my skin. She goes, ‘You’re the first dark person I’ve ever had.’ It just kept going on for like 20 minutes. I sat there and had to deal with that. After that, I left and never went back.” Amnesty International, 2010 A Kenyan woman who had given birth as a teenager in a maternity recalled that the nurses would tell young teenage mothers: “You young girl, what were you looking for in a man? Now you can’t even give birth.” Center for Reproductive Rights and FIDA, 2007 16 Pr ud en ce C um in g A ss oc ia te s Ltd . Onesima Montero, from the Dominican Republic, was 29 years old when she died after having a normal birth in the early morning hours of October 20, 2005. Onesima was already in rigor mortis when her relatives found her during hospital visiting hours (between 2 and 6 PM) . She had died from hypovolemic shock due to postpartum hemorrhage. The doctors and nurses never checked on the patient in the immediate postpartum period. She had been completely wrapped up (because patients in shock often feel cold), and no one realized her condition, nor did they investigate. “When I heard this story I broke down crying, NEVER AGAIN! This was the most preventable death I have ever heard of, there was no reason outside of gross negligence and lack of attention to human and women’s rights and dignity that Onesima should have bled to death alone in a big city hospital with hundreds of staff,” said Suellen Miller. This story and artwork was contributed to the WRA’s “Stories of Mothers Lost” initiative by the University of California, Berkeley, School of Public Health—Maternal & Child Health Department, USA, and included in: McConville, Bridget, John Shearlaw, Catharine Taylor, and Tamara Windau, eds. 2008. Stories of Mothers Lost: Created by the White Ribbon Alliance. Cambridge: Cambridge University Press. 17 Article 6 Every woman has the right to healthcare and to the highest attainable level of health. No one can prevent you from getting the maternity care you need. Instead of receiving attentive care, women are sometimes left to deliver by themselves, but a woman who is in labor or has just given birth should never be left alone. At health facilities, women should be able to have a companion of their choice, such as a family member, with them throughout labor and birth to provide con- tinuous support. Examples of abandonment include • Women at a facility being left alone during labor and not receiving any medical attention; • Women giving birth by themselves, or having other patients assist them; • Women not being allowed to bring a companion into the birthing area; and • Providers failing to monitor women in labor and intervene in life-threatening situations. Aicha recounted her first delivery experience at a district hospital in Burkina Faso: “All of the maternity personnel left, they told me that they had to go to a baptism. I felt abandoned. There were no more medical personnel that afternoon. So we had to wait for the night shift to come, at midnight.” Aicha reported that she labored on her own … and delivered a stillborn baby that night. Amnesty International, 2009 18 HILDA KHUMALO AND CHARITY NDLOVU’S STORIES Several women told The Zimbabwean they were being ill-treated by authorities there because they could not pay. “I was detained in the pre-natal ward for almost a day after I failed to raise $155 user fees. My sister had to come to my rescue—paying half of the amount. The balance is being taken from her monthly water account,” said Hilda Khumalo, younger sister to Tabitha Khumalo, the MDC-T MP for Bulawayo East. Tabitha confirmed that her sister was detained at Mpilo until she agreed to pay. “I paid $155 for Hilda after she was detained at Mpilo. What these people are doing is very unfair,” she said. Another mother, Charity Ndlovu, said she was also detained at the hospital failing to raise the user fees. “I was detained for a night last year after delivering my baby boy. When I said I did not have the required money the accounts clerks insulted me saying I should have prepared for my pregnancy. After realising that I did not have any means to raise the money, I was referred to the social welfare offices in town,” said Ndlovu, whose husband is unemployed. Some mothers have also been denied birth records for their babies after failing to raise the fees. “I have not secured a birth certificate for my baby since last year because I failed to obtain a birth record. …” said [one] mother. Hilda Khumalo and Charity Ndlovu’s stories are excerpted from “Mothers, babies detained at Mpilo for non-payment,” by Zwanai Sithole, which was published in The Zimbabwean on February 22, 2012. To access the original article, go to: http://www.thezimbabwean.co/news/zimbabwe/56509/mothers-babies-detained-at-mpilo.html. Th e Zi m ba bw ea n 19 Article 7 Every woman has the right to liberty, autonomy, self- determination, and freedom from coercion. No one can detain you or your baby without legal authority. Some health facilities have been known to detain or prevent women from leaving with their ba- bies, because they cannot pay their bills. This is usually only for a day or two, but there are reports of patients being held for weeks and months. Even women whose babies died have been detained because they could not pay their bills. A woman from Burundi reported that after having a cesarean delivery, “when I got the bill, the doctor said to me, ‘Since you have not paid, we will keep you here.’” Human Rights Watch, 2006 In Ghana, a woman reported visiting her baby in a large hospital for up to three weeks in order to breastfeed her detained baby because she could not pay the bill. IRIN, 2005 Conclusion Every woman, when receiving healthcare during pregnancy and childbirth, has the right to • Freedom from harm and ill treatment; • Information, informed consent and refusal, and respect for her choices and preferences, including the right to her choice of companionship during maternity care, whenever possible; • Privacy and confidentiality; • Treatment with dignity and respect; • Equality, freedom from discrimination, and equitable care; • Healthcare and the highest attainable level of health; and • Liberty, autonomy, self-determination, and freedom from coercion. When a woman experiences disrespect and abuse during facility-based care, her rights are being violat- ed. Often when this happens, more than one of her seven rights are being violated at the same time. Around the world, in both wealthy and poor communities and countries, women have been, and are, experiencing disrespect and abuse. All women deserve respectful and dignified care during pregnancy and childbirth. When we speak out and demand respectful care, we make it safe for women everywhere to do so. If you want more information, have questions, or wish to share your stories about RMC, please contact the WRA at info@whiteribbonalliance.org with the subject line: ADVOCATING FOR RMC. For more information about RMC, click here to visit the WRA’s webpage or go to: http://whiteribbonalliance.org/ index.cfm/the-issues/respectful-maternity-care/. 20 Jo hn H ea ly P ho to gr ap hy 21 How Can You Raise Awareness and Generate Demand from Civil Society for Respectful Maternity Care Rights? 3 Disrespect and abuse are widespread global problems; however, they may be so entrenched in a culture that many individuals and communities don’t even realize that women’s basic human rights are being violated when disrespect and abuse occur. Such treatment may be seen as a normal part of the childbearing experience, or it may not be discussed because women who experience it are traumatized or embarrassed. If you want to raise public awareness of respectful maternity care, the following sections present some ideas and tools to do this. However, if you want to target a particular group of people—or a specific sector of civil society—then take some time to consider why you chose this audience and for what (what outcome you would like your efforts to produce). Your audience, main objective, and the key RMC messages you want to convey should be well thought out before you move forward. Once you decide on these, get started and feel free to use and adapt any of the ideas and tools presented here to best meet your needs. Distribute the Respectful Maternity Care Poster and Brochure Raise the visibility of RMC. The following are ways you can share information on RMC with the public and other relevant groups by using tools that have already been developed: • Make copies of the RMC Poster and post them in clearly visible areas where people gather—such as the market, health clinics, factories, bus stations, and libraries. The Poster is on page 22, and in the Appen- dix. You can also download a digital copy of the Poster here or from: http://www.whiteribbonalliance.org/ WRA/assets/File/RMC_POSTER_R3_WEB.pdf. • Leave copies of the RMC Brochure in public places where people are likely to take one. The Brochure is on pages 23 and 24, as well as in the Appendix. You can also download a digital copy of the Brochure here or from: http://www.whiteribbonalliance.org/ WRA/assets/File/RMC_BROC_FINr3_web2.pdf. • Set up an informational booth about RMC. • Identify relevant meetings or other opportunities where you can distribute RMC materials. • Consider developing your own RMC materials for distribution—these could take the form of a story- board or a cartoon that uses pictures or illustrations to describe RMC rights. BEFORE YOU GET STARTED, REMEMBER: You should obtain permission from the proper authorities before you post the RMC Poster or share the Brochure and any other RMC materials in public spaces. 22 Disrespect and abuse during maternity care are a violation of women’s basic human rights. In seeking and receiving maternity care before, during and after childbirth: RESPECTFUL MATERNITY CARE: THE UNIVERSAL RIGHTS OF CHILDBEARING WOMEN Safe Motherhood is more than the prevention of death and disability…It is respect for every woman’s humanity, feelings, choices, and preferences. 6article Vi all rights are grounded in established international human rights instruments, including the Universal Declaration of Human Rights; the Universal Declaration on Bioethics and Human Rights; the International Covenant on Economic, Social and Cultural Rights; the International Covenant on Civil and Political Rights; the Convention on the Elimination of All Forms of Discrimination Against Women; the Declaration of the Elimination of Violence Against Women; the Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternal mortality and morbidity and human rights; and the United Nations Fourth World Conference on Women, Beijing. National instruments are also referenced if they make specific mention of childbearing women. For more information visit: www.whiteribbonalliance.org/respectfulcare 1be fREE froM Harm AND ILL treatment a r ti c le i NO ONE CAN PHYSICALLY ABUSE YOU eVery woman has the right to 2article ii INFORMATION, iNfORmEdCONSENTANDREfUSAL, ANDrespect FOR HER CHOICES AND preferences, INCLuDING COmPANIONSHIP DuRING MATERNITy CARE eVery woman has the right to 3article iii PRIVACYAND confIDentIalIty eVery woman has the right to 7article Vii eVery woman has the right to eVery woman has the right to 5article V EqUALITY, freedom FROM discriMination, AND EqUITABLE care NO ONE CAN dISCRImINATE BECAUSE Of SOmETHING THEY dO NOT LIKE ABOUT YOU eVery woman has the right to LIBERTY, autonoMy, self-deterMination, ANDfREEdOm from coercion NO ONE CAN dETAIN YOU OR YOUR BABY WITHOUT LEGAL AUTHORITY HEALTHCARE AND TO THE HigHest attainable level of HEALTH NO ONE CAN PREVENT YOU fROm GETTING THE mATERNITY CARE YOU NEEd 4article iV eVery woman has the right to BE TrEaTEd wiTh dIGNITYAND RESPECT NO ONE CAN HUmILIATE OR VERBALLY ABUSE YOU NO ONE CAN fORCE YOU OR dO THINGS TO YOU WITHOUT YOUR KNOWLEdGE ANd CONSENT NO ONE CAN EXPOSE YOU OR YOUR PERSONAL INfORmATION The C harter ad d resses the issue of d isresp ect and ab use am ong w om en seeking m aternity care and p rovid es a p latform for im p rovem ent by • R aising aw areness o f child b earing w o m en’s inclu sio n in the g u arantees o f hum an rig hts reco g nized in internatio nally ad o p ted U nited N atio ns and o ther m ultinatio nal d eclaratio ns, co nventio ns, and co venants; • H ig hlig hting the co nnectio n b etw een hum an rig hts lang u ag e and key p ro g ram issues relevant to m aternity care ; • Increasing the cap acity o f m aternal health ad vo cates to p articip ate in hum an rig hts p ro cesses; • A lig ning child b earing w o m en’s sense o f entitlem ent to hig h -q u ality m aternity care w ith internatio nal hum an rig hts co m m unity stand ard s; and • P ro vid ing a b asis fo r ho ld ing the m aternal care system and co m m unities acco untab le to these rig hts. A b road group of stakehold ers rep resenting research, clinical, hum an rights, and ad vocacy p ersp ectives cam e together in a com m unity of concern to d evelop this charter. The cam p aign to p rom ote resp ectful m aternity care is led by the W hite R ib b on A lliance for S afe M otherhood, w ith sup p ort from U S A ID through the H ealth P olicy P roject. J o in U s : H e lp e n su re th a t e ve ry w o m a n ’s rig h t to re sp e c tfu l m a te rn ity c a re is u p h e ld . A s w e sp eak o u t an d d em an d resp ectfu l care, w e m ake it safe fo r w o m en everyw h ere to d o so to o . RESPECTFUL M ATERNITY CARE: THE UNIVERSAL RIGHTS OF CHILDBEARING WOMEN To fi n d o u t m o re, visit: w w w .w h iterib b o n allian ce.o rg /resp ectfu lcare istock A ll childbearing w om en need and deserve respectful care and protection; this includes special care to protect the m other-baby pair as w ell as w om en in a context of m arginalization or heightened vulnerability (e.g., adolescents, ethnic m inorities, and w om en living w ith physical or m ental disabilities or H IV ). D isresp ect an d ab u se d u ring m atern ity care are a vio latio n o f w o m en’s b asic h u m an rig hts. A s s e r t io n o f t h e U n iv e r s A l r ig h t s o f C h il d b e A r in g W o m e n the world bank 24 Th e D is ti n ct iv e Im p o rt an ce o f th e C h ild b ea ri n g P er io d P re gn an cy a nd c hi ld b irt h ar e m om en to us e ve nt s in th e liv es o f w om en a nd fa m ilie s ev er yw he re a nd a ls o a tim e of in te ns e vu ln er ab ilit y. “ S af e m ot he rh oo d ” us ua lly s ug ge st s p hy si ca l s af et y, b ut c hi ld b ea rin g is al so a n im p or ta nt r ite o f p as sa ge w ith d ee p p er so na l an d c ul tu ra l s ig ni fic an ce . B ec au se m ot he rh oo d is s p ec ifi c to w om en , ge nd er e q ui ty a nd g en d er vi ol en ce a re a ls o at t he c or e of m at er ni ty c ar e. Th e ca m p ai gn to p ro m ot e re sp ec tf ul m at er ni ty c ar e fo cu se s sp ec ifi ca lly o n th e in te rp er so na l a sp ec ts o f ca re r ec ei ve d b y w om en s ee ki ng m at er ni ty s er vi ce s. A w om an ’s r el at io ns hi p w ith h er m at er ni ty p ro vi d er s is v ita lly im p or ta nt . N ot o nl y ar e th es e en co un te rs th e ve hi cl e fo r es se nt ia l l ife sa vi ng h ea lth s er vi ce s, b ut w om en ’s e xp er ie nc es w ith c ar eg iv er s ca n em p ow er a nd c om fo rt o r in fli ct la st in g d am ag e an d em ot io na l t ra um a. E ith er w ay , w om en ’s m em or ie s of t he ir ch ild b ea rin g ex p er ie nc es s ta y w ith t he m fo r a lif et im e an d a re o fte n sh ar ed w ith o th er w om en , co nt rib ut in g to a c lim at e of c on fid en ce o r d ou bt ar ou nd c hi ld b ea rin g. S af e m o th er h o o d is m o re t h an t h e p re ve n ti o n o f d ea th a n d d is ab ili ty : I t is r es p ec t fo r ev er y w o m an ’s h u m an it y, f ee lin g s, c h o ic es , a n d p re fe re n ce s. G ro w in g E vi d en ce o f D is re sp ec t an d A b u se Im ag in e th e p er so na l t re at m en t yo u w ou ld e xp ec t fro m t he h ea lth w or ke r en tr us te d to h el p y ou o r a w om an y ou lo ve g iv e b irt h. W e en vi si on a r el at io ns hi p ch ar ac te riz ed b y ge nt le , ef fe ct iv e co m m un ic at io n, su p p or t, ki nd ne ss , an d r es p ec t. U nf or tu na te ly , to o m an y w om en e xp er ie nc e ca re t ha t d oe s no t m at ch th is im ag e. A g ro w in g b od y of r es ea rc h ev id en ce , ex p er ie nc e, a nd c as e re p or ts c ol le ct ed in m at er ni ty ca re s ys te m s fro m t he w ea lth ie st to p oo re st n at io ns w or ld w id e p ai nt s a d iff er en t an d d is tu rb in g p ic tu re . B ow se r an d H ill (2 01 0 ) d es cr ib ed s ev en m aj or ca te go rie s of d is re sp ec t an d a b us e th at c hi ld b ea rin g w om en e nc ou nt er d ur in g m at er ni ty c ar e. T he se ca te go rie s oc cu r al on g a co nt in uu m fr om s ub tle d is re sp ec t an d h um ilia tio n to o ve rt v io le nc e: • P hy si ca l a b u se • N o n -c o ns en te d c lin ic al c ar e • N o n -c o nfi d en ti al c ar e • N o n -d ig ni fie d c ar e (in cl u d in g v er b al a b u se ) • D is cr im in at io n b as ed o n sp ec ifi c p at ie nt a tt ri b u te s • A b an d o nm en t o r d en ia l o f ca re • D et en ti o n in f ac ili ti es D is re sp ec t an d a b us e of w om en s ee ki ng m at er ni ty ca re is b ec om in g an u rg en t p ro b le m a nd c re at in g a gr ow in g co m m un ity o f c on ce rn t ha t sp an s th e d om ai ns o f h ea lth ca re r es ea rc h, q ua lit y, a nd ed uc at io n; h um an r ig ht s; a nd c iv il rig ht s ad vo ca cy . D is re sp ec t an d a b u se d u ri n g m at er n it y ca re a re a vi o la ti o n o f w o m en ’s b as ic h u m an r ig h ts . In s e e k in g a n d r e ce iv in g m a te rn it y ca re b e fo re , d u ri n g , a n d a ft e r ch il d b ir th : h u m a n r ig h ts a re f u n d a m e n ta l e n ti tl e m e n ts d u e t o a ll p e o p le , re co g ni ze d b y so ci et ie s an d g o ve rn m en ts a nd e ns hr in ed in in te rn at io na l d ec la ra ti o ns a nd c o nv en ti o ns . U nt il no w , n o in st ru m en t ha s sp ec ifi ca lly d el in ea te d h o w hu m an r ig ht s ar e im p lic at ed in t he c hi ld b ea ri ng p ro ce ss o r af fir m ed t he ir a p p lic at io n to ch ild b ea ri ng w o m en a s b as ic , i na lie na b le r ig ht s. S ev e n r ig h ts a re d ra w n f ro m t h e c at e g o ri e s o f d is re sp e c t a n d a b u se id e n ti fie d b y re se a rc h e rs a n d r ig h ts a d vo c at e s in t h e cu rr e n t lit e ra tu re . B y d ra w in g o n r e le va n t ex tr a c ts f ro m e st a b lis h e d h u m a n r ig h ts in st ru m e n ts , th e C h a rt e r d e m o n st ra te s th e le g it im at e p la c e o f m at e rn a l h e a lt h r ig h ts w it h in t h e b ro a d e r c o n te x t o f h u m a n r ig h ts . be fR EE fr oM Ha rm AN D IL L tr ea tm e n t 1 4 ever y w o m a n h a s t h e r Ig h t to NO O NE C AN P HY SI CA LL Y AB US E YO U P r o m o t in g r e s P e C t f U l m A t e r n it y C A r e be t re at ed w it h dI GN IT YA ND RE SP EC T NO O NE C AN H UM IL IA TE OR V ER BA LL Y AB US E YO U e v e r y w o m a n h a s t h e r Ig h t to 2INF OR MA TIO N, iN fO RM Ed CO NS EN TA ND R Ef US AL , AN D r es pe ct FO R HE R c HO ic es AN D pr ef er en ce s, INC Lu DIN G CO M PA NI ON SH IP Du RIN G MA TE RN ITy C AR E e v e r y w o m a n h a s r Ig h t to NO O NE C AN f OR CE Y OU O R dO TH IN GS T O YO U W IT HO UT Y OU R KN OW LE dG E AN d CO NS EN T 3 P RI VA CY AN D co n fi d en ti al it y e v e r y w o m a n h a s t h e r Ig h t to NO O NE C AN E XP OS E YO U OR YO UR P ER SO NA L IN fO RM AT IO N Al l r ig ht s ar e gr ou nd ed in e st ab lis he d in te rn at io na l h um an ri gh ts in st ru m en ts , in cl ud in g th e Un iv er sa l D ec la ra tio n of H um an R ig ht s; th e Un iv er sa l D ec la ra tio n on B io et hi cs an d Hu m an R ig ht s; th e In te rn at io na l C ov en an t o n Ec on om ic , S oc ia l a nd C ul tu ra l R ig ht s; th e In te rn at io na l C ov en an t o n Ci vi l a nd P ol iti ca l R ig ht s; th e Co nv en tio n on th e El im in at io n of A ll Fo rm s of D is cr im in at io n Ag ai ns t W om en ; t he D ec la ra tio n of th e El im in at io n of V io le nc e Ag ai ns t W om en ; t he R ep or t o f t he O ffi ce o f t he U ni te d Na tio ns H ig h Co m m is si on er fo r H um an R ig ht s on p re ve nt ab le m at er na l m or ta lit y an d m or bi di ty a nd h um an ri gh ts ; a nd th e Un ite d Na tio ns Fo ur th W or ld C on fe re nc e on W om en , B ei jin g. N at io na l i ns tru m en ts a re a ls o re fe re nc ed if th ey m ak e sp ec ifi c m en tio n of c hi ld be ar in g w om en . 