What women want

"Of course, I didn't want to attend the clinic in my uniform so I either had to go there before work or I'd have to leave work early to attend the clinic. Not many clinics are open before 8am so it meant that even if I was the first one to be seen, I would already be two hours late for work," says Rose. She adds that she had to dig into her pocket and pay for ANC services at a private clinic.

"I really needed a place where I could go in and out within an hour so I could at least be at work by 9am. Of course, as my belly began to grow, my supervisors were more understanding but I still did not want to inconvenience my colleagues by being away the whole day," Rose says, adding that one of the other things she considered was the courteous services she received at the clinic when sought medical services for her other children.

"Let's just say it is our favourite family clinic. They know me and my children as I often take them there so I also chose it because of their friendly services," Rose says adding that this was very important to her as he had her first child when she was a teenager.

"I had accompanied a friend to the clinics back at home. I didn't like the way they treated the young girls there. So when I found out I was pregnant, I did not want to attend the clinics. I was also afraid that the older women would see me there and they would tell my parents that I was attending the clinics for pregnant women. I was not ready to face my parents with the truth," Rose says.

Later, Rose went to visit her aunt in another town. Her aunt noticed that she was pregnant and encouraged her to start the clinics. She also helped her break the news to her parents and stayed with her until she delivered.

Like Rose, many women consider various factors when choosing where to go for antenatal clinics. Unfortunately, so many women have limited choices as to which facility they visit as the nearest facilities are far away or not easily accessible.

According to a July 2019 study published in the International Journal of Public Health and Epidemiology Research titled, "Health System Factors Affecting Uptake of Antenatal Care by Women of Reproductive Age in Kisumu County, Kenya", these factors affect whether they attend ANC or how early in their pregnancies they do so.

In the study, whose respondents were aged 16 - 46 years, most (96 per cent) respondents had attended ANC during pregnancy, though more than half (53.4 per cent) started ANC within 3-6 months of pregnancy.

Only 21.2 per cent of the respondents attended the first visit of the ANC clinic in the first trimester which is between 0-3 months. The majority of the respondents, (53.4 per cent) visited in the second trimester while 25.3 (per cent) visited in the third trimester. This indicates that the majority do not visit the ANC clinics immediately in the first trimester.

Negative or positive

The study concluded that health system factors affect the uptake of ANC -- long distances to the hospital, long waiting times, poor quality of services, commodity stock outs and poor attitude of staff.

While factors such as long distances to hospitals and commodity stockouts are symptoms of a health system failure, the human face of maternity services is directly related to the healthcare providers.

A woman's relationship with healthcare providers and the healthcare system during pregnancy, childbirth and the postpartum period is crucial. Her experiences with a caregiver can either empower and comfort them or cause emotional trauma and damage to her self-esteem and confidence.

The World Health Organization (WHO) recommends antenatal visits at least eight times during pregnancy and to initiate antenatal care in the first trimester.

According to Jactinta Angote who coordinates reproductive health services in Kakamega County, if a woman experiences disrespect or abuse during any of her visits to a healthcare facility, it is likely to keep her away. She adds that negative experiences by others might also affect perceptions about health facilities as news of such spreads very quickly by word of mouth.

"It is so important that we have continuity of care for expectant mothers. If they miss out on any of those services then the health of the mother and the baby will be compromised," Ms Angote says.

The growing awareness of this fact has, in the last decade, influenced the global public health sector's interest in understanding and addressing the harms of disrespect and abuse experienced by women seeking reproductive health services in health facilities. As a result, there have been various global actions.

In 2011, the White Ribbon Alliance (WRA) published the Respectful Maternity Care Charter: The Universal Rights of Childbearing Women. The Respectful Maternity Care Charter addresses the issue of disrespect and abuse toward women and newborns who are utilising maternal and newborn care services and provides a platform for improvement. This document has formed the basis of various advocacy programmes around the world.

In 2014, the World Health Organization released a statement advocating for the fundamental human rights of women in childbirth. In 2016, the Ministry of Health developed and launched the Respectful Maternity Care (RMC) package that provides a structure for the adoption of RMC at health facilities.

Women's voices

In 2018, WRA led the What Women Want (WWW) Campaign which sought to gather information on women's needs and use their own voices to set the agenda for women's health globally and in Kenya.

This year, as part of an advocacy and social accountability project, White Ribbon Alliance Kenya (WRA Kenya) rolled out a listening exercise designed to capture the voices of women, girls and health service providers on what respectful maternity care meant to them.

The findings were recently released in a report titled, Respectful Maternity Care (RMC) Listening Exercise Report.

"We are intentional about listening to women and girls particularly the underserved who often experience disrespect and abuse while seeking maternal and newborn healthcare, including adolescent mothers and women with disabilities. This ensures no one is left behind since their voices contribute to the shaping of the care they all deserve," says Angela Nguku, Founder and Executive Director, WRA Kenya.

While great advances have been made in respectful maternity care, there are still some gaps.

In 2018, for example, a Bungoma court made a landmark ruling, awarding USD25,000 in compensation for the "disrespect and abuse" she suffered during childbirth in 2013 at Bungoma County Hospital. Apart from having to buy medicine to induce her labour, she was also subjected to harassment for delivering on the floor unaided.

While the ruling did not bring an end to disrespect and abuse in maternal care, it brought to the public domain the dire need for urgent action towards respectful maternity care.

Way forward

And the solutions, according to an analysis of a qualitative interview (Lusambili AM, Obure J, Wisofschi S, et al, BMJ Open 2022) titled: Views of nurses and other healthcare workers on interventions to reduce disrespectful maternity care in rural health facilities in Kilifi and Kisii counties, the solutions will primarily come from healthcare workers.

In the interviews, the healthcare workers identified four interconnected areas that were associated with improving the respectful delivery of care to women and their newborns.

"These include continuous training on the components of respectful maternity care through mentorships, seminars and organised training; gender-responsive services and workspaces; improved staffing levels; and adequate equipment and supplies for care," reads the analysis.

A 2021 report by WRA (What Women Want: Perspectives from a Listening Exercise with Midwives in Kenya) revealed similar challenges.

"The survey highlighted challenges midwives face in delivering respectful and dignified quality care to Kenyan women and girls," reads the report. "They included a weak health system, lack of adequate space, beds, ambulances, weak referral systems, coupled with understaffing and shortage of trained midwives to render services."