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  • Writer's pictureTiffany M. Montgomery

R-E-S-P-E-C-Tful Maternity Care

When birthing people choose to have a hospital birth--or any other birth for that matter--they are choosing to put their lives and that of their child(ren) in the staff's hands. But more than keeping them free from physical harm, they are expecting us to also keep them free from emotional, psychological, and spiritual harm. Unfortunately, healthcare providers don't always pass the test.

As the already abysmal numbers rise and word spreads about racial inequities in maternal health, healthcare organizations are beginning to think about the ways in which they can insulate themselves from collateral damage. This is the wrong way to go about it. Instead of coming from a place of litigation prevention and risk management, we should come from a place of compassion, empathy, and a genuine desire for justice. We need to get back to a place where we do what's right simply because it's right, and not because it will keep us out of courtrooms and off the news.

Real People, Real Hurt

When we treat our jobs like income generators and not like environments in which our purpose is fulfilled, we shortchange our patients. When we treat birthing people like numbers or worse, like inconveniences, instead of like human beings made in the image of God, we contribute to and perpetuate the obstetric harm that is historically prevalent and ever-growing in the present-day U.S. healthcare system.

We owe people the respect of engaging them in their care plan, providing them with informed consent, and supporting their autonomy while they are in our care. How dare we perpetuate the patriarchy that our forefathers established in medicine and healthcare, or the disrespect and disregard of minoritized groups long established in nursing? These same thoughts, beliefs, and social norms kept Black people from having the right to vote until the 1960s and prevented women from owning credit cards-- without the signature of their father or husband-- until the 1970s. This way of thinking is archaic and needs to be thrown away like the stinking garbage it is.

As nurses, we care for real people. We are not Louise Fletcher acting out a scene as Nurse Ratched in One Flew Over the Cuckoo's Nest. We are professional healthcare providers caring for real people who have real healthcare needs. And if we aren't careful, we can cause real harm that is unforgettable and sometimes, irreversible.

Doing the Work

There are several maternal health organizations that have answered the call to curate formalized, evidence-based training that goes beyond implicit bias workshops and the Harvard Implicit Association Tests to promote actionable and sustainable racially equitable care. I've worked with two such organizations that have prepared and disseminated resources that clinicians may utilize to change or support the current environment in which their providers work.

The first organization, the Alliance for Innovation in Maternal Health Community Care Initiative (AIM-CCI), has amassed a seven-module Racial Equity Learning Series (RELS) along with a Health Equity Framework. The modules are accompanied by activities and quizzes. These aren't your grandmother's educational modules. They cover a range of topics from an individual acknowledgment of racism to institutional transformation, and systemic change. In my experience, this is the first learning series of its kind.

The basic tenets of the AIM-CCI Health Equity Framework are diversity, inclusivity and belonging, racial equity, respectful equitable care, and community integration. The thing that I love about AIM-CCI, its learning series, and its Health Equity Framework is the community focus. AIM-CCI takes the spotlight off of the inpatient experience and magnifies the importance of outpatient healthcare clinics, non-profit and other community organizations, and home environments. With the realization that nearly one-third of maternal mortality occurs during the postpartum period after the birthing person is home, we must focus on what we can and should do when people are back in their community working, playing, worshipping, and adjusting to life as new parents.

While I am extremely proud of the work done by AIM-CCI, I am also extremely humbled. I was on the health equity committee that began this work. I remember the two-day, in-person meeting that brought us all together and the many monthly virtual meetings where we gathered information, collated ideas, and presented revisions. I am so grateful to see this work come to fruition. I feel like a beaming mother at her child's kindergarten graduation. I look forward to the continued work of AIM-CCI and all the changes that will result from it.

The other organization is one you'll hear me speak about often--the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). Their Respectful Maternity Care (RMC) framework has the potential to change the game in maternity units across the country. Through its implementation, healthcare organizations are poised to address key factors attributing to obstetric violence and patient harm. The basis of RMC is an acknowledgment of the fundamental right of every human being to be treated respectfully--"every patient, every interaction, every time."