5 6 E q U AL IT Y, fr ee do M FR OM di sc ri Mi na tio n, AN D e qu ita bl e c ar e NO O NE C AN d IS CR IM IN AT E BE CA US E Of S OM ET HI NG T HE Y dO N OT L IK E AB OU T YO U e v e r y w o m a n h a s t h e r Ig h t to HE AL TH CA RE AN D TO th e h ig he st at ta in ab le le ve l OF H EA LT H NO O NE C AN P RE VE NT Y OU fR OM G ET TI NG T HE M AT ER NI TY C AR E YO U NE Ed 7LI BE RT Y, au to no My , se lf -d et er Mi na tio n, AN D f RE Ed OM fr o m c o er ci o n NO O NE C AN d ET AI N YO U OR Y OU R BA BY W IT HO UT L EG AL A UT HO RI TY e v e r y w o m a n h a s t h e r Ig h t to e v e r y w o m a n h a s t h e r Ig h t to Fo r m o re in fo rm at io n, v is it : w w w .w hi te ri b b o na lli an ce .o rg /r es p ec tf ul ca re shutterstock white ribbon alliance article i article ii article iii article iV article Viiarticle Vi article V 25 BEFORE YOU GET STARTED, REMEMBER: The Respectful Maternity Care Charter is meant to be used to talk about disrespect and abuse during maternity care in a positive, rights-based framework. It is very important to ensure that your efforts are raising awareness and generating demand in a way that avoids blaming and shaming—especially of health providers. No one stands to win when midwives and clinicians are demonized, and everyone must work together to address and correct these problems. Host an Event Get people talking about RMC by bringing them together at a special event. Get creative and think about how you can use the stories and quotations from Chapter 2 that describe the types of disrespect and abuse to explain RMC Rights. Consider doing any of the following: • Form a discussion group. Discussion groups can be as formal or informal as you would like them to be. Examples include a group of friends who meet weekly to share their thoughts and experiences or a one-time meeting of concerned citizens to discuss the importance of RMC. You can also use one of the RMC PowerPoint presentations. The presentations are aimed at three different audiences and address the issue from different perspectives: advocacy, human rights, and clinical. Click on the following links to access the presentation you want to use: • Advocacy (or go to http:// whiteribbonalliance.org/WRA/assets/File/ RMC PPT-Original.pptx) • Human Rights (or go to http:// whiteribbonalliance.org/WRA/assets/File/ Respectful-Maternity-CareRSFDT.pptx) • Clinical (or go to http://whiteribbonalliance.org/ WRA/assets/File/ WRA Respectful-Maternity-Care for HCW edits added 4-8-12.pptx) • Perform RMC-focused community theater. Live drama gives audiences a chance to experience real and hypothetical situations in a personal, non-threatening way. Many forms of theater engage the audience in the action. Post-show discussions will allow audience members talk about what happened in the performance and propose actions to solve problems. Performances can be held in any number of locations: open space beneath a tree, a market street, the back of a truck, or formal stages. • Write a song or hold a concert. Music is an integral part of every culture and inspires both singing and dancing. It also allows for message repetition, which can aid people’s recollection of specific information. Music easily attracts crowds and songs and dancing can draw people to events. Songs can reach an even larger audience and have a stronger impact when they are broadcast on the radio. • Host a film screening. Share the WRA’s film Break the Silence: Respectful Maternity Care, and hold a discussion afterward. Click here to view the film, or access it via YouTube: http://www.youtube. com/watch?v=K105F9o3HtU. You could also develop your own film. Don’t forget to invite the media to your event! The following tips will help you get media coverage of and participation in your event: 26 O pe nD em oc ra cy Plan ahead to engage the media in your event: • Request that media outlets announce your RMC event in their community calendars. • Contact reporters who cover community events and pitch your event as a future story. • Prepare a “news alert” or invitation that clearly states the theme, date, time, place, and other details. • Send or hand-deliver the invitations several days in advance. • Call key media outlets and contacts one or two days before the event to remind them about it. • Prepare a sufficient number media kits to distribute at the event. The day of the event: • Set up a media sign-in table with media kits to distribute. • Arrange interviews when reporters arrive and escort them to the appropriate spokesperson. • Issue name badges to promote better communication among the media, the event organizers, and participants. • Take photos to accompany articles and other publications. • Start the event on time. After the event: • Send an immediate news release to reporters who could not attend. • Send follow-up letters to newspaper editors, thanking the community and informing them of the event’s success. Refer to Chapter 6 on engaging the media for further information, tools, and tips. Use Social Media The internet can help create buzz and heighten people’s interest in and understanding of RMC. Start the conversation by creating a Facebook page, YouTube channel, or Twitter account about RMC. You can spread information through messages, pictures, videos, and tweets, and invite your colleagues and friends to join 27 the conversation. More ideas for you to consider are listed below: • Post or share the RMC Charter, Poster, and Brochure on your Facebook page or through your Twitter account. The internet can help create buzz and heighten people’s interest in and understanding of RMC. Start the conversation by creating a Facebook page, YouTube channel, or Twitter account about RMC. You can spread information through messages, pictures, videos, and tweets, and invite your colleagues and friends to join the conversation. More ideas for you to consider are listed below: • Post or share the RMC Charter, Poster, and Brochure on your Facebook page or through your Twitter account. Click on the links below to access these resources: • The Respectful Maternity Care Charter: The Universal Rights of Childbearing Women (or go to: http://www.whiteribbonalliance.org/ WRA/assets/File/Final_RMC_Charter.pdf) • Respectful Maternity Care Poster (or go to: http://www.whiteribbonalliance.org/WRA/ assets/File/RMC_POSTER_R3_WEB.pdf) • Respectful Maternity Care Brochure (or go to: http://www.whiteribbonalliance.org/WRA/ assets/File/RMC_BROC_FINr3_web2.pdf) • You can also download the Charter, Poster, and Brochure as a zip file in other languages. Click on the links for: English, French, Portuguese, Spanish, or Arabic; or go to http://whiteribbonalliance.org/index.cfm/the- issues/respectful-maternity-care/ for links to the files. • Post or share the RMC film, Break the Silence, on your Facebook page, YouTube channel, or through your Twitter account. Click here to access the film, or go to: http://www.youtube.com/ watch?v=K105F9o3HtU. • Change your Facebook profile picture or cover photo to one of the seven rights of childbearing women, and encourage or challenge your friends to do the same. You can download high-resolution cover photos here, or from the WRA website: http:// www.whiteribbonalliance.org/index.cfm/the-issues/ respectful-maternity-care/charter-articles-to- download-for-facebook/. • Visit any of the WRA’s social media sites for more inspiration, or to post a RMC message: • Facebook: http://www.facebook.com/ whiteribbonalliance • Twitter: https://twitter.com/wraglobal • YouTube: http://www.youtube.com/ whiteribbonalliance Conclusion Disrespect and abuse of childbearing women must stop. You have the power to raise public awareness of and generate civil society demand for RMC rights in your community. Remember, RMC is a sensitive issue, so keep your discussions positive and avoid blaming and shaming. Be creative—think of innovative ways you can involve and engage your community to learn more about RMC. When we speak out and demand respectful care, we make it safe for women everywhere to do so. If you want more information, have questions, or wish to share your story about raising awareness of and generating demand for RMC, contact the WRA at info@whiteribbonalliance.org with the subject line: ADVOCATING FOR RMC. For more information about RMC, click here to visit the WRA’s webpage or go to: http://whiteribbonalliance.org/index.cfm/the-issues/ respectful-maternity-care/. 28 Pr oj ek tH op e 29 How Can You Mobilize the Community to Hold Local Leaders and Service Providers Accountable for Respectful Maternity Care? One powerful approach to advocating for RMC is bringing together those who are directly affected by disrespect and abuse during childbirth, and have the most to gain by receiving RMC and exercising their right to RMC. The process of reaching out, influencing local leaders and service providers, and holding them accountable for RMC can be collaborative and build support for positive change rather than being adversarial. Mobilizing the community requires resources and planning, but can result in real change. You can hold a high-profile event, such as a rally, march, or demonstration on a special day (e.g., International Women’s Day), or use specific approaches like social watch techniques. Facilitated by civil society organizations (CSOs), social watch brings the community together to collect and present evidence of disrespect and abuse during childbirth, and asks citizens to share this evidence with local leaders and service providers. Evidence can be collected and shared in a number of ways. Whether it takes the form of personal stories and testimonies of RMC or disrespect and abuse, gathered numerical data, or the collective voice of the BEFORE YOU GET STARTED, REMEMBER: Discussing disrespectful care and abuse can be extremely upsetting for anyone who has experienced them. Always choose your words carefully when talking about this topic, especially during an event in a public space. If you meet someone who has experienced disrespect and abuse, here are some things you can say: “I’m sorry this happened to you.” “Thank you for telling me.” “Can I do anything for you?” “It wasn’t your fault.” 4 Things you should NEVER say to someone who experienced disrespect and abuse during childbirth include: “It was your fault.” “You could have avoided it had you ____________.” “It’s been so long since this happened, you need to get over it.” “It’s not that big of a deal; it happens to lots of people.” “I don’t believe you.” Adapted from Pandora’s Project (PandorasProject.org), Tips for Friends and Family of Rape & Sexual Abuse Survivors. Retrieved January 15, 2013, from http://www.pandys.org/articles/tipsforfriends.html. 30 ProjektH ope community demanding improvement, evidence about the health situation can significantly improve the quality of services women receive during childbirth. Before you get started using social accountability approaches and planning your events, consider who it is you want to reach and influence, why you want to influence them, and for what—what outcome you wish to achieve. Having a clear idea of your target audience, your message, and your goal will make your efforts to mobilize the community more straightforward and effective. Public hearings are designed to influence service providers, policymakers, the media, and women and their families to support and demand respectful maternity care policies and practices. During hearings, community members, elected government officials, members of the media, and NGO representatives stand up to call for action to improve RMC. These events can follow other high-profile events, such as rallies, in which community members show support for RMC. The objectives of these hearings are increasing women’s awareness of their RMC rights, encouraging them to share their stories, and demanding change from decisionmakers. Depending on your strategy, there are a number of reasons why you may want to hold a public hearing on RMC. You may wish to Hold a Public Hearing • open discussions about RMC; • communicate a sense of community concern about RMC; • increase community awareness of RMC; • attract media attention; • gather information/evidence; and • find out what the community knows about the issue and where people stand on RMC. Give yourself plenty of time to plan and publicize your public hearing. Review the following tips on what to do before, during, and after the event. BEFORE YOU GET STARTED, REMEMBER: Public hearings don’t cost a lot in terms of staff time and money, and they’re a great way to get the message out. However, it is best to limit the use of public hearings for times when you really want to attract attention or need to hear different viewpoints to help you decide what to do in an upcoming activity or campaign. Don’t hold these events too often because attendance will fall and the impact can be diluted. Plan carefully and deliberately because convening public hearings will convey your authority and credibility on the issue of RMC, but holding them too often may tarnish that image. 31 before the public hearing Step 1: Establish clear goals for the hearing What do you want to accomplish by holding this event? • Knowing your goals will help you choose the best possible people to testify and stay clear about why you’re doing this. Step 2: Find people to testify and thoroughly prepare them Who is in line with your goals and can speak to your message? • Gather a mix of expert opinions (service providers, clinic administrators, academics) and personal narratives (women who experienced disrespect and abuse during childbirth). • Include a cross-section of people who represent different ages, ethnic backgrounds, and socioeconomic statuses. • Work with your speakers to rehearse their testimony. When is a good time and what is an appropriate venue for this event? • Try to find a location that can accommodate an audience, but don’t pick a place that is too big. If the room is too large, any photos or videos from the event will give the impression that very few people attended. Step 3: Book a venue and set a date and time for the event Step 4: Choose a facilitator Who is an appropriate individual to handle the flow of the hearing? • The facilitator should be an impartial party who is not affiliated with the issue. His or her job is to introduce the speakers, guide the discussion, and make sure that all the participants are heard. Step 5: Publicize the event How can you spread the word so people are aware of and attend this event? • Send out a media release announcing the event. • Arrange for public service announcements about the hearing on local radio and television stations. • Put up flyers advertising the event. • If you have contacts in the media, ask them to cover the hearing. Step 6: Try to ensure a supportive audience Why should we try to have supporters attend the event? • For the people who are testifying, speaking publicly about disrespect and abuse during childbirth can be frightening, and friendly faces in the crowd can make it easier. The information on public hearings is adapted from Chapter 33, Section 13 of The Community Tool Box: Bringing Solutions to Light. Retrieved May 7, 2013, from http://ctb.ku.edu/en/tablecontents/sub_section_main_1257.aspx. 32 at the public hearing Step 1: Start with a brief introduction • The facilitator should take a few minutes at the beginning of the hearing to briefly describe the issue, the process that will be used to discuss the issue, and the goals of the discussion. • If only a few people are testifying, you can introduce them at the beginning. If many people will be speaking, it’s best to introduce them (or let them introduce themselves) just before they speak. • Setting a time limit for each person’s testimony can keep the hearing from being too lengthy. If you decide to do this, inform each speaker well in advance so they can prepare. Step 2: Allow each speaker the opportunity to offer their testimony Step 3: Take thorough notes • Assign someone to take notes ahead of time and ask them to record who testifies, what is said, how many people attend, what prominent or influential people are present, and whether representatives from relevant agencies or other groups are there. after the public hearing • If any of your speakers testify about personal experiences with disrespect and abuse during childbirth, consider how you can support them after their testimony (if they need it). You may want to arrange for a professional counselor to be present. Step 1: Offer support to testifiers Step 2: Engage with the news media • Following a public hearing, the news media will likely approach you for comments on the event. This is your opportunity to offer your perspective on the hearing and present the results in a way that portrays your side of the issue in the best possible light. • You should focus on things your side said that made a lot of impact. • While you should already have an idea of how things went before you talk to the press, in the days following the hearing you will have the time to sit down and evaluate how things went and where to go from there. • Did the people who were present seem to understand and support the issue? Did the press? Did the decisionmakers? Step 3: Get together with those involved to discuss the outcome 33 W hi te R ib bo n A lli an ce case example Letting Women’s Voices Be Heard— Public Hearings in Orissa State, India Since 2006, 30 public hearings have been organized by WRA–Orissa. With 500–1,300 women taking part in each event, this resulted in more than 30,000 women participating in hearings. Participants learned about their rights and had the opportunity to present their grievances directly to decisionmakers. They also presented information about local maternal deaths that was gathered using verbal autopsies. Local media covered the hearings, which generated excitement and debate in communities. Issues raised at the public hearings included the lack of adequate health providers, the need for improving the quality of care, irregularities in government-issued benefits to women and their families, and the need for improving the attitudes of reproductive and child health service providers. Key Results: During the hearings in the 30 districts in Orissa State, elected local government representatives were responsive to community members and asked questions on the concerns raised. As a result of the hearings, media outlets in the 30 districts had a continuous flow of news on maternal health problems and continued to report on maternal health issues long after the hearings ceased. Citizens in the area became more aware of the issues around safe motherhood. The service delivery system became more responsive and accountable, as demonstrated by the following actions: • The government of Orissa started a new process for the disbursement of payments through checks, rather than cash, to avoid the misappropriation of funds intended for pregnant women and to better enforce government policies. • The state health department gave instructions to ensure the presence of auxiliary nurse midwives at specified facilities. • The chief minister of Orissa declared that women’s self-help groups would be involved in the monitoring of maternal health programs. In some districts, female self-help group members were assigned the responsibility of forming a committee to track bribes taken by maternal healthcare providers. • In one district, authorities pledged to take action against doctors who were found to be demanding bribes for institutional deliveries. • Grievance cells were opened in six district hospitals. Adapted from the USAID | Health Policy Initiative’s Promoting Accountability for Safe Motherhood: The White Ribbon Alliance’s Social Watch Approach. Accessed on January 15, 2013, from http://www.healthpolicyinitiative.com/Publications/ Documents/1282_1_Social_Watch_WRA_HPI_FINAL_acc.pdf. BEFORE YOU GET STARTED, REMEMBER: Like all efforts toward promoting RMC, the CSC is NOT about finger-pointing or blaming, NOT designed to settle personal scores, and NOT supposed to create conflict. Use Community Score Cards The Community Score Card (CSC) is a two-way, ongoing participatory and interactive tool for assessing, planning, monitoring, and evaluating services. CARE Malawi developed the CSC in 2002 as part of a project aimed at developing innovative and sustainable models to improve health services. Since then, the CSC has become an internationally recognized participatory governance approach. The CSC is easy to use and can be adapted for RMC. It can bring together the demand side (childbearing women and their communities) and the supply side (service providers, such as midwives) to jointly analyze the issues that underlie disrespect and abuse, and find a common way to address them. It is an exciting way to increase participation, accountability, and transparency among service users, providers, and decisionmakers. The CSC is a participatory tool that • Is conducted at the local level and uses the community as the unit of analysis; • Generates information through focus group interactions and enables maximum participation of the community; • Provides immediate feedback to service providers and emphasizes immediate response and joint decision making; • Plans for reforms that are based on mutual dialogue between users and providers, and can be followed by joint monitoring. Positively influencing the quality, efficiency, and ac- countability with which services are provided and can be used to improve RMC are the goals of the CSC. The core implementation strategy uses dialogue in a par- ticipatory forum that engages both service users and service providers. The CSC is more than a tool for mobilizing community members to hold providers and decisionmakers accountable for RMC. The real value in using the CSC to improve RMC is that it creates a sustainable, equitable system for women, communities, service providers, and local governments to engage in a mutual process to identify RMC barriers and generate solutions. The groups work in partnership to track the effectiveness of the solutions in an ongoing process of quality improvement (CARE, 2011). An effective CSC implementation requires a skilled application of a combination of techniques: • Understanding the local administrative setting, including decentralized governance and management at this level; • Participatory facilitation skills to support the process; • A strong awareness-raising process to ensure maximum participation from the community and other local stakeholders; and • planning ahead of time. Social accountability approaches in advocacy have the potential to bring about major positive change in your community and country. They not only provide a platform for community members to have their voices heard, but also offer an opportunity to collect evidence (qualitative evidence like women’s and health workers’ stories and quantitative evidence from Community Score Cards) that can be used to influence decisionmakers to focus on and improve RMC. If you want more information, have questions, or wish to share your story about mobilizing the community to hold local leaders and service providers accountable for RMC please contact the WRA at info@whiteribbonalliance.org with the subject line: ADVOCATING FOR RMC. For more information about RMC, click here to visit the WRA’s webpage or go to: http://whiteribbonalliance.org/index.cfm/the-issues/ respectful-maternity-care/. Conclusion 34 The information on Community Score Cards was adapted from: CARE Malawi, 2013, “The Community Score Card (CSC): A generic guide for implementing CARE’s CSC process to improve quality of services.” CARE Inc., available from http://governance. care2share.wikispaces.net/Community+Score+Card+CoP (accessed May 31, 2013). community score card The CSC consists of five phases and is implemented through a series of interrelated activities that feed into each other. The table below outlines the main activities that fall under each phase. PHASE ACTIVITIES 35 1. Planning and Preparation This phase is the foundation of the CSC process. It includes operational planning components such as: identifying the service type and geographical target area; identifying the facilitators; getting buy-in from service providers, local leaders, and others; and building understanding, commitment, and trust among parties. During this phase, you will want to • Build the capacity of CSC implementers on the RMC Charter; • Introduce the RMC Charter to CSC stakeholders; and • Analyze any policies and available data related to RMC. 2. Conducting the Score Card with the Community Before creating the Score Card with the community, entitlements must be discussed and an input tracking matrix created (see page 37 for an input tracking matrix example). To create an RMC input tracking matrix, outline the Seven Universal Rights of Childbearing Women alongside stakeholders’ perceptions of actual RMC services. Once you have done so, you are ready to move forward. Community Score Card (see page 37 for a sample Score Card) • Conduct a community-level assessment of priority issues in one village—what are the barriers to delivery of RMC services? • Develop indicators for assessing priority issues • Complete the Score Card by scoring available services and providers against each indicator and giving reasons for the scores • Generate suggestions for improvement = Complete Community Score Card for the village Cluster consolidation meeting • Solicit feedback from the process • Consolidate the scores for each indicator to come up with a representative score for the entire village • Consolidate the community priority issues and suggestions for improvement = Complete (consolidated) Score Card for the cluster 3. Conducting the Score Card with Service Providers • Conduct a general assessment of RMC service provision—what are the barriers to delivery of high-quality health services? • Develop indicators for high-quality RMC health service provision • Complete the Score Card by scoring programs, policies, structures, pro- cesses, etc. against each indicator • Identify priority health issues • Generate suggestions for improvement 4. Interface Meeting and Action Planning Interface meeting • Include the community at large, community leaders, committee members, health center staff, district officials, and process facilitators • Invite communities and health center staff to present their findings from the Score Cards • Invite communities and health center staff to present identified priority health issues • Prioritize the issues together (in a negotiated way) Action planning • Develop a detailed action plan from the prioritized issues—an agreed/ negotiated action plan • Agree on responsibilities for activities in the action plan and set timeframes for the activities (appropriate people should take appropriate responsibility—community members, community leaders, health center staff, government staff, community committees, and process facilitators) 5. Action Plan Implementation, Monitoring and Evaluation • Execute the action plan • Monitor and evaluate actions • Repeat the cycle to ensure institutionalization For additional guidance on the CSC phases and steps, refer to: CARE Malawi, 2013, “The Community Score Card (CSC): A generic guide for implementing CARE’s CSC process to improve quality of services,” CARE Inc., 2013, available from http://governance. care2share.wikispaces.net/Community+Score+Card+CoP (accessed May 31, 2013); and CARE Tanzania (2010/2011), “The Community Score Card in Tanzania: Process, Successes, Challenges, Lessons Learned,“ available from http://familyplanning. care2share.wikispaces.net/file/view/Community+Score+Card+case+study.pdf (accessed January 15, 2013). There are three approaches for choosing Score Card indicators in Phases 2 and 3. First, ask the community what the barriers are to RMC, group the barriers into themes, and create indicators from major themes that emerge (this is the approach described in the table); second, develop indicators using the Seven Universal Rights of Childbearing Women; and third, combine the first two approaches. A majority of CARE’s CSC health programs use the participatory approach to ensure that the indicators are relevant to the stakeholders and to foster ownership. 36 sample input tracking matrix Indicator Input Entitlement Actual (community Remarks/Evidence (as specified by service perception, what is really mandate) happening in community, or at health center) Number of service 4 providers with certi- 2 qualified providers provider staff present fication or qualification for this level of care available Number of 100 per village/GVH 50 are employed on beneficiaries employed the project 37 sample score card Indicator Score (out of 100) Reasons for the Score 1.1 Punctuality of staff 40 They start work late, sometimes after 9 a.m. 1.2 Reception of patients 50 Some staff members receive patients politely, while others are rude to patients. 1.3 Attitude of health workers 30 Some of the health workers at times neglect patients and chatter around with their friends. 1.4 Observing official working hours and days 60 The Health Centre is open on all proper days, but the health workers sometimes do not observe working hours, especially after lunch. 1.5 Attention and listening to patients’ problems 70 Sometimes the medical assistant writes in the health passport and gives it back before one has finished explaining about the patients’ ailment. 1.6 Respect for patients’ privacy 80 There is a considerable amount of privacy, but patients are despised, especially at the maternity section, where some women are mocked. Sample Input Tracking Matrix and Sample Score Card adapted from CARE Malawi, 2013, “The Community Score Care (CSC): A generic guide for implementing CARE’s CSC process to improve quality of services” CARE Inc., pp. 12, 34. 38 C G IA R C lim at e 39 How Can You Secure Commitment at the National Level to Institutionalize Respectful Maternity Care as the Standard of Care? 5 Institutionalizing change is about promoting long-term policy changes at the village, district, and facility levels, through national and international policy influence. You can ensure decisionmakers’ commitment to RMC by influencing them to introduce policy changes and pressuring the government to hold them responsible and answerable to their constituents. It is essential that you sensitize leaders to the importance of RMC and women’s childbearing rights in addition to engaging leaders, such as members of Parliament, to push for policy changes that uphold RMC. Civil society must take a stand and work with elected representatives and local leaders. As advocates, we must not assume, but ensure, that leaders understand the reality for women in their constituencies. We must also clarify their critical role in ensuring that commitments to health and childbearing rights have a real impact in the communities where they are needed most. Bring the facts—and the promises—home to individuals within the political system, because change can happen when there is political will. As advocates, we can work with politicians. They can be mobilized if they are aware of RMC, and understand the steps they must take to correct disrespect and abuse in their regions. Where politicians are already engaged and leading the charge, you can celebrate their efforts and help them to spread their message. BEFORE YOU GET STARTED, REMEMBER: One of the key relationships to maintain as an advocate is with your government. Depending on the responsiveness of the national government and the political space allowed for citizen engagement, this relationship may be harmonious or characterized with suspicion and mistrust. Navigating all the different aspects of such a relationship can be tricky. The following are some general suggestions for maintaining balance, but you must adapt everything to your specific context: • Stay politically neutral by keeping the focus on RMC; • Understand how your government works and who the important players are; • Know the parameters and expectations of the relationship; • Present a clear message and proposed solutions; • Be prepared in meetings; • Understand that compromise is an important part of the process; • Maintain contact with your representative; • Be sure that your own accountability and transparency will pass public scrutiny; and • Have confidence when interacting with government representatives. 40 Develop a National Respectful Maternity Care–Focused Advocacy Strategy To secure a national-level commitment to institutionalizing RMC as the standard of care, you will need to develop an RMC-focused advocacy strategy. An important distinction when developing an advocacy strategy is the difference between strategy and tactics. Tactics are specific actions or activities—writing letters, meeting with decisionmakers, and issuing reports. This chapter includes many examples of tactics you may wish to use; Chapters 3 and 4 also provide examples and information on advocacy tactics. Strategy is an overall map that guides your advocacy effort toward clear objectives. It is an assessment of where you are, where you want to go, and how you can get there. The following tools and tips can help you map out your advocacy strategy. Set Your Advocacy Priorities The first thing to do is to select your priority—your issue for advocacy. RMC can be considered an issue, but it is not specific enough for this purpose. Take time to hone in on what you want to focus on and how you are going to do it. For example: What is the issue you want to focus on? • To determine your issue, begin by identifying the prob- lem you want to address. What are some of the barriers to solving this problem? • Barriers can be related to guidelines, policies, and laws. What change would help remove the barriers? • The answer to this question is your advocacy issue. Be as specific and concrete as possible. Ask yourself questions like: Should a new policy be created? Should a harmful policy be removed? Does an existing policy need to be revised? Does an existing policy need to be fully implemented? Assess the Political Environment The second thing to do is to assess the environment in which you are working and the key factors to consider before getting started. To do this, you need to collect the following information: • Current legal situation as it relates to advocacy activities and laws concerning RMC; • General public’s knowledge of and attitude toward your RMC-focused issue; • Policymakers’ knowledge of and attitude toward RMC; • Influential actors who have the potential to affect RMC policies (such as individuals, organizations, coalitions, policymakers, government offices, media sources, etc.); • Other organizations’ advocacy activities related to RMC; • Formal and informal channels for NGOs to access policymakers and/or participate in the policy-making process; • Types of information policymakers seek when forming or revising policies. This information will help you determine who you are trying to influence, what their interests are, who the other key actors are, and how to best exert your influence. Map Your Strategy Now you can develop your detailed advocacy strategy. Based on the issue you identified and your environment, you must answer the following questions: • What is your advocacy goal? • What specific objectives will contribute to the achievement of your goal? • Who do you want to partner or collaborate with? What are their contributions? • Who are the targets (policymakers, government agencies, etc.) you need to influence to achieve your goal? • What are the key upcoming events that may provide opportunities for mobilization and advocacy? • What is your approach to advocacy (e.g., direct or indirect)? • What specific activities will you carry out? When? How? With these questions in mind, use the template on the following pages to map out your RMC-focused advocacy strategy. BEFORE YOU GET STARTED, REMEMBER: Don’t be intimidated by strategy development— it will provide you with a purpose and direction. 41 RESPECTFUL MATERNITY CARE ADVOCACY STRATEGY MAPPING TOOL Issue, Goal, and Objectives What is your issue? Your issue should be specific and concrete. It should clearly reflect the change you want to achieve (i.e., the issue should be directly linked to your goal). respectful maternity care advocacy strategy mapping tool Your goal builds on your issue by adding who (e.g., person, institution, office) will make the change, how the change will be made (e.g., through a specific bill, guidance, regulation), and when it will be achieved (set an attainable goal with a realistic timeframe). What is your goal? What are your objectives? Your goal should be broken down into a few short-term objectives that will directly contribute to achieving your overall goal. They should be clear and focused, and should include: the change you want to see, who will make the change, and when it will be achieved. They should be limited in number (no more than three). Objective 1 Objective 2 Objective 3 Adapted from Pathfinder International’s Straight to the Point Series on Setting Advocacy Priorities (Watertown, MA: Pathfinder International, 2011), http://www.pathfinder.org/publications-tools/pdfs/Straight-to-the-Point-Setting-Advocacy-Priorities.pdf; Straight to the Point Series on Assessing the Political Environment for Advocacy (Watertown, MA: Pathfinder International, 2011), http://www.pathfinder.org/publications-tools/pdfs/Straight-to-the-Point-Assessing-the-Political-Environment-for-Advocacy.pdf; and Straight to the Point Series on Mapping an Advocacy Strategy (Watertown, MA: Pathfinder International, 2011), http://www. pathfinder.org/publications-tools/pdfs/Straight-to-the-Point-Mapping-an-Advocacy-Strategy.pdf. 42 RESPECTFUL MATERNITY CARE ADVOCACY STRATEGY MAPPING TOOL Partners and Alliances Targets Forming strong partnerships with other groups/organizations is essential to a successful strategy. You need to identify partners who will bring helpful, unique skills and contributions to your effort. Identify some potential partners and what they can contribute to your advocacy initiative. Include yourself and your resources on the list. Potential Partner Contributions (human resources; funding; political and media connections; advocacy, communications, technical expertise, etc.) Your primary targets are the people, groups, and offices that have the power to make the change you are advocating for. When you cannot influence your primary targets, choose secondary targets (a person or group you can influence, who can then, in turn, influence your primary target). The targets must be specific (such as a person, newspaper, department, or committee)—“the public” and “the government” are too general and, therefore, are not good targets. Identify some primary targets for each objective. Then fill in each target’s position on your issue based on two criteria: supportive/neutral/opposed, and informed/uninformed. Next, note who in your organization or among your partners has the connections needed to influence each primary target. If you do not have the connections you need to influence the primary target, choose a secondary target (who can influence the primary one). Primary Target Name Position on RMC Partner with Connections to Influence Target O BJ EC TI V E 1 What resources are still needed? 43 RESPECTFUL MATERNITY CARE ADVOCACY STRATEGY MAPPING TOOL Primary Target Name Position on RMC Partner with Connections to Influence Target O BJ EC TI V E 2 Primary Target Name Position on RMC Partner with Connections to Influence Target O BJ EC TI V E 3 Approaches There are different ways to approach advocacy. One way is a public approach, which generally means mobilizing broad support from the government and/or the public through highly visible activities. Compare this to a private approach, which involves working quietly with a few key partners to make changes behind the scenes. You might also want to consider direct versus indirect approaches. Direct approaches involve directly asking policymakers to take action. Indirect approaches involve influencing opinion through a third party such as the media, the public, or other actors. Which approaches do you want to take? • Public • Private • Direct • Indirect Timing What upcoming events, significant dates, or government decisions might be important mobilization and communication opportunities? 