The basic tenets of RMC include awareness, acceptance, mutual respect, and shared decision-making. Each one of these four tenants helps to form an important boundary in which patient autonomy, dignity and respect, accountability, provision of care and informed consent, and freedom from harm and mistreatment can flourish. In a similar vein as the 10 Steps to Successful Breastfeeding, AWHONN has established 10 Steps to Respectful Maternity Care. These steps include:

  1. Confirming your commitment to respectful maternity care

  2. Assembling an implementation team

  3. Relating the readiness of your department/unit

  4. Educating all staff and providers

  5. Proposing new policies and policy revisions

  6. Adapting to the new culture

  7. Assuming accountability for individual and department actions

  8. Tailoring data management to fit your needs

  9. Test measurement integration

  10. Have a celebration

The acronym for these steps is CARE PATTH.

Just as I am proud of the work of AIM-CCI, I am even more proud of the work of AWHONN. I have been a member of AWHONN for 16 years; it is my professional home. I have been a hard-working and faithful member of the organization and I longed for the day that we would speak up and out regarding the current maternal health crisis in the U.S. This work is the result of many years of advocacy and behind-the-scenes scholarship of maternal health equity warriors like Rose Horton, past AWHONN President and creator of the #NotOnMyWatch movement; Dr. Debra Bingham, Founder and CEO of the Institute for Perinatal Quality Improvement, and Dr. Kelly McGlothen-Bell, Assistant Professor at UT San Antonio School of Nursing. AWHONN has not always been at the forefront of maternal health equity work, but now that we are here, we aren't turning back.

There are several others doing this impactful work, including Family to Family which created the Respectful Equitable Care Certification, and Dr. Karen Scott who founded Birthing Cultural Rigor and created the scientifically sound and validated Patient Reported Experience of Obstetric Care (PREM OB) scale.

Why Now?

When I wanted to know why AWHONN chose to tackle the maternal respect issue, I went to the head. Jonathan Webb is the current CEO of AWHONN. Jonathan is committed to DEI work and on his watch, the organization has taken a deep dive into all things diversity. So when I asked, "Why this? Why now?" I received a pleasantly surprising response. Per Jonathan, AWHONN chose to do this work because of a few important reasons:

  • Increasing fetal, maternal, newborn, and infant morbidity and mortality, specifically in underrepresented populations

  • We have major historical shifts from predominantly midwife-attended birth to predominantly physician-attended birth, with this came a medical model of birth versus a physiologic model.

  • In a medical model, providers determine the interventions provided without full informed consent of the patient.

  • Increased medical interventions often lead to loss of autonomy in labor and birth and negative patient experiences and outcomes.

  • Promoting respectful care increases the patient’s voice and control over the labor and birth process leading to positive experiences and improved outcomes.

  • Maternal deaths are increasing in the home setting after birth. Patients who have positive birth experiences and positive interactions with the healthcare team develop trust and will come back and seek care when complications arise.

  • CDC promotes respectful care as one way to improve maternal mortality

  • Developing resources to promote the components of respect in reproductive settings is one way to improve outcomes and decrease mortality

It's Not About You

When it comes to the implementation of respectful maternity care, it has never been and will never be about maternal health providers. Everything we do is for the birthing people in our care. If we aren't in the business of birth for them, we have the wrong mindset (and we may need to consider a career change).

We've all heard the old adage, "Do unto others as you would have them do unto you." This saying is widely known as the Golden Rule. Well, I recently learned of the Platinum Rule and for those of us in healthcare, it's an important shift in our thinking. It says, "Do unto others as they would have you to do unto them." We are to treat people the way they want to be treated, and not the way we want to be treated.

So, how do we know how other people want to be treated? Like the late great Aretha Franklin sang: R-E-S-P-E-C-T, find out what it means to me. Find out what they expect during the course of their labor and childbirth. Determine how they want to be spoken to, educated, and supported. Empower them to use their voice and express their autonomy. Encourage them to own their experience and to hold tight to the dear memories being made.

Under no circumstance should a birthing person ever be coerced into doing something we want them to do, or even something we believed we would do if we were in their shoes. Again, it's not about us. It has never been about us. It will never be about us. It's about the lives we help to bring into this world and those we help to sustain before, during, and after the period during which they are with child.

As long as you are entrusted to care for those admitted to your inpatient unit or with whom you interact in community health settings, you should be protective of them. Give them the respect they deserve. Not because they've earned it, but simply because they are human and are worthy of it.

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