44 RESPECTFUL MATERNITY CARE ADVOCACY STRATEGY MAPPING TOOL Activities Your activities should be designed to help you achieve your individual objectives, moving you toward your goal. In this guide, you will find a number of different approaches and techniques to consider based on your goal and objectives. When deciding which activities to pursue, consider using a combination of options for each objective. Do not be afraid to use your imagination, but be selective. You cannot and should not do everything. Think about your expertise, capacity, what will have the greatest impact on your target, and your funds. When you have thought about these factors, fill out the chart to help you decide which activities will con- tribute to meeting your objectives. For each activity, determine the approximate timing. Timing will depend on each activity’s priority. Do not try to do everything at the same time. Identify the cost of the activity, the person/organization primarily responsible for leading it, and partners who will support them. Be as detailed as possible regarding your specific plans and tactics, including how they will reach your targets. Activity Lead Person or Organization Partner(s) O BJ EC TI V E 1 Timing Cost Activity Lead Person or Organization Partner(s) O BJ EC TI V E 2 Timing Cost Activity Lead Person or Organization Partner(s) O BJ EC TI V E 3 Timing Cost 45 Launch a National Campaign to Promote Respectful Maternity Care With your RMC-focused advocacy strategy in mind, you can begin developing and launching your national campaign to promote RMC. Campaigns have a lot of room for creativity and new approaches, but also need to be organized and well-designed before you jump into action. This section provides information on the necessary steps to move forward with campaign planning and implementation. The Campaigning Cycle will help you to develop a successful campaign and to become more strategic and efficient when designing and implementing your campaign. It is divided into three main phases that each take into account the stakeholders involved and decisions that need to be made. Phase 1: Define the Issue and Identify the Problem At this stage, you need to decide on the focus of your campaign. Ideally, representative members, board members, executive directors, and senior managers are involved in this decision, perhaps with some input from outside specialists. • Issue: In the first strategic decision, you must define the specific RMC issue on which you will focus the campaign. This decision needs to be based on care- ful analysis of both external and internal factors. • Problem: There are many aspects to any one RMC issue. To focus resources more strategically, you should select only one or two of the specific prob- lems you have identified that are related to RMC. the campaigning cycle The issue and problem to be addressed by the campaign are decided. The strategy is designed and implemented. The outcomes of the campaign are evaluated and its results are analyzed. Phase 1 Phase 2 Phase 3 Adapted from Developing a Campaign Strategy: Introduction by Rafael Barca. Accessed from IFEX, The Global Network for Free Expression, at http://www.ifex.org/campaigns/developing_campaign_strategy/ on January 15, 2013. Pr oj ek tH op e 46 Phase 2: Design and Implement the Strategy This stage covers the design and implementation of the campaign strategy, which includes setting the concrete objectives that you aim to achieve in the timeframe of your campaign. The below is an example of a national campaign strategy goal and objectives. This strategy was developed by the White Ribbon Alliance in Nigeria for a year-long campaign to advocate for RMC. In this phase, you also need to outline the activities, tools, and resources you will employ to achieve your objectives. • Strategy Design: Based on thorough internal and external analysis around the campaign problem, you need to define: the SMART (Specific, Measurable, Achievable, Relevant and Time-bound) objectives for the campaign; the plan of action that will deliver those objectives; and the monitoring, evaluation, and impact assessment methodologies. • Strategy Implementation: You will need to conduct the campaign action plans and periodically monitor progress made toward achieving your objectives. Based on the evaluation and impact analysis, you can respond with adjustments to your strategy. Phase 3: Identify Changes to the Issue and the Problem and Assess Impact As the campaign comes to an end, you will need to identify how the issue and problem have changed since your initiative got underway. Changes may be immediately visible—a new law was passed that meets your RMC campaigning objective—but the impact of this change may take time to become clear. • Identify Changes: You need to identify, analyze, and communicate the changes achieved and triggered by the campaign. • Assess Impacts: You will then assess the impact of the changes on the problem and the issue over time. Monitor, Document, and Report the Results It is important that, as the design of a campaign strategy is underway, the methodology for monitoring and evaluating is identified. Thus, at every step of the Campaigning Cycle and within the plan for each activity, you know what data will be collected and when opportunities will be built in for evaluation to ensure that the strategy is still on target. advocating for improved delivery of maternal and newborn health Campaign Goal Objective 1 The right of Nigerian women to Respectful Maternity Care is embedded at all levels of the maternal health system and reflected in a sense of entitlement among women. The Federal Ministry of Health, state ministries of health, state lawmakers, regulatory bodies, and health professional associations incorporate Respectful Maternity Care principles into practice. Objective 2 Health workers uphold the rights of pregnant and childbearing women and provide Respectful Maternity Care in Gombe and Cross Rivers states. Establishment of a government-backed social accountability mechanism in Gombe and Cross Rivers states. Objective 3 47 W hi te R ib bo n A lli an ce case example Launching a National Campaign at Tanzania’s White Ribbon Day Since 2006, WRATZ (White Ribbon Alliance– Tanzania) has used White Ribbon Day (held annually each spring) to launch an annual national campaign. The shortage of health workers in Tanzania is a major challenge in reducing maternal and newborn deaths, so the 2006 and 2008 campaigns focused on training and recruiting adequate numbers of qualified health workers and increasing facility deliveries. These campaigns were aimed at motivating community members to demand qualified health staff at their local facilities, holding government officials accountable to their staffing policies, and encouraging women to deliver their babies in health facilities. Key results: As a result of the 2006 and 2008 campaigns, the Ministry of Health and Social Welfare received permission to employ and deploy all graduates from health institutions. This reversed a hiring freeze that had been in effect since 1994. In 2007, the ministry employed 3,890 health workers and deployed them to areas with critical shortages. Results included a 33 percent increase in staffing levels and a 50 percent increase in facility deliveries in selected dispensaries (these health facilities were part of a 2005 staffing level survey conducted by WRATZ). After the launch of the 2008 campaign, community members in one village were empowered to demand that a clinical officer with midwifery skills be assigned to their dispensary. Six months later, when WRATZ checked on the progress of this demand, the appropriate officer had been assigned by the ministry and was working in the dispensary. Adapted from the WRA blog post, “Working with Politicians and Local Leaders to Improve Maternal Health.” Accessed January 15, 2013, from http://www.whiteribbonalliance.org/index.cfm/news-blogs/wra-blogs/ working-with-politicians-and- local-leaders-to-improve-maternal-health/. 48 Establishing the relevant data for collection should be undertaken during the strategy-building process. The monitoring and data collection could relate to the broad objectives of a campaign. This type of broad monitoring (e.g., around progress on outcomes or impacts) will indicate whether there has been progress in influencing the key decisionmakers. Rigorous monitoring and data collection could also be undertaken with respect to a specific activity. Once the relevant data are collected, they need to be evaluated to establish lessons learned and make any necessary changes to secure the success of a campaign. It is imperative that you develop clear indicators when you begin planning your campaign, so you are able to monitor and document your results. Without this information, you will not be able to gauge the impact of your efforts. The next sections of this chapter outline a number of activities and approaches you can consider implementing in your national RMC campaign. Hold a Meeting An effective way to influence your member of Parliament or another local leader is to speak with them face-to-face to inform them about the issue of RMC and encourage them to bring about positive change. Remember that they may not be aware of how critical RMC is to maternal health in their community and country, and you have the power to change this. Below are some tips to consider when reaching out to your leader and holding a personal meeting on RMC. Make an Appointment Officials may require that you request an appointment in writing. Some leaders might allow you to schedule a meeting over the phone or hold “walk-in” office hours, but requesting an appointment is the best way to reach out, as many representatives have very busy schedules. You may want to use the formal letter template below. [Your Address] [Date] The Honorable [full name] [title] [address] Dear [title and last name]: I am writing to request an appointment with you. I am a member of the [your group/organization, if any] in [your city], and I’m concerned about the rights of childbearing women and the respectful maternity care they receive. Respectful maternity care (RMC) is a universal human right due to every childbearing woman in every health system around the world. There are indications that disrespect and abuse of women seeking mater- nity care are becoming urgent problems, and there is a growing community of concern. In fact, evidence suggests that the fear of encountering disrespect and abuse in facility-based maternity care is a more powerful deterrent to seeking skilled care than commonly recognized barriers such as cost or distance. I realize that you are a very busy individual, but I would greatly appreciate the opportunity to meet with you. I can be reached at my home address [address], by phone at [phone number], or email at [email ad- dress]. During the week of [1–2 weeks before the visit] I will contact your office to confirm the appoint- ment. Thank you for your consideration, and I look forward to meeting with you. Sincerely, [Your Name] Adapted from Developing a Campaign Strategy: Monitoring and Evaluation by Rafael Barca. Accessed from IFEX, The Global Network for Free Expression, at http://www.ifex.org/campaigns/developing_campaign_strategy/index6.php on January 15, 2013. W hi te R ib bo n A lli an ce case example Working With Politicians to Improve Maternal Health Joseph Mbilinyi, who is a member of Parliament, a tireless campaigner for health equality, and a leading rap artist in Tanzania, told the WRA that he was shocked to learn that 26 women die every day in pregnancy or childbirth in his country. If members of Parliament are unaware of the commitments that their heads of state make in global forums,and the reality for pregnant women and mothers in their constituencies, then who will make it a priority to ensure that governments are upholding their commitments to maternal health? Local leaders are just as important to engage as politicians. When WRA members in Zambia held a meeting to discuss maternal health with Chief Mumena, he decided that no more women in his village would die from pregnancy complications, and that was that. Chief Mumena made provisions for every pregnant woman to receive dedicated healthcare, and not one woman in his village has died during pregnancy or childbirth since. What do your politicians and local leaders know about RMC? Adapted from the USAID | Health Policy Initiative’s Promoting Accountability for Safe Motherhood: The White Ribbon Alliance’s Social Watch Approach. Accessed on January 15, 2013, from http://www.healthpolicyinitiative.com/Publications/ Documents/1282_1_Social_Watch_WRA_HPI_FINAL_acc.pdf . 50 W hi te R ib bo n A lli an ce case example WRA Uganda Petitions for Change As an individual or as a group, sending letters, making appointments with leaders, and speaking to the media DOES make a vital difference in making change happen. In Uganda, WRA members in the Kabale district worked with the District Health Officer, local politicians, and the Ministry of Finance to increase the number of midwives by 30 percent. This was achieved by simply pushing the right people in the right direction at the right time—an informed petition CAN make all the difference. Kabale members sent a petition—informed by the District Health Officer—to their local politician requesting that health workers who had been employed be put on the payroll. The politician engaged with the Ministry of Finance and within one month of the petition, there were 30 percent more midwives on the payroll. Adapted from the WRA blog post, “Working with Politicians and Local Leaders to Improve Maternal Health.” Accessed on Jan- uary 15, 2013, from http://www.whiteribbonalliance.org/index.cfm/news-blogs/wra-blogs/working-with-politicians-and-lo- cal-leaders-to-improve-maternal-health/. 51 Prepare for the Meeting Once you have made the appointment, start your preparations. Be sure to research and learn more about the leader with whom you are meeting. For example, you will want to know what kinds of initiatives they are passionate about, what their voting record is on topics related to RMC and maternal health, and the scope of their authority and ability to implement change based on your requests. Your meeting will likely last between 15 and 45 minutes, so plan accordingly. Bring copies of the RMC Charter, Poster, Brochure, and any other material you think will be helpful. Make sure you have enough copies for additional staff members who may also be in attendance. At the Meeting On the day of the meeting, dress professionally and arrive at least 10 minutes before your scheduled appointment time. When you enter the meeting, introduce yourself to the leader and/or their staff members by explaining who you are and where you’re from. Start the conversation on a positive note, and if you’re aware of something the person has done recently (given a speech, voted on a law), try to mention it. Then, move the conversation to RMC and what you want to discuss. You should be ready to answer questions and provide details on all of your points. Keep the conversation professional, be polite and respectful, and conclude the meeting on a positive note. If the official is busy, you may meet with members of his or her staff, who may have more time and be better equipped to discuss the issue. These individuals will convey your message and any requests to the leader. After the Meeting After the appointment, send a thank you letter to the leader or staff members with whom you met. If they requested any additional information during the meeting, be sure to include it with your letter. It is important to follow up because you want to continue building the relationship with your leader and ensure their knowledge of and engagement in RMC issues. Petitions are a great way to inform people on the issue of RMC, demonstrate widespread community support for RMC, encourage change, or peacefully protest a policy related to RMC. A petition is a collection of signatures from people who support RMC. You can present your petition to decisionmakers who have the power to create the change you want. A petition by itself is not a useful tactic for securing a national-level commitment to institutionalize RMC as the standard of care—what you do once you have collected the signatures is most important. Use Petitions SEE ‘STARTING A PETITION’ ON PAGE 52 Facilitate Formation of a Parliamentary Group for Respectful Maternity Care As advocates, we can bring together members of Parliament who are interested and active in maternal health and rights to form a group to push for RMC issues. For example, for the Promotion of Midwifery as a Career in Tanzania project, WRA Tanzania led the establishment of the Parliamentarians Group for Safe Motherhood (PGSM) and increased PGSM members’ understanding of midwifery as a profession through meetings with midwives. Consequently, the PGSM agreed to advocate for midwives, developed an advocacy action plan, worked on drafting a safe motherhood bill (which is still in progress), and met with religious leaders to encourage their involvement in safe motherhood issues. You can be the catalyst in bringing members of Parliament together and encouraging them to push initiatives to improve RMC. RESPECTFUL MATERNITY CARE ADVOCACY STRATEGY MAPPING TOOL • Who is the petition aimed at? Make sure the target of your petition can take action on the change you want. • What are you asking for? Focus your petition to go beyond just expressing the need for RMC. Make requests or demands for a particular action to be taken by a specific date. starting a petition IDENTIFY YOUR TARGET Be clear about what it is you want done, who needs to do it, and by when. DO YOUR RESEARCH Be sure to look into and follow any rules, regulations, or protocols set out by the authorities regarding petitions. If you don’t follow these rules, your petition may be declared invalid. • How many signatures will you need? Find out the number of signatures necessary to submit your petition, and then aim to collect more (up to 50% more). • Who is considered eligible to sign the petition (must they be a certain age or a registered voter)? • Must all signatures be on certified petition sheets? • How should people’s names be signed (printed, by signature, or both)? • Should addresses be included? • What other information must be included by the signer, or by the submitter? • Are there limitations you must adhere to, or quotas you must meet (for example, signatures per district)? • When must the petitions be returned, and to whom? • What are the official next steps? WRITE YOUR PETITION Be clear and concise. • Describe the issue of RMC in one paragraph at the top of the petition. • At the end, frame your request in an active and understandable way, such as, “The people of [city] demand that [specific action you want to happen related to RMC].” Adapted from The Community Tool Box: Bringing Solutions to Light. “Chapter 33, Conducting a Direct Action Campaign; Section 9. Conducting a Petition Drive.” Retrieved May 7, 2013, from http://ctb.ku.edu/en/tablecontents/sub_section_ main_1251.aspx. 52 RESPECTFUL MATERNITY CARE ADVOCACY STRATEGY MAPPING TOOL GATHER SIGNATURES Be proactive in planning how you are going to collect the necessary number of signa- tures for your petition. Is an online petition a useful method to gather signatures? This depends on the exact rules and regula- tions you must follow in order to submit a legitimate petition. But if an online petition is allowable, it may have certain advantages—for example, it may be easier for the masses to access. After you have done your research and determined an online petition may be a good fit for you, go to any of these online resources for more information and to create your own online petition: Change.org (www.change.org); GoPetition (www.gopetition.com); Petition Online (www.petitiononline.com); Petition Spot (www.petitionspot. com). Is a paper and pen petition the best method to gather signatures, or a requirement based on who you will be submitting it to? If so, consider the following next steps: 1. Find and recruit enough petition carriers to collect signatures. You can figure out exactly how many you need by estimating a reasonable number of signatures each carrier could probably col- lect in your given timeframe, and divide the total number of signatures needed by that estimate. 2. Educate the carriers on the issue of RMC and the aim of the petition; and train them in both the petition rules and guidelines, and in how to collect signatures. A group meeting would be a good place to initially train, supplemented with specific written instructions. 3. Assign the carriers to locations. It is usually easier to collect signatures indoors rather than outdoors, so consider this in addition to any scheduled outdoor event where you may be able to utilize an already gathered crowd. 4. Inform the carriers of the protocol you would like them to use when collecting signatures. For example: • When approaching potential signers, ensure your petition carriers are dressed appropriate- ly, smile and make eye contact, are assertive and polite in their approach, and have sufficient knowledge of RMC and the aim of the petition so they can explain what the specific petition is intended to do and answer questions. The following is a basic script you could consider using: • “Excuse me, (sir or ma’am); I am collecting signatures to ____________. The petition will be presented (or sent) to __________________, and our goal is to _______________. Do you think you would be able to sign the petition?” 5. Have the petition carriers, or you yourself, number the pages on the petition and make photo- copies of them. Also, provide informational handouts, such as the RMC Charter or Brochure, for your petition signers to hand out to individuals who are interested in RMC. 6. Consider other ways you can collect the needed signatures—for example, you could involve the media in publicizing your petition drive or an event where you will be collecting signatures. You could combine your petition drive with other advocacy actions, such as a letter writing campaign. SUBMIT YOUR PETITION Be creative and make some noise! 53 • Present your petition in a dramatic manner. Call a press conference, create a news release, or hold some kind of demonstration or event in conjunction with the submission of your petition. • It is ideal to present your petition in person to your target with as many of the actual signers as possible. 54 Jo se ph H ill case example Legal Petition to Set National Standards 0n RMC Another approach to consider is one where you seek legal accountability. Partnering with legal aid organizations or other legal agencies to take individual women’s cases of disrespect and abuse to court gives you the opportunity to set national standards on the issue of RMC. For example, the Center for Reproductive Rights filed a case before the High Court of Kenya on behalf of two women who were illegally detained in Pumwani Maternity Hospital in Nairobi for their inability to provide full payment for maternal health services they received. In the petition to the constitutional division of the High Court of Kenya, the Center is holding the hospital—as well as the Attorney General, Minister for Local Government, City Council of Nairobi, and Minister for Medical Services— accountable for the ill treatment of the two women, including human rights violations under Kenya’s constitution and international law. The Center’s aim is to halt the practice of arbitrary and illegal detention of women and to ensure that the Kenyan government takes affirmative measures to prevent it from happening in the future, in accordance with its constitutional and human rights obligations. “Illegally detaining women in healthcare facilities because they are unable to pay their medical fees is an egregious violation of women’s fundamental rights to health and freedom,” said Nancy Northup, President and CEO of the Center for Reproductive Rights. “Very few formal channels exist to provide redress for the serious human rights violations taking place in both public and private hospitals throughout Kenya,” said Judith Okal, Acting Regional Director for Africa at the Center for Reproductive Rights. This is the first case of its kind before the High Court of Kenya. Adapted from the Center for Reproductive Rights,“Kenya Broadcasting Corporation: Center files case on unlawful detention,” December 7, 2012; accessed on May 13, 2013, from http://reproductiverights.org/en/press-room/kenya-broadcasting- corporation-center-files-case-on-unlawful-detention on May 13; and “In Pursuit of Justice,” December 7, 2012; accessed on May 13, 2013, from http://reproductiverights.org/en/feature/kenya-detention-center-Pumwani.working-with-politicians-and-local- leaders-to-improve-maternal-health/. 55 Childbirth can be a frightening experience for many women, but it should also be a joyous occasion and every woman should feel valued, respected, and appreciated by those who aid her in her journey of bringing new life into the world. To realize this goal, influencing decisionmakers to change policies and pressuring the government to hold politicians responsible and answerable to their constituents are the focal points of a national RMC campaign. You can mobilize and work with your elected representatives so they are aware of what is happening on the ground and have the opportunity to stop disrespect and abuse of women in pregnancy and childbirth. Launching a national campaign on RMC will take a lot of time, effort, and resources, but your campaign has the potential to create change and greatly benefit the health and well-being of many women. For additional information on the issues covered in this chapter, consult the following resources: Advocacy Tools and Skills • Citizens Information Board (Ireland). 2008. Advocacy Project Resource Pack: Supporting Advocacy Services to People with Disabilities by Community and Vol- untary Organisations. Dublin: Citizens Information Board. http://www.google.com/url?sa=t&rct=- j&q=&esrc=s&source=web&cd=1&ved=0C- C0QFjAA&url=http%3A%2F%2Fwww. citizensinformationboard.ie%2Fpublications%2Fso- cial%2Fdownloads%2FResourcePack.pln.Revised. Sep2008.rd.doc&ei=HnG4UbjdIfOo4AOliIHoAg- &usg=AFQjCNFilEx_AucIG2EUQRXhQquJo- 7MCMw&sig2=ldmOt8omKHfk6bMwiRpaUQ&b- vm=bv.47810305,d.dmg • de Toma, C. 2012. Advocacy Toolkit: Guidance on How to Advocate for a More Enabling Environment for Civil Society in Your Context. Brussels: Open Forum for CSO Development Effectiveness. http://cso-effec- tiveness.org/IMG/pdf/120110-of-advocacy_toolkit- en-web-2.pdf Conclusion • International HIV/AIDS Alliance. 2003. Advocacy in Action: A Toolkit to Support NGOs and CBOs Respond- ing to HIV/AIDS. Brighton, UK: International HIV/ AIDS Alliance. http://www.innonet.org/resources/ files/Alliance_-_Advocacy_in_Action.pdf • International Planned Parenthood Federation. 2010. Handbook for Advocacy Planning. New York: Inter- national Planned Parenthood Federation, Western Hemisphere Region. http://www.ippfwhr.org/sites/ default/files/Advocacy Planning web version.pdf • MacDonald, L. and R. Levine. 2008. Learning While Doing: A 12-step program for policy change. Washington, DC: Center for Global Development. http://www.cgdev.org/sites/default/files/15417_file_ PolicyChange.pdf • Networking for Policy Change: An Advocacy Train- ing Manual. 1999. Washington, DC: POLICY Project. http://www.policyproject.com/pubs/ AdvocacyManual.pdf • Networking for Policy Change: An Advocacy Training Manual, Maternal Health Supplement. 1999. Washington, DC: POLICY Project. http://www.policyproject.com/pubs/advocacy/ MaternalHealth/MH_FULL.pdf • Pact Cambodia. The Advocacy Expert Series. • Ayer, V. and C. Bunn. 2004. Advocacy Cam- paign Management: Module 1. Phnom Penh: Pact Cambodia. http://www.pactcambodia. org/Publications/Advocacy_Policy/Advoca- cy%20-%20Module%201%20-%20English.pdf • Bunn, C. and V. Ayer. 2004. Building Relation- ships with Government: Module 2. Phnom Penh: Pact Cambodia. http://www.pactcambodia. org/Publications/Advocacy_Policy/Advoca- cy%20-%20Module%202%20-%20English.pdf • Ayer, V., C. Bunn, and S. Gralton. 2004. Work- ing with the Media: Module 3. Phnom Penh: Pact Cambodia. http://www.pactcambodia. org/Publications/Advocacy_Policy/Advoca- cy%20-%20Module%203%20-%20English.pdf • Ayer, V. and C. Bunn. 2004. Building and Main- taining Coalitions: Module 4. Phnom Penh: Pact Cambodia. http://www.pactcambodia.org/ Publications/Advocacy_Policy/Advocacy%20 -%20Module%204%20-%20English.pdf 56 C ar l W el sb y case example Advocating for Safe Motherhood in Nepal The Safe Motherhood Network Federation of Nepal (SMNF) is currently advocating for the inclusion of the key points of the Respectful Maternity Care Charter as rights in the Ministry of Health and Population’s draft of the Safe Motherhood and Newborn Health Care Bill. SMNF’s strategy and approach include the following: Step 1. The executives and board members of SMNF are organizing one-to-one meetings with the Minister of Health and Population and other key ministry officials to orient them to RMC issues. Prior to the meetings, SMNF will develop Nepalese versions (language and context, including the international human rights instruments to which the government of Nepal has committed) of the RMC Brochure and Poster, and the Break the Silence film, which will be shared at the briefing with the officials. SMNF will also commission a brief report to document specific disrespectful maternity practices that occur in Nepal. Step 2. SMNF will take the lead in organizing consultative workshops with various members of Parliament, the Ministry of Health and Population’s Planning Division and Legal Officers, and the Director of the Family Health Division who is responsible for the bill within the ministry. Officials from the Ministries of Law and Justice; Home Affairs; Finance; Women, Children, and Social Welfare; as well as a representative from the Parliamentary Committee on Health and Social Welfare, will also be invited to these consultations. Step 3. The finalized bill will be shared at a national-level advocacy workshop with wider participation from stakeholders representing members of Parliament; officials of the ministries of law and justice, home affairs, and finance; the media; associations of medical professionals; legal experts; and other partner agencies. The workshop will aim to popularize the issues included in the Respectful Maternity Care Charter and get final feedback and support for the bill. Step 4. Two post-workshop consultations will review the key points and ensure that they are included in the bill before it is sent to Parliament. Step 5. A final press/media meeting will be organized to disseminate the final outcomes of the project. 57 • Kludt, M., V. Ayer, and C. Bunn. 2004. Advocacy Through Legal Services: Module 5. Phnom Penh: Pact Cambodia. http://www. pactcambodia.org/Publications/Advocacy_ Policy/Advocacy%20-%20Module%205%20 -%20English.pdf • Ayer, V., C. Vuthy, K. Sambaddh, S. Sambath, N. Sinthay 2006. Community Mobilization: Module 6. Phnom Penh: Pact Cambodia. http://www. pactcambodia.org/Publications/Advocacy_ Policy/Advocacy%20-%20Module%206%20 -%20ENGLISH.pdf • Russell, N. and M. Levitt-Dayal. 2003. Igniting Change! Accelerating Collective Action for Reproductive Health and Safe Motherhood. Washington, DC: Centre for Development and Population Activities (CEDPA). http://www.cedpa. org/content/publication/detail/711.html • Sprechmann, S. and E. Pelton. 2001. Advocacy Tools and Guidelines: Promoting policy change. Atlanta: Cooperative for Assistance and Relief Everywhere, Inc. (CARE). http://www.care.org/getinvolved/ advocacy/tools.asp • Work Group for Community Health and Development. 2013. The Community Toolbox. Lawrence, Kansas: University of Kansas. http://ctb. ku.edu Setting Goals and Objectives • Centre for Development and Population Activities (CEDPA). 2000. Social Mobilization for Reproductive Health: A Trainer’s Manual. Washington, DC: CEDPA. http://www.cedpa.org/content/publication/ detail/747.html • de Toma, C. 2012. Advocacy Toolkit: Guidance on how to advocate for a more enabling environment for civil society in your context. Brussels: Open Forum for CSO Development Effectiveness. http://cso- effectiveness.org/IMG/pdf/120110-of-advocacy_ toolkit-en-web-2.pdf Monitoring and Evaluation • Coffman, J. 2013. Monitoring and Evaluating Advo- cacy: Companion to the Advocacy Toolkit. New York: UNICEF. http://www.unicef.org/evaluation/files/ Advocacy_Toolkit_Companion.pdf • de Toma, C. 2012. Advocacy Toolkit: Guidance on how to advocate for a more enabling environment for civil society in your context. Brussels: Open Forum for CSO Development Effectiveness. http://cso- effectiveness.org/IMG/pdf/120110-of-advocacy_ toolkit-en-web-2.pdf • Networking for Policy Change: An Advocacy Training Manual, Maternal Health Supplement. 1999. Washington, DC: POLICY Project. http://www. policyproject.com/pubs/advocacy/MaternalHealth/ MH_FULL.pdf • Russell, N. and M. Levitt-Dayal. 2003. Igniting Change! Accelerating Collective Action for Reproductive Health and Safe Motherhood. Washington, DC: Centre for Development and Population Activities (CEDPA). http://www.cedpa. org/content/publication/detail/711.html • Sprechmann, S. and E. Pelton. 2001. Advocacy Tools and Guidelines: Promoting policy change. Atlanta: Cooperative for Assistance and Relief Everywhere, Inc. (CARE). http://www.care.org/getinvolved/ advocacy/tools.asp Working with Government • Bunn, C. and V. Ayer. 2004. Building Relationships with Government: Module 2 (The Advocacy Expert Series). Phnom Penh: Pact Cambodia. http://www. pactcambodia.org/Publications/Advocacy_Policy/ Advocacy%20-%20Module%202%20-%20English. pdf • Sprechmann, S. and E. Pelton. 2001. Advocacy Tools and Guidelines: Promoting policy change. Atlanta: Cooperative for Assistance and Relief Everywhere, Inc. (CARE). http://www.care.org/getinvolved/ advocacy/tools.asp If you want more information, have questions, or wish to share your story about securing national-level commitment to institutionalize RMC as the standard of care, contact the WRA at info@whiteribbonalliance. org with the subject line: ADVOCATING FOR RMC. For more information about RMC, click here to visit the WRA’s webpage or go to: http:// whiteribbonalliance.org/index.cfm/the-issues/ respectful-maternity-care/. 58 A m i V ita le , T he W or ld B an k 59 How Do You Engage the Media In Your Respectful Maternity Care Efforts? 6 Most people—politicians, service providers, men, and women—get much of their news and information from the popular press. Working with media partners can be an incredibly effective approach to advocating for RMC. No matter what you want to do in advocating for RMC, there will likely be a media component to it. If there isn’t, you should consider partnering or engaging with the media. You can develop a specific media strategy that addresses how and when you deliver your key messages and other information to the press. Your media strategy can: • Identify how you plan to involve news media before, during, and after your event, and which approaches you plan to use. • Outline standard operating procedures for interac- tions with the media. • Identify key messages to convey to different types of media. • Specify plans for monitoring media coverage. • Outline processes to respond to misinformation in media coverage. • Establish when to proactively seek news coverage. The following pages present standard approaches for sharing information through news media that you may want to consider using. BEFORE YOU GET STARTED, REMEMBER: Journalists and editors use a set of criteria to help them decide what is newsworthy— information, topics, or events that are interesting enough to report to the public. A subject is often considered newsworthy only if it meets at least two of the following criteria: • Timing: Is the story providing brand new information? Is it current? • Proximity: Is the story local? • Uniqueness: Is the information distinct or unusual? • Significance: Are many people affected? Does the information concern people personally? • Timeliness: Is the material being released at a conference or some other event? • Permanence: Is it timeless or enduring? • Prominence: Is the event or person well known? • Context: Does your story relate to bigger issues, such as national health priorities? • Human interest: Does the material inspire human interest, such as sympathy, or hope? This chapter has been adapted with permission from FHI 360’s Communications Handbook for Clinical Trials: Strategies, Tips, and Tools to Manage Controversy, Convey Your Message, and Disseminate Results. To access the tool in its entirety, go to: http://fhi360.org/resource/communications-handbook-clinical-trials-strategies-tips-and-tools-manage-controversy-convey. 60 Press Conference/Media Briefing PURPOSE • Announce the launch of a major new RMC pro- gram or event. • Draw attention to an urgent situation related to RMC. TIPS • Invite journalists from many different outlets, including community radio, print publications, internet sites, and television programs. • Identify key spokespersons available for inter- views, since many journalists will want to do follow-up interviews. • Refer to the section Host a Press Conference in this chapter for more tips and information. Press Kits PURPOSE • Provide short materials and background infor- mation for a story. The press release is the main document, which can be supplemented by fact sheets, Q&A’s, visual aids, reports, and more. TIPS • Prepare press kits for journalists whenever you do a press briefing or invite journalists to attend an event. Keep the information concise and easy to scan—for example, include the Respectful Ma- ternity Care Charter, RMC Brochure, and RMC Poster. You can also include individual women’s stories. • When possible, translate key materials into the local language. • Include contact information for spokespeople in case reporters have follow-up questions. Telephone Calls to Reporters or Editors TIPSPURPOSE • Alert reporters to a breaking RMC news story or other announcement. • Follow up on a press release or invitation to an up- coming RMC event. • Inform reporters or editors of errors and ask for a correction to be printed. • If possible, give reporters adequate notice. For ex- ample, do not wait until the day before a big event or announcement to contact journalists. • Do not assume that because you sent a press release the reporter has seen it or has had time to read it. • Always leave a telephone number where they can reach you, preferably both an office and mobile number. • Start by asking if they have time to talk. If they are on deadline and busy, ask when you can call back. 61 Media Release PURPOSE • Provide the key elements—What, Why, When, Where, and How—of a story. • Offer reporters a news hook, as well as compelling quotes, statistics, or concepts to help frame your RMC story. • Use to support or respond to an RMC announcement or situation. TIPS • You can distribute media releases many different ways depending on whether and how much media coverage you are seeking. Consider using a wire service if you want to make sure many media outlets see your statement, or opt to post it on your organization’s website if you are not actively seeking coverage. • A media release should be factual. Never overstate or oversell. • Always be sure to proofread your media release for grammatical mistakes or misspelled words. • Refer to Issue a Media Release in this chapter for more tips and information. Letters to the Editor PURPOSE • Reinforce the importance of a published story on RMC. • Present an alternative opinion to the one put for- ward by the person quoted in a story. • Point out and correct an important mistake. • Keep letters short, concise, fresh, and professional. Do not repeat and reinforce negative information. • When correcting an error, consider whether a telephone call would be more appropriate and effective or if both responses are necessary. TIPS Social Media PURPOSE • Reach out to new influencers and global stake- holders through online media tools and sites, including blogs. • Share information, especially on topics where you would like feedback or to engage in an online dialogue. • Provide short updates that do not require much detail or explanation. • Social media, such as Facebook and Twitter, make it easy for readers to share your RMC content with others in their networks. If your stakeholders are online, you may want to be as well. • Be aware of the risks involved and be careful to monitor any social media tools you use, as naysayers are just as likely to engage as supporters. • Refer to the Section on Utilize Social Media in Chapter 3 for more tips and information. TIPS 62 Opinion Pieces/Op-Ed Columns PURPOSE • Express a strong opinion about an RMC-related issue with local impact. These are typically written and signed by a prominent person or expert or by a group of organizations. TIPS • News editors are looking for op-ed pieces that say something new or provide a fresh perspective. Issue a Media Release A media release, also referred to as news or press release depending on your interpretation, is a “ready-to-print” story about an issue, event, or activity that you prepare and provide to the media. Topics for RMC-related news releases include • Special activities and events in support of RMC; • Personal stories of women who have received high-quality care and RMC; • Programs working to address RMC; • Profiles of outstanding maternal health caregivers, such as a midwives. See the next page for an example of a media release which was disseminated by the WRA in September 2012. BEFORE YOU GET STARTED, REMEMBER: When writing a media release, be sure to do the following: • Clearly state what is new and newsworthy in the first paragraph. • Cover what, why, when, where, and how at the beginning. • Clearly identify the source of the media release, including the name of the organization, the office address, contact person, and telephone numbers (home and work). • Specify the time or date of release or state “For Immediate Release.” • Use simple language. • Include usable quotes from key people. • Raise local issues which relate to RMC. • Keep it short—one or two pages is enough. • Deliver it on time for deadlines. • Call key media people to be sure they re- ceived the release and encourage them to do a story. • Keep records of who used the media release and who did not. • Save press clippings or recordings of programs. 63 media release MEDIA RELEASE: September 2012 White Ribbon Alliance at the UNGA: Collecting on the Promises The world has woken up to the scandal that a pregnant woman dies every 90 seconds. $70 billion was pledged for women’s and children’s health by global and national leaders at last year’s UNGA. The White Ribbon Alliance is now collecting on the promises… New York City, September, 2012 – White Ribbon Alliance activists from India, Nepal, and Tanzania will be at this year’s UNGA to raise the voices of women around the world and ensure world leaders gathering in New York for the UNGA don’t forget about the 800 women and 8,500 babies still dying every day from complications in pregnancy and childbirth. White Ribbon Alliance leaders in New York will be reporting back to their countries to ensure they are aware of commitments made to women and children’s health by world leaders, and that fellow citizens have the information they need to hold their own governments to account. On September 21, the White Ribbon Alliance is holding its annual “Wake Up Call; Women’s Breakfast for Maternal Health” UNGA event in New York, in collaboration with Urban Zen and Merck for Mothers. Hosted by Arianna Huffington, Donna Karan, and White Ribbon Alliance Global Patron Sarah Brown, the breakfast, now in its third year, will reveal what’s happening on the ground in countries, what’s working, and next steps for ensuring we stop this global tragedy. “A third fewer mothers are dying in pregnancy and childbirth today compared to twenty years ago. This is the best indicator of what the White Ribbon Alliance has always known—we can stop mothers dying. They can bring up their children, ensure they are fed, educated, and loved. Our message at the UNGA is that leaders need to deliver the $70 billion pledged now—to make pregnancy and childbirth a time of joy and hope for all women around the world,” said Sarah Brown, Global Patron of the White Ribbon Alliance. The White Ribbon Alliance, as a network of volunteer citizens, is bringing real and rapid change across Africa and Asia by holding governments accountable for the pledges made on the world stage, helping to release government funds, and ensuring these are spent properly so that thousands of lives can be saved. In India, where more women die in childbirth than in any other country, government policies are excellent— women are entitled to free maternity care, in theory. In some of the poorest areas of India, White Ribbon Alliance members have been using checklists to find out if medicines and services are provided as promised by the government. They found some dangerous gaps—such as lack of running water and electricity, no phone connections or ambulances, and drastic shortages of trained staff. When these shortfalls were made public and reported to officials, the changes were swift and dramatic: safe births have doubled, and 24/7 ambulance and nursing services have tripled. The following White Ribbon Alliance leaders will be in New York to speak about their work: Rose Mlay, leader of White Ribbon Alliance Tanzania; Dr. Aparajita Gogoi, leader of White Ribbon Alliance India; and Samjhana Phuyal, member of the White Ribbon Alliance in Nepal. 64 FILM: View the White Ribbon Alliance Citizen’s Voice Reports from the UNGA http://www.whiteribbonalliance. org/citizensvoice/. Reports from UNGA activity will be uploaded throughout the week. How you can help The White Ribbon Alliance needs funding to support members around the world who hold their governments accountable for the funds and actions they have promised to maternal health. Every dollar you donate will help us release the billions of dollars promised to stop women and babies dying in pregnancy and childbirth. Donate now at www.whiteribbonalliance.org/donate. More information: www.whiteribbonalliance.org Follow our activities at the UNGA on Twitter and Facebook Press Materials Available: • Case Studies & Spokespeople for India, Nepal and Tanzania—see separate document • WRA Citizens’ Voice film reports before and from the UNGA • Photography and footage from the breakfast • Infographics for the latest maternal health global trends • WRA spokespeople in NYC The White Ribbon Alliance Every day, 800 girls and women die needlessly in pregnancy and childbirth. Almost all of them are in the developing world. This has been going on for too long—yet together we can put an end to it. The White Ribbon Alliance is a global movement, with members uniting to push for change so that all women and newborns in every country have the lifesaving healthcare that is their right. We are making remarkable progress—but we still have a long way to go. Merck Today’s Merck is a global healthcare leader working to help the world be well. Merck is dedicated to improving maternal health through Merck for Mothers—a 10-year, half-billion-dollar initiative to create a world where no woman has to die from complications of pregnancy and childbirth. For more information, visit www.merck. com and connect on Twitter, Facebook, and YouTube. Press Enquiries: Jenny Rose, Press Officer, The White Ribbon Alliance Jrose@whiteribbonalliance.org /T: 00 44 (0) 7957 551 697 www.whiteribbonalliance.org Click here to join the WRA! 65 Host a Press Conference A press conference presents a special opportunity to disseminate your RMC message to multiple members of the media simultaneously and to showcase your stron- gest RMC leaders and spokespeople. You may want to host a press conference because • It is interactive and you can give more information than in a media release (e.g., you can answer ques- tions from the press, and emphasize certain points); • You can announce an important development and explain its significance and implications; • You can often generate the kind of notice or pub- licity—a spot on the news, for instance—that you’d otherwise have to pay a large amount for; and • When many media representatives are present, it makes your conference seem really newsworthy—the media presence itself adds to the importance. Remember that you must have something newsworthy to announce, release, or talk about at your press confer- ence. You don’t want to hold press conferences too often as they are special events. Some cases when a press conference might be a good idea include • When the event includes a prominent individual to whom the media should have access; • When you have significant announcements to make; • When there is an emergency or crisis centered on RMC; • When a number of groups are participating in an RMC-focused action and the show of support will emphasize that this action is news; and • When you want to react to an RMC-related event. Consider the following steps when planning and exe- cuting your RMC press conference. Define the Message BEFORE THE PRESS CONFERENCE Define your key RMC message. Your goal may be to introduce or shed more light on your issue, announce a new program or event, or react to a news story. What- ever the message, it should be summarized in three to five key points to the press. If a date, time, address, phone number, or other specific information is part of the message (for example, if the purpose of the press conference is to announce an upcoming event), make sure to state it more than once, and to display it promi- nently in your press kit. Schedule the Date and Time Determine a date and time for the press conference, and check that it doesn’t conflict with other press events or media deadlines. You can consult with the local media and the wire services to find out if your press conference conflicts with another. International Inform ation Program The information on hosting a press conference was adapted from The Community Tool Box: Bringing Solutions to Light. “Chapter 6, Promoting Interest in Community Issues”; and “Section 8. Arranging a Press Conference.” Accessed March 13, 2013 from http://ctb.ku.edu/en/tablecontents/sub_section_main_1066.aspx. 66 Here are some other tips for scheduling your press conference: • Tuesdays, Wednesdays, and Thursdays are the best days for press conferences, as they are considered slower news days. Try to hold your press conference on one of these days if possible. • The best time to schedule your press conference is be- tween 10:00 a.m. and 11:00 a.m., to ensure maximum coverage. If you schedule it later, you risk missing the afternoon paper or evening news. • Remember, you are competing with all the other news of the day, so don’t be worried if everyone you invited doesn’t show up. Pick the Site Try to choose a location for the press conference that is accessible by public transportation, has adequate parking, and is not too far away for reporters to travel. Also, pick a site that provides visual interest and relates to your RMC issue. Select and Train Your Participants You want your participants to be knowledgeable and articulate about the issue. They should be able to handle press questioning and scrutiny as well. People with high credibility may make effective spokespeople. Firsthand testimony from people in the community who are affect- ed by RMC can be extremely powerful and convincing. In addition to the press conference participants, you will need a moderator who is experienced with the press and the issue. He or she will be in charge of convening the press conference by introducing the issue and partici- pants. The moderator also answers questions or directs them to the appropriate participants. Contact the Media The first step in contacting the media is to create a comprehensive list of assignment editors at television stations, news directors at radio stations and major newspapers, and editors at weekly newspapers. You may also want to include wire services. The list should include reporters you have worked with before, your existing media contacts, and reporters who may have covered the issue in recent months. Prepare and send (via mail or email) a media advisory about one week before the press conference to inform the media about it. A press advisory is similar to a press or media release, but press advisories can provide back- ground information to your media contacts. The format is basically the same as that of a media release. Follow Up with the Media After you have mailed the press advisories, follow up with phone calls to the major media outlets. Allow three days for delivery of the press advisory, and then begin your telephone follow-ups (if people say they never got your press advisory, offer to email or fax one to them). Also, follow up a second time the morning of the press conference. Develop a Press Kit Your press kit should contain • A list of press conference participants; • A media release; • Background information about the issue (consider using the RMC Charter, Poster, and Brochure); • Short (less than a page) biographies of participants; and • Related news stories, if possible. Note: When assembling the kit, the media release goes in the right side of the folder, and the other information goes in the left side of the folder. Prepare the Room Prepare the room where you’re holding the press conference by • Checking the location of electrical outlets for microphones and lights; • Setting up a table that is long enough to seat all your spokespeople, with name cards; • Providing enough seating for reporters, and enough room for their supporting equipment (e.g., cameras, microphones); • Displaying visuals as a backdrop to your speaker’s table: charts, posters, etc.; • Having a sign-in sheet for attendance; • Providing a podium for the moderator, perhaps with your organization’s logo on it; and • Setting up a table with coffee, tea, water, and any other refreshments. 67 AT THE PRESS CONFERENCE 1. Welcome members of the press as they arrive. 2. Ask members of the press to sign in and list their affiliation, and give each of them a press kit. 3. Seat the participants behind the table, facing the reporters. 4. Check the sign-in sheet to see which media outlets are represented. You may also want to make personal contact with major media representatives before or after the press conference. 5. Start on time—no later than five minutes after the scheduled time. 6. Record or film the event for your own records, and for possible media use. 7. Have the moderator welcome the press and introduce the issue and the participants. 8. Ask participants to present for no more than three to five minutes, and to make three to five key points. 9. Allow the press to ask questions after the presentations are complete; the moderator should answer questions or direct them to the appropriate participants. 10. Conclude the conference after about 45 minutes. Thank the participants for presenting, and the media for attending. You may want to encourage the media to stay for further informal conversa- tion with the participants. To the extent that you are able, make personal contact with representatives of the major media outlets. If you can have a short, pleasant conversation and make a good impression, they’ll remember you when they need information or a story about your issue, and they’ll respond when you contact them. AFTER THE PRESS CONFERENCE By looking through your attendance register, you can determine which major media were not represented. Not everyone may attend, and your conference may be preempted by late breaking news. You may want to hand deliver a press release and press packet to those who did not attend, send a tape feed, or try to schedule an interview with a reporter and one of the press conference participants. You should review the press conference process with others who were involved. For example, ask them what went well, what could have been done better, and how you can improve the next press conference you hold. Produce a Public Service Announcement A public service announcement (PSA) is a short message that is produced on film, videotape, DVD, CD, audiotape, or as a computer file, and given to radio and television stations. Generally, a PSA is sent as a ready-to-air audio or video tape, although radio stations (especially com- munity or public stations) sometimes prefer a script that their announcers can read live on the air. PSAs can be done very simply with a single actor reading or perform- ing a message, or they can be more elaborate, featuring music, dramatic storylines, and sound or visual effects. Since radio and television stations often need short pieces to fill broadcast time between music, programs, and commercials, a PSA is an inexpensive way to reach a wide audience with your RMC message. To write a PSA, first decide upon and clarify the pur- pose of it. What is your goal—what do you want to accomplish by putting a PSA on the air? The following tips will help you decide how to focus your PSA: • Target your audience. What type of people are you hoping to reach? This will help you focus on your desired media outlets and PSA content. • Survey media outlets to determine which are best able to reach your audience. This means that you need to know what media outlets are available in your geo- graphic area. 68 • Prioritize your media outlets. You need to know which outlets your target audience is most likely to prefer. When you are ready to draft your PSA, remember: • Because you’ve only got a few seconds to reach your audience, the language should be simple and vivid. Take your time and make every word count. Make your message crystal clear. • The content of the writing should have the right “hooks” (words or phrases that grab attention) to attract your audience. • The PSA should request a specific action, such as calling a specific number to get more information. You want listeners to do something as a result of having heard the PSA. Be creative! But be very clear about the RMC issue you are relaying and what you are “asking” the listener to do. The following is an example of a live copy PSA script for radio: BEFORE YOU GET STARTED, REMEMBER: When writing a PSA script, be sure to do the following: • Time the PSA to run for 10 seconds (25 words) to 60 seconds (150 words) and submit it to stations in varying lengths. • Include the name and telephone num- bers of a contact person. • Include a release date (either “For Immediate Release” or “For Release: [date]”). • Include the heading “Public Service Announcement.” • Include the title and length of the PSA. • Format the typed script to be double or triple-spaced, using short para- graphs (it should only cover one side of a piece of paper). Use: IMMEDIATE Time: 20 seconds Agency: The White Ribbon Alliance Title: “The Right to Respectful Maternity Care” Main Point: All women deserve respectful and dignified care during pregnancy and child- birth. Unfortunately, disrespect and abuse of women seeking maternity care is becoming an urgent problem. This is a violation of women’s basic human rights. Join us. As we speak out and demand respectful care, we make it safe for women everywhere to do so too. The information on public service announcements was adapted from The Community Tool Box: Bringing Solutions to Light. “Chapter 6, Promoting Interest in Community Issues; Section 7. Preparing Public Service Announcements.” Accessed March 13, 2013, from http://ctb.ku.edu/en/tablecontents/sub_section_main_1065.aspx. 69 W hi te R ib bo n A lli an ce case examples What I Want is Simple—Improving the Public Perception of Midwives in Tanzania What I Want is Simple is a short film produced by the White Ribbon Alliance in collaboration with the Health Policy Project to improve the public perception of midwives in Tanzania. The film also aims to mobi- lize support for advocacy activities targeting improve- ments in the working conditions of midwives while directly addressing sensitive respectful maternity care issues. It has been broadcast on both radio and tele- vision. To watch the film, click here or go to: http:// www.youtube.com/watch?v=OMzhj9O3rFU&list=- FLuotZ_gy7TTUD7oy0Br3JKA&index=3. Hosting Media Sensitization Workshops in India In 2008 and 2009, 462 media representatives participated in 32 District Media Sensitization workshops held by White Ribbon Alliance–India (WRAI) as part of its national advocacy initiative. These representatives were given information about safe motherhood in general and the situation for mothers in India. Fourteen workshop participants were taken on field visits, where they could see firsthand what women were experiencing. Key results: As a result of the sensitization workshops and further engaging the media in the Adapted from USAID | Health Policy Initiative’s Promoting Accountability for Safe Motherhood: The White Ribbon Alliance’s Social Watch Approach. Accessed on January 15, 2013, from http://www.healthpolicyinitiative.com/Publications/ Documents/1282_1_Social_Watch_WRA_HPI_FINAL_acc.pdf. WRAI campaigns, overall media coverage increased, as did the accuracy and relevance of information reported. A 2009 media analysis showed that news reports discussed the need for greater government accountability and strategic interventions. Published stories were also increasingly focused on individual women’s experiences, significant cultural issues (such as early marriage), important health factors for women and children (such as nutrition), and a woman’s right to high-quality healthcare. 70 Hold a Media Sensitization Workshop Treating the media as partners in your work can be very effective in helping you reach your advocacy goal and objectives. For example, on World Population Day in 2012, the White Ribbon Alliance in Rwanda and the country’s leading newspaper, The New Times, teamed up to mark the occasion of the world population reaching seven billion by highlighting family planning in the paper’s weekly magazine. The publication featured interviews with experts as well as articles examining religion and family planning, women’s empowerment, and the environmental and economic challenges of population growth. Achieving such media coverage requires developing and maintaining relationships and partnerships with media outlets, which takes time and effort. One way to initiate a relationship is holding a media sensitization workshop—which is exactly what WRA Rwanda did—to support and encourage media outlets to inform the public about the benefits of respectful maternal care. Consider bringing media representatives together at a formal workshop where you have the opportunity to discuss RMC, your goals and objectives, and the crucial role of the media. Emphasize how much each party has to gain from working together. Journalism contests are a great way to incentivize and obtain media coverage of your RMC issue. Consider organizing and hosting a journalism competition to • Investigate the issue of RMC in your community or country; • Reinforce the importance of the role journalists play in promoting RMC; • Reward, recognize, and encourage journalistic talent across various media. You will need to develop a set of eligibility criteria for your competition. For example, you may decide that the journalists must be working in your country for country-owned, or headquartered, media Host a Journalism Contest organizations, and their work must have appeared in printed publications or electronic media that are targeted at a particular audience. If you can recruit high-profile or well-respected individuals to serve as judges, your competition will attract public attention and the interest of high-quality journalists. Create a competition entry form that includes a list of qualities your judges will be looking for in the submissions. You can ask that stories • Are told in a balanced, comprehensive, and objective manner that avoids blaming and shaming healthcare providers; • Demonstrate journalistic integrity and resourcefulness, and follow the standards of informed consent, protecting and respecting the privacy of individuals interviewed; • Communicate in a way that makes RMC accessible and relevant to the audience; • Display well-organized research and insight; and • Were broadcast or published in a particular language during a particular period of time, and that proof is supplied. Be sure to include the deadline and instructions for submission. The prizes the winner (or winners) will receive should be communicated on the entry form as well. Be creative and consider working with appropriate sponsors to offer a desirable prize. When you have received all of the entries, consider other ways you can use the collected articles. Investigative journalism can be very persuasive in convincing decisionmakers to take action. Conclusion Engaging the media in your RMC efforts can be critical to your success. Media coverage is one of the best ways to publicize community events and gain the attention of decisionmakers. Reaching out to the popular press to cover your activities or partner with you in other ways can positively and significantly impact your efforts. Some final tips to consider when dealing with the media include: • Do things differently and have a good story so journalists will publish your exciting news items. 71 • Develop and cultivate your network of media contacts. Sometimes getting media coverage is based on who you know. • Do not be surprised if journalists or newspapers expect to be paid for attending your press conference or publishing an article. While this expectation and provision of payment is considered unethical in some countries, it is regular practice in others and may be a practical necessity. • Beware of the possibility that press coverage of your RMC issue may be negative or distorted. You must be ready to state your message clearly and positively, and clear up any myths or misinformation. If you would like additional information on involving the media in your advocacy efforts, consult the following resources: Media & Communications • Ayer, V., C. Bunn, and S. Gralton. 2004. Working with the Media: Module 3 (The Advocacy Expert Series). Phnom Penh: Pact Cambodia. http://www. pactcambodia.org/Publications/Advocacy_Policy/ Advocacy%20-%20Module%203%20-%20English. pdf • Centre for Development and Population Activities (CEDPA). 2000. Social Mobilization for Reproductive Health: A Trainer’s Manual. Washington, DC: CEDPA. http://www.cedpa.org/content/publication/ detail/747.html • de Toma, C. 2012. Advocacy Toolkit: Guidance on how to advocate for a more enabling environment for civil society in your context. Brussels: Open Forum for CSO Development Effectiveness. http://cso- effectiveness.org/IMG/pdf/120110-of-advocacy_ toolkit-en-web-2.pdf • Gilbreath Holdar, Gina and Olha Zakharchenko. 2002. Citizen Participation Handbook: People’s Voice Project. International Centre for Policy Studies. Kyiv: “iMedia” Ltd. http://siteresources.worldbank.org/ INTBELARUS/Resources/eng.pdf • Health Communication Unit at the Centre for Health Promotion, University of Toronto. 2000. Media Advocacy Workbook. Toronto: University of Toronto. http://www.thcu.ca/infoandresources/publications/ ma%20workbook%20v104.pdf • Networking for Policy Change: An Advocacy Training Manual, Maternal Health Supplement. 1999. Washington, DC: POLICY Project. http://www. policyproject.com/pubs/advocacy/MaternalHealth/ MH_FULL.pdf • Robinson, Elizabeth T., Deborah Baron, Lori L. Heise, Jill Moffett, and Sarah V. Harlan. 2010. Communications Handbook for Clinical Trials: Strategies, tips, and tools to manage controversy, convey your message, and disseminate results. Research Triangle Park, North Carolina: FHI 360. http://fhi360.org/resource/communications- handbook-clinical-trials-strategies-tips-and-tools- manage-controversy-convey • Sprechmann, S. and E. Pelton. 2001. Advocacy Tools and Guidelines: Promoting policy change. Atlanta: Cooperative for Assistance and Relief Everywhere, Inc. (CARE). http://www.care.org/getinvolved/ advocacy/tools.asp • Work Group for Community Health and Development. 2013. The Community Toolbox. Lawrence, Kansas: University of Kansas. http://ctb. ku.edu If you want more information, have questions, or wish to share your experience of engaging the media in your RMC efforts, contact the WRA at info@whiteribbonalliance. org with the subject line: ADVOCATING FOR RMC. For more information about RMC, click here to visit the WRA’s webpage or go to: http://whiteribbonalliance.org/ index.cfm/the-issues/respectful-maternity-care/. 72 73 References • Amnesty International. 2010. Deadly Delivery: The maternal health care crisis in the USA. London: Amnesty International Publications. • Amnesty International. 2009. Giving Life, Risking Death: Maternal mortality in Burkina Faso. London: Amnesty International Publications. • Bowser, D. and K. Hill. 2010. Exploring Evidence for Disrespect and Abuse in Facility-Based Childbirth: Report of a Landscape Analysis. Bethesda, MD: USAID-TRAction Project and Harvard School of Public Health. Accessed June 12, 2013, from http:// www.tractionproject.org/sites/default/files/upload/ RFA/Respectful%20Care%20at%20Birth%209-20- 101%20Final.pdf. • Bradby, B. 1998. “Like a video: The sexualisation of childbirth in Bolivia.” Reproductive Health Matters 6: 50–56. • CARE. 2011. “Towards Better Governance: A Governance Programming Framework for CARE.” Retrieved May 31, 2013 from http://governance. care2share.wikispaces.net/GPF. • Center for Reproductive Rights and Federation of Women Lawyers–Kenya (FIDA). 2007. Failure to Deliver: Violations of women’s human rights in Kenyan health facilities. New York: Center for Reproductive Rights. • CLADEM (Latin American and Caribbean Committee for the Defense of Women’s Rights)/ CRLP (Legal Center for Reproductive Rights and Public Policies). 1998. Silencio y complicidad: violência contra las mujeres en los servicios publicos en el Perú. Lima, Peru. • d’Ambruoso, L., M. Abbey, and J. Hussein. 2005. “Please understand when I cry out in pain: women’s accounts of maternity services during labour and delivery in Ghana.” BMC Public Health. 5: 140–11. • d’Oliveira, A. F. Pires Lucas, S. G. Diniz, and L. B. Schraiber. 2002. “Violence against women in health- care institutions: An emerging problem.” The Lancet 359(9318): 1681–1685. • Human Rights Watch. 2006. “A High Price to Pay: Detention of patients in Burundian hospitals.” Vol. 18, no. 8A. Accessed June 12, 2013, from http://www.hrw.org/sites/default/files/reports/ burundi0906webwcover_1.pdf. • International Confederation of Midwives (ICM). 2010. Essential Competencies for Basic Midwifery Pratice. The Hague: ICM. • IRIN News Service. 2005. “Ghana: Despite new health scheme, newborn babies are detained in hospital pending payment.” Accessed June 12, 2013, from http://www.irinnews.org/Report/56380/ GHANA-Despite-new-health-scheme-newborn- babies-detained-in-hospital-pending-payment. • Kruk, M. E., et al. 2009. “Bypassing primary care facilities for childbirth: a population-based study in rural Tanzania.” Health Policy and Planning. 24(4): 279–288. • Miller, S., A. Tejada, P. Murgueytio, et al. 2002. Strategic Assessment of Reproductive Health in the Dominican Republic. New York: Population Council. • Ministerio de Salud Publica del Ecuador. 2007. Manual para Humanizacion y Adecuacion Cultural de la Atencion del Parto. • Yakong, V. N., K. L. Rush, J. Bassett-Smith, J. L. Bottorff, and C. Robinson. 2010. “Women’s experiences of seeking reproductive health care in rural Ghana: Challenges for maternal health service utilization.” Journal of Advanced Nursing. 66(11): 2431–2441. 74 Appendix Appendix Respectful Maternity Care PowerPoint Presentations RMC PowerPoint presentations have been developed for your use. The presentations are aimed at three different audiences and address the issue from different perspectives: advocacy, human rights, and clinical. Click on the following links for the presentation you want to use: • Advocacy (or go to http://whiteribbonalliance.org/ WRA/assets/File/RMC%20PPT-Original.pptx) • Human Rights (or go to http://whiteribbonalliance. org/WRA/assets/File/Respectful-Maternity-CareRSF- DT.pptx) • Clinical (or go to http://whiteribbonalliance.org/ WRA/assets/File/WRA%20Respectful-Materni- ty-Care%20for%20HCW%20edits%20added%204-8- 12.pptx) Break the Silence: Respectful Maternity Care Film Click here to access the WRA’s film Break the Silence: Respectful Maternity Care, or go to the YouTube link: http://www.youtube.com/watch?v=K105F9o3HtU. The Appendix contains materials developed by the White Ribbon Alliance that may be very helpful to your advocacy efforts for RMC. Please photocopy or print any of the following documents and use them to promote Respectful Maternity Care. • RMC Charter • RMC Brochure • RMC Poster     1              The Distinctive Importance of the Childbearing Period In every country and community worldwide, pregnancy and childbirth are momentous events in the lives of  women and families and represent a time of intense vulnerability. The concept of “safe motherhood” is usually  restricted to physical safety, but childbearing is also an important rite of passage, with deep personal and cultural  significance for a woman and her family. Because motherhood is specific to women, issues of gender equity and  gender violence are also at the core of maternity care. Thus, the notion of safe motherhood must be expanded  beyond the prevention of morbidity or mortality to encompass respect for women’s basic human rights, including  respect for women’s autonomy, dignity, feelings, choices, and preferences, including companionship during  maternity care.    By design, this document focuses specifically on the interpersonal aspects of care received by women seeking  maternity services. A woman’s relationship with maternity care providers and the maternity care system during  pregnancy and childbirth is vitally important. Not only are these encounters the vehicle for essential and  potentially lifesaving health services, women’s experiences with caregivers at this time have the impact to  empower and comfort or to inflict lasting damage and emotional trauma, adding to or detracting from women’s  confidence and self‐esteem. Either way, women’s memories of their childbearing experiences stay with them for a  lifetime and are often shared with other women, contributing to a climate of confidence or doubt around  childbearing.    Growing Evidence of Disrespect and Abuse Imagine the personal treatment you would expect from a maternity care provider entrusted to help you or a  woman you love give birth. Naturally, we envision a relationship characterized by caring, empathy, support, trust,  confidence, and empowerment, as well as gentle, respectful, and effective communication to enable informed  decision making. Unfortunately, too many women experience care that does not match this image. A growing  body of research evidence, experience, and case reports collected in maternity care systems from the wealthiest  to poorest nations worldwide paints a different and disturbing picture. In fact, disrespect and abuse of women  seeking maternity care is becoming an urgent problem and creating a growing community of concern that spans  the domains of healthcare research, quality, and education; human rights; and civil rights advocacy.      In 2010, a landscape report by Bowser and Hill, Exploring Evidence for Disrespect and Abuse in Facility‐based  Childbirth, summarized the available knowledge and evidence on this topic.i While the review revealed a relative  lack of formal research on the topic, the authors’ in‐depth search of published and technical literature as well as  interviews and discussions with content experts described seven major categories of disrespect and abuse that  childbearing women encounter during maternity care. These categories overlap and occur along a continuum  from subtle disrespect and humiliation to overt violence; they include physical abuse, non‐consented clinical care,  non‐confidential care, non‐dignified care (including verbal abuse), discrimination based on specific patient  attributes, abandonment or denial of care, and detention in facilities.    Interpersonal care that is disrespectful and abusive in nature to women before, during, and after birth is appalling  because of the high value societies attach to motherhood and because we know the intense vulnerability of  women during this time. All childbearing women need and deserve respectful care and protection of their  autonomy and right to self‐determination; this includes special care to protect the mother‐baby pair as well as  women in a context of marginalization or heightened vulnerability (e.g., adolescents, ethnic minorities, and    RESPECTFUL MATERNITY CARE: THE UNIVERSAL RIGHTS OF CHILDBEARING WOMEN      2    women living with physical or mental disabilities or HIV). Furthermore, disrespect and abuse during maternity  care are a violation of women’s basic human rights.      Assertion of the Universal Rights of Childbearing Women Human rights are fundamental entitlements due to all people, recognized by societies and governments and  enshrined in international declarations and conventions. To date, no universal charter or instrument specifically  delineates how human rights are implicated in the childbearing process or affirms their application to childbearing  women as basic, inalienable human rights. This Charter aims to address the issue of disrespect and abuse among  women seeking maternity care and provide a platform for improvement by   Raising awareness of childbearing women’s inclusion in the guarantees of human rights recognized in  internationally adopted United Nations and other multinational declarations, conventions, and covenants;   Highlighting the connection between human rights language and key program issues relevant to  maternity care;   Increasing the capacity of maternal health advocates to participate in human rights processes;    Aligning childbearing women’s sense of entitlement to high‐quality maternity care with international  human rights community standards; and    Providing a basis for holding the maternal care system and communities accountable to these rights.     By drawing on relevant extracts from established human rights instruments, the Charter demonstrates the  legitimate place of maternal health rights within the broader context of human rights. Seven rights are included,  drawn from the categories of disrespect and abuse identified by Bowser and Hill (2010) in their landscape analysis  (see table). All these rights are grounded in international or multinational human rights instruments, including the  Universal Declaration of Human Rights; the Universal Declaration on Bioethics and Human Rights; the  International Covenant on Economic, Social and Cultural Rights; the International Covenant on Civil and Political  Rights; the Convention on the Elimination of All Forms of Discrimination Against Women; the Declaration of the  Elimination of Violence Against Women; the Report of the Office of the United Nations High Commissioner for  Human Rights on preventable maternal mortality and morbidity and human rights; and the United Nations Fourth  World Conference on Women, Beijing. National instruments are also referenced if they make specific mention of  childbearing women. Each right is sourced to the relevant instruments.ii    Tackling Disrespect and Abuse: Seven Rights of Childbearing Women Category of Disrespect and Abuse i Corresponding Right 1.  Physical abuse  Freedom from harm and ill treatment  2.  Non‐consented care  Right to information, informed consent and refusal,  and respect for choices and preferences, including  companionship during maternity care  3.  Non‐confidential care  Confidentiality, privacy  4.  Non‐dignified care (including verbal abuse)  Dignity, respect  5.  Discrimination based on specific attributes  Equality, freedom from discrimination, equitable care  6.  Abandonment or denial of care  Right to timely healthcare and to the highest  attainable level of health  7.  Detention in facilities  Liberty, autonomy, self‐determination, and freedom  from coercion      3    In seeking and receiving maternity care before, during, and after childbirth:     ARTICLE I: Every woman has the right to be free from harm and ill treatment International Standards  Declaration of the Elimination of Violence Against Women, 1994, Article 1   International Covenant on Civil and Political Rights (ICCPR), 1966, Article 7   International MotherBaby Childbirth Initiative: A Human Rights Approach to Optimal Maternity Care, 2010,  Article 9   International Planned Parenthood Federation Charter on Sexual and Reproductive Rights,  1996, Article 12   Universal Declaration on Bioethics and Human Rights, 1997, Article 4  Multinational and National Standards  European Charter of Patient’s Rights, 2002, Article 9   Ley Orgánica sobre el Derecho de las Mujeres a una Vida Libre de Violencia de Venezuela, 2007, Article 15j      ARTICLE II: Every woman has the right to information, informed consent and refusal, and respect for her choices and preferences, including companionship during maternity care International Standards  International Covenant on Civil and Political Rights (ICCPR), 1966, Article 7, 19   International Planned Parenthood Federation Charter on Sexual and Reproductive Rights, 1996, Article 6   International MotherBaby Childbirth Initiative: A Human Rights Approach to Optimal Maternity Care, 2010,  Article 3, 4   Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternal  mortality and morbidity and human rights, 2010   Universal Declaration on Bioethics and Human Rights, 1997, Article 6  Multinational and National Standards  Birth Justice as Reproductive Justice, NAPW, 2010   Charter of Fundamental Rights of the European Union, 2000, Article 3.2, 7   Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the  Application of Biology and Medicine: Convention on Human Rights and Biomedicine, 1997, Article 5   Declaration on the Promotion of Patients’ Rights in Europe, 1994, Articles 1.5, 2, 3, 4.6, 5   European Charter of Patient’s Rights, 2002, Article 3, 4, 5, 12   Ley de Acompañamiento durante el Trabajo de Parto, Nacimiento y Post‐parto de Puerto Rico, 2006,  Article 3e, 3f   Ley de Parto Humanizado—Ley Nacional No. 25.929 de Argentina, 2004, Article 2f, 2g   The Rights of Childbearing Women, Childbirth Connection 1999, 2006, Articles 3, 4, 5, 6, 9, 12, 13, 14, 16, 19            4    ARTICLE III: Every woman has the right to privacy and confidentiality International Standards   International Covenant on Civil and Political Rights (ICCPR), 1966, Article 17   International Planned Parenthood Federation Charter on Sexual and Reproductive Rights, 1996, Article 4   Universal Declaration on Bioethics and Human Rights, 1997, Article 9  Multinational and National Standards  Declaration on the Promotion of Patients’ Rights in Europe, 1994, Article 1.4, 4   European Charter of Patient’s Rights, 2002, Article 6   The Rights of Childbearing Women, 1999, 2006, Article 7    ARTICLE IV: Every woman has the right to be treated with dignity and respect International Standards  International Covenant on Civil and Political Rights (ICCPR), 1966, Article 2   International MotherBaby Childbirth Initiative: A Human Rights Approach to Optimal Maternity Care,  Article 1   Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternal  mortality and morbidity and human rights, 2010   United Nations Fourth World Conference on Women, Beijing 1995   Universal Declaration on Bioethics and Human Rights, 1997, Article 8, 10, 11  Multinational and National Standards  Birth Justice as Reproductive Justice, NAPW, 2010   Charter of Fundamental Rights of the European Union, 2000, Article 1, 3, 7   Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the  Application of Biology and Medicine: Convention on Human Rights and Biomedicine, 1997, Article 1   Declaration on the Promotion of Patients’ Rights in Europe, 1994, Article 1.1, 1.4, 1.5   European Charter of Patient’s Rights, 2002, Article 7    ARTICLE V: Every woman has the right to equality, freedom from discrimination, and equitable care International Standards  Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), 1979, Article 1   International Covenant on Economic, Social and Cultural Rights (ICESCR), 1976, Article 2   International Covenant on Civil and Political Rights (ICCPR), 1966, Article 26   International Planned Parenthood Federation Charter on Sexual and Reproductive Rights, 1996, Article 3   Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternal  mortality and morbidity and human rights, 2010   United Nations Fourth World Conference on Women, Beijing 1995, Article 28   Universal Declaration on Bioethics and Human Rights, 1997, Article 10, 11  Multinational and National Standards  Charter of Fundamental Rights of the European Union, 2000, Article 21, 23   Declaration on the Promotion of Patients’ Rights in Europe, 1994, Article 5.1          5    ARTICLE VI: Every woman has the right to healthcare and to the highest attainable level of health International Standards  Declaration of Alma Ata, International Conference on Primary Care, 1978, Preamble, Articles 4, 6   International Planned Parenthood Federation Charter on Sexual and Reproductive Rights.  1996, Article 9   Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternal  mortality and morbidity and human rights, 2010   United Nations Fourth World Conference on Women, Beijing 1995   Universal Declaration of Human Rights, 1948, Article 25   Universal Declaration on Bioethics and Human Rights, 1997, Article 14.2  Multinational and National Standards  Charter of Fundamental Rights of the European Union, 2000, Article 35   Constitución Política del Estado Plurinacional de Bolivia, 2008, Article 45.V   Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the  Application of Biology and Medicine: Convention on Human Rights and Biomedicine, 1997, Article 3   Declaration on the Promotion of Patients’ Rights in Europe, 1994, Article 5   The Rights of Childbearing Women, 1999, 2006, Article 1      ARTICLE VII: Every woman has the right to liberty, autonomy, self-determination, and freedom from coercion International Standards  Declaration of the Elimination of Violence Against Women, 1994, Article 1   International Covenant on Economic, Social and Cultural Rights (ICESCR), 1976, Article 1   International Planned Parenthood Federation Charter on Sexual and Reproductive Rights, 1996, Article 2   International Covenant on Civil and Political Rights (ICCPR), 1966, Article 9.1, 18.2   Universal Declaration on Bioethics and Human Rights, Article 5  Multinational and National Standards  Charter of Fundamental Rights of the European Union, 2000, Article 6   Declaration on the Promotion of Patients’ Rights in Europe, 1994, Article 1.2                                                                  i Bowser, D., and K. Hill. 2010. Exploring Evidence for Disrespect and Abuse in Facility‐based Childbirth: Report of a Landscape  Analysis. Bethesda, MD: USAID‐TRAction Project, University Research Corporation, LLC, and Harvard School of Public Health.   ii The Charter borrows heavily from the framework of the International Planned Parenthood Federation Charter on Sexual and  Reproductive Rights, 1996.          This charter was developed collaboratively by a multi‐stakeholder group with expertise bridging research,  educational, clinical, human rights, and advocacy perspectives. Members of a community of concern working in  concert to address the issue of disrespect and abuse during maternity care within their various constituencies  contributed to this consensus document, including:     Debbie Armbruster, USAID    Robina Biteyi, WRA‐Uganda   Diana Bowser , Harvard School of Public Health    Neal Brandes, USAID    Catherine Carr, MCHIP/JHPIEGO    Blami Dao, JHPIEGO    Rae Davies, International MotherBaby Childbirth  Organization    Barbara Deller, JHPIEGO    Farah Diaz‐Tello, National Advocates for  Pregnant Women (NAPW)   Simone Diniz, Researcher    Soo Downe, University of Central Lancashire    Lorraine Fontaine, Regroupement Naissance‐ Renaissance    Lynn Freedman, Averting Maternal Death and  Disability, Columbia University    Maura Gaughan, Translating Research into  Action Project     Joanne Gleason, Population Council    Kathleen Hill, Translating Research into Action  Project , URC   Rima Jolivet, WRA   Debra Jones, Family Care International    Marge Koblinsky, John Snow International     Douglas Laube, USAID    Kathleen MacFarland, Family Care International    Peg Marshall, USAID    Liz Mason, World Health Organization    Mona Moore, Independent consultant    Nester Moyo, International Confederation of  Midwives    Martha Murdock, Family Care International    Winnie Mwebesa, Save the Children    Dave Nicholas, Translating Research into Action  Project    Doyin Oluwole, Academy for Educational  Development    Debra Pascali‐Bonaro, International MotherBaby  Childbirth Organization    Bertha Pooley, Save the Children    Annie Portela, World Health Organization    Veronica Reis, JHPIEGO    Aram Schvey, Center for Reproductive Rights    Rebecca Spence, Legal Advocates for Birth  Options and Rights (LABOR)   Mary Ellen Stanton, USAID    Ann Starrs, Family Care International    Erin Thornton, Every Mother Counts   John Townsend, Population Council    Melissa Upreti, Center for Reproductive Rights    Helene Vadeboncoeur, Perinatal researcher and  author    Charlotte Warren, Population Council   White Ribbon Alliance Global Secretariat and  National Alliance representatives   Rachel Wilson, PATH  For more information, visit: www.whiteribbonalliance.org/respectfulcare White Ribbon Alliance One Thomas Circle NW, Suite 200 Washington, DC 20005 sid e 2 The C harter ad d resses the issue of d isresp ect and ab use am ong w om en seeking m aternity care and p rovid es a p latform for im p rovem ent by • R aising aw areness o f child b earing w o m en’s inclu sio n in the g u arantees o f hum an rig hts reco g nized in internatio nally ad o p ted U nited N atio ns and o ther m ultinatio nal d eclaratio ns, co nventio ns, and co venants; • H ig hlig hting the co nnectio n b etw een hum an rig hts lang u ag e and key p ro g ram issues relevant to m aternity care ; • Increasing the cap acity o f m aternal health ad vo cates to p articip ate in hum an rig hts p ro cesses; • A lig ning child b earing w o m en’s sense o f entitlem ent to hig h -q u ality m aternity care w ith internatio nal hum an rig hts co m m unity stand ard s; and • P ro vid ing a b asis fo r ho ld ing the m aternal care system and co m m unities acco untab le to these rig hts. A b road group of stakehold ers rep resenting research, clinical, hum an rights, and ad vocacy p ersp ectives cam e together in a com m unity of concern to d evelop this charter. The cam p aign to p rom ote resp ectful m aternity care is led by the W hite R ib b on A lliance for S afe M otherhood, w ith sup p ort from U S A ID through the H ealth P olicy P roject. J o in U s : H e lp e n su re th a t e ve ry w o m a n ’s rig h t to re sp e c tfu l m a te rn ity c a re is u p h e ld . A s w e sp eak o u t an d d em an d resp ectfu l care, w e m ake it safe fo r w o m en everyw h ere to d o so to o . RESPECTFUL M ATERNITY CARE: THE UNIVERSAL RIGHTS OF CHILDBEARING WOMEN To fi n d o u t m o re, visit: w w w .w h iterib b o n allian ce.o rg /resp ectfu lcare istock A ll childbearing w om en need and deserve respectful care and protection; this includes special care to protect the m other-baby pair as w ell as w om en in a context of m arginalization or heightened vulnerability (e.g., adolescents, ethnic m inorities, and w om en living w ith physical or m ental disabilities or H IV ). D isresp ect an d ab u se d u ring m atern ity care are a vio latio n o f w o m en’s b asic h u m an rig hts. A s s e r t io n o f t h e U n iv e r s A l r ig h t s o f C h il d b e A r in g W o m e n the world bank 82 si d e 1 Th e D is ti n ct iv e Im p o rt an ce o f th e C h ild b ea ri n g P er io d P re gn an cy a nd c hi ld b irt h ar e m om en to us e ve nt s in th e liv es o f w om en a nd fa m ilie s ev er yw he re a nd a ls o a tim e of in te ns e vu ln er ab ilit y. “ S af e m ot he rh oo d ” us ua lly s ug ge st s p hy si ca l s af et y, b ut c hi ld b ea rin g is al so a n im p or ta nt r ite o f p as sa ge w ith d ee p p er so na l an d c ul tu ra l s ig ni fic an ce . B ec au se m ot he rh oo d is s p ec ifi c to w om en , ge nd er e q ui ty a nd g en d er vi ol en ce a re a ls o at t he c or e of m at er ni ty c ar e. Th e ca m p ai gn to p ro m ot e re sp ec tf ul m at er ni ty c ar e fo cu se s sp ec ifi ca lly o n th e in te rp er so na l a sp ec ts o f ca re r ec ei ve d b y w om en s ee ki ng m at er ni ty s er vi ce s. A w om an ’s r el at io ns hi p w ith h er m at er ni ty p ro vi d er s is v ita lly im p or ta nt . N ot o nl y ar e th es e en co un te rs th e ve hi cl e fo r es se nt ia l l ife sa vi ng h ea lth s er vi ce s, b ut w om en ’s e xp er ie nc es w ith c ar eg iv er s ca n em p ow er a nd c om fo rt o r in fli ct la st in g d am ag e an d em ot io na l t ra um a. E ith er w ay , w om en ’s m em or ie s of t he ir ch ild b ea rin g ex p er ie nc es s ta y w ith t he m fo r a lif et im e an d a re o fte n sh ar ed w ith o th er w om en , co nt rib ut in g to a c lim at e of c on fid en ce o r d ou bt ar ou nd c hi ld b ea rin g. S af e m o th er h o o d is m o re t h an t h e p re ve n ti o n o f d ea th a n d d is ab ili ty : I t is r es p ec t fo r ev er y w o m an ’s h u m an it y, f ee lin g s, c h o ic es , a n d p re fe re n ce s. G ro w in g E vi d en ce o f D is re sp ec t an d A b u se Im ag in e th e p er so na l t re at m en t yo u w ou ld e xp ec t fro m t he h ea lth w or ke r en tr us te d to h el p y ou o r a w om an y ou lo ve g iv e b irt h. W e en vi si on a r el at io ns hi p ch ar ac te riz ed b y ge nt le , ef fe ct iv e co m m un ic at io n, su p p or t, ki nd ne ss , an d r es p ec t. U nf or tu na te ly , to o m an y w om en e xp er ie nc e ca re t ha t d oe s no t m at ch th is im ag e. A g ro w in g b od y of r es ea rc h ev id en ce , ex p er ie nc e, a nd c as e re p or ts c ol le ct ed in m at er ni ty ca re s ys te m s fro m t he w ea lth ie st to p oo re st n at io ns w or ld w id e p ai nt s a d iff er en t an d d is tu rb in g p ic tu re . B ow se r an d H ill (2 01 0 ) d es cr ib ed s ev en m aj or ca te go rie s of d is re sp ec t an d a b us e th at c hi ld b ea rin g w om en e nc ou nt er d ur in g m at er ni ty c ar e. T he se ca te go rie s oc cu r al on g a co nt in uu m fr om s ub tle d is re sp ec t an d h um ilia tio n to o ve rt v io le nc e: • P hy si ca l a b u se • N o n -c o ns en te d c lin ic al c ar e • N o n -c o nfi d en ti al c ar e • N o n -d ig ni fie d c ar e (in cl u d in g v er b al a b u se ) • D is cr im in at io n b as ed o n sp ec ifi c p at ie nt a tt ri b u te s • A b an d o nm en t o r d en ia l o f ca re • D et en ti o n in f ac ili ti es D is re sp ec t an d a b us e of w om en s ee ki ng m at er ni ty ca re is b ec om in g an u rg en t p ro b le m a nd c re at in g a gr ow in g co m m un ity o f c on ce rn t ha t sp an s th e d om ai ns o f h ea lth ca re r es ea rc h, q ua lit y, a nd ed uc at io n; h um an r ig ht s; a nd c iv il rig ht s ad vo ca cy . D is re sp ec t an d a b u se d u ri n g m at er n it y ca re a re a vi o la ti o n o f w o m en ’s b as ic h u m an r ig h ts . In s e e k in g a n d r e ce iv in g m a te rn it y ca re b e fo re , d u ri n g , a n d a ft e r ch il d b ir th : h u m a n r ig h ts a re f u n d a m e n ta l e n ti tl e m e n ts d u e t o a ll p e o p le , re co g ni ze d b y so ci et ie s an d g o ve rn m en ts a nd e ns hr in ed in in te rn at io na l d ec la ra ti o ns a nd c o nv en ti o ns . U nt il no w , n o in st ru m en t ha s sp ec ifi ca lly d el in ea te d h o w hu m an r ig ht s ar e im p lic at ed in t he c hi ld b ea ri ng p ro ce ss o r af fir m ed t he ir a p p lic at io n to ch ild b ea ri ng w o m en a s b as ic , i na lie na b le r ig ht s. S ev e n r ig h ts a re d ra w n f ro m t h e c at e g o ri e s o f d is re sp e c t a n d a b u se id e n ti fie d b y re se a rc h e rs a n d r ig h ts a d vo c at e s in t h e cu rr e n t lit e ra tu re . B y d ra w in g o n r e le va n t ex tr a c ts f ro m e st a b lis h e d h u m a n r ig h ts in st ru m e n ts , th e C h a rt e r d e m o n st ra te s th e le g it im at e p la c e o f m at e rn a l h e a lt h r ig h ts w it h in t h e b ro a d e r c o n te x t o f h u m a n r ig h ts . be fR EE fr oM Ha rm AN D IL L tr ea tm e n t 1 4 ever y w o m a n h a s t h e r Ig h t to NO O NE C AN P HY SI CA LL Y AB US E YO U P r o m o t in g r e s P e C t f U l m A t e r n it y C A r e be t re at ed w it h dI GN IT YA ND RE SP EC T NO O NE C AN H UM IL IA TE OR V ER BA LL Y AB US E YO U e v e r y w o m a n h a s t h e r Ig h t to 2INF OR MA TIO N, iN fO RM Ed CO NS EN TA ND R Ef US AL , AN D r es pe ct FO R HE R c HO ic es AN D pr ef er en ce s, INC Lu DIN G CO M PA NI ON SH IP Du RIN G MA TE RN ITy C AR E e v e r y w o m a n h a s r Ig h t to NO O NE C AN f OR CE Y OU O R dO TH IN GS T O YO U W IT HO UT Y OU R KN OW LE dG E AN d CO NS EN T 3 P RI VA CY AN D co n fi d en ti al it y e v e r y w o m a n h a s t h e r Ig h t to NO O NE C AN E XP OS E YO U OR YO UR P ER SO NA L IN fO RM AT IO N Al l r ig ht s ar e gr ou nd ed in e st ab lis he d in te rn at io na l h um an ri gh ts in st ru m en ts , in cl ud in g th e Un iv er sa l D ec la ra tio n of H um an R ig ht s; th e Un iv er sa l D ec la ra tio n on B io et hi cs an d Hu m an R ig ht s; th e In te rn at io na l C ov en an t o n Ec on om ic , S oc ia l a nd C ul tu ra l R ig ht s; th e In te rn at io na l C ov en an t o n Ci vi l a nd P ol iti ca l R ig ht s; th e Co nv en tio n on th e El im in at io n of A ll Fo rm s of D is cr im in at io n Ag ai ns t W om en ; t he D ec la ra tio n of th e El im in at io n of V io le nc e Ag ai ns t W om en ; t he R ep or t o f t he O ffi ce o f t he U ni te d Na tio ns H ig h Co m m is si on er fo r H um an R ig ht s on p re ve nt ab le m at er na l m or ta lit y an d m or bi di ty a nd h um an ri gh ts ; a nd th e Un ite d Na tio ns Fo ur th W or ld C on fe re nc e on W om en , B ei jin g. N at io na l i ns tru m en ts a re a ls o re fe re nc ed if th ey m ak e sp ec ifi c m en tio n of c hi ld be ar in g w om en . 5 6 E q U AL IT Y, fr ee do M FR OM di sc ri Mi na tio n, AN D e qu ita bl e c ar e NO O NE C AN d IS CR IM IN AT E BE CA US E Of S OM ET HI NG T HE Y dO N OT L IK E AB OU T YO U e v e r y w o m a n h a s t h e r Ig h t to HE AL TH CA RE AN D TO th e h ig he st at ta in ab le le ve l OF H EA LT H NO O NE C AN P RE VE NT Y OU fR OM G ET TI NG T HE M AT ER NI TY C AR E YO U NE Ed 7LI BE RT Y, au to no My , se lf -d et er Mi na tio n, AN D f RE Ed OM fr o m c o er ci o n NO O NE C AN d ET AI N YO U OR Y OU R BA BY W IT HO UT L EG AL A UT HO RI TY e v e r y w o m a n h a s t h e r Ig h t to e v e r y w o m a n h a s t h e r Ig h t to Fo r m o re in fo rm at io n, v is it : w w w .w hi te ri b b o na lli an ce .o rg /r es p ec tf ul ca re shutterstock white ribbon alliance article i article ii article iii article iV article Viiarticle Vi article V 83 Disrespect and abuse during maternity care are a violation of women’s basic human rights. In seeking and receiving maternity care before, during and after childbirth: RESPECTFUL MATERNITY CARE: THE UNIVERSAL RIGHTS OF CHILDBEARING WOMEN Safe Motherhood is more than the prevention of death and disability…It is respect for every woman’s humanity, feelings, choices, and preferences. 6article Vi all rights are grounded in established international human rights instruments, including the Universal Declaration of Human Rights; the Universal Declaration on Bioethics and Human Rights; the International Covenant on Economic, Social and Cultural Rights; the International Covenant on Civil and Political Rights; the Convention on the Elimination of All Forms of Discrimination Against Women; the Declaration of the Elimination of Violence Against Women; the Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternal mortality and morbidity and human rights; and the United Nations Fourth World Conference on Women, Beijing. National instruments are also referenced if they make specific mention of childbearing women. For more information visit: www.whiteribbonalliance.org/respectfulcare 1be fREE froM Harm AND ILL treatment a r ti c le i NO ONE CAN PHYSICALLY ABUSE YOU eVery woman has the right to 2article ii INFORMATION, iNfORmEdCONSENTANDREfUSAL, ANDrespect FOR HER CHOICES AND preferences, INCLuDING COmPANIONSHIP DuRING MATERNITy CARE eVery woman has the right to 3article iii PRIVACYAND confIDentIalIty eVery woman has the right to 7article Vii eVery woman has the right to eVery woman has the right to 5article V EqUALITY, freedom FROM discriMination, AND EqUITABLE care NO ONE CAN dISCRImINATE BECAUSE Of SOmETHING THEY dO NOT LIKE ABOUT YOU eVery woman has the right to LIBERTY, autonoMy, self-deterMination, ANDfREEdOm from coercion NO ONE CAN dETAIN YOU OR YOUR BABY WITHOUT LEGAL AUTHORITY HEALTHCARE AND TO THE HigHest attainable level of HEALTH NO ONE CAN PREVENT YOU fROm GETTING THE mATERNITY CARE YOU NEEd 4article iV eVery woman has the right to BE TrEaTEd wiTh dIGNITYAND RESPECT NO ONE CAN HUmILIATE OR VERBALLY ABUSE YOU NO ONE CAN fORCE YOU OR dO THINGS TO YOU WITHOUT YOUR KNOWLEdGE ANd CONSENT NO ONE CAN EXPOSE YOU OR YOUR PERSONAL INfORmATION 86 86 White Ribbon Alliance c/o Futures Group One Thomas Circle NW, Suite 200 Washington, DC 20005 USA www.whiteribbonalliance.org info@whiteribbonalliance.org

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