Improving Respectful Midwifery Care in

Rural Malawi: a Human Rights Approach

Facilitators’ Handbook

Acknowledgements:

This Handbook was compiled by Professor Rebecca Wallace and Ms Karen Wylie, Robert Gordon

University, Aberdeen.

R Wallace and K Wylie would like to thank Catherine Sekwalor for her assistance and contribution

to the development of the case scenarios contained in this Handbook. Thank you also to Levi

Mvula, doctoral candidate at the University of Essex, for his comments.

The Definition Game is adapted from a resource created by the International Federation of Health

and Human Rights Organisation (IFHHRO), http://www.ifhhro.org/.

The Handbook was developed with a grant from the Burdett Trust for Nursing,

http://www.btfn.org.uk/.

CONTENTS

1. Aims and Outcomes of Training

2. Definition Game

3. Introduction to Human Rights Power Point Presentation

4. Health as a Human Right Power Point Presentation

5. Table of Human Rights Instruments

6. PANEL Approach and FAIR Flowchart Power Point Presentation

7. Case Scenarios

Aims and Outcomes of Training

Materials to Use

Overall Aim: to demonstrate to participants the link between human rights and health care, with

an emphasis on maternal health care, and how a human rights based approach may be introduced

to improve the experiences of patients and providers.

DAY 1

Session 1: Introduction and Definition Game – pdf and Word Document to print and cut up

Aims:

to introduce the programme

to introduce participants to one another

to introduce concepts used during training

Learning Outcomes: at the end of this session participants should:

have an understanding of what the programme will involve

know one another

be aware of some of the concepts which will be discussed in greater depth at future

sessions

Session 2: Introduction to Human Rights – Power Point Presentation

Aims:

to introduce the international human rights legal system

to identify the sources of international human rights

to describe the nature of human rights

to identify the obligations imposed on states

to provide an understanding of cross-cutting elements

to acknowledge cultural and gender sensitivity

Learning Outcomes: at the end of this session participants should:

possess knowledge of the international human rights legal system

be able to identify the sources of human rights

be able to describe the nature of rights and cite examples

be able to describe the obligations incumbent on states

have an awareness of the overarching principles common to all human rights

understand the need for cultural and gender sensitivity

Session 3: Health as a Human Right – Power Point Presentation. Activity: Need sheets of flipchart

paper, coloured paper, markers and blu tac - participants think of human rights concepts in

examples of own practice – e.g. participation, information & expression, non-discrimination &

equality – group discusses responses stuck on the different sheets.

Aims:

for participants to see the link between human rights and the delivery of health care

to demonstrate what is meant by health as a human right

to encourage participants to think about how human rights impact on their own delivery of

health care

Learning Outcomes: at the end of this session participants should:

understand the link between human rights, health and health care

be able to cite examples of how human rights are reflected in their own practice

DAY 2

Session 4: The PANEL Principles and FAIR Approach – Power Point Presentation

Aims:

to demonstrate the application of a human rights based approach

to introduce the PANEL principles

to introduce the FAIR flowchart

to discuss each principle in turn

Learning Outcomes: at end of this session participants should:

have knowledge of the PANEL principles

understand the elements of the FAIR flowchart

understand their operation

Session 5: Case Studies on the PANEL Principles in Practice – Word Document to print and cut up

Aims:

to demonstrate through scenarios the PANEL principles in practice

to demonstrate the use of the FAIR flowchart in influencing practice

Learning Outcomes: at end of this session participants should:

understand the relevance of the PANEL principles and FAIR flowchart

understand how to practically implement the PANEL principles and FAIR flowchart

Essential medicines

------------------- -------------------------------------------------------------------------------------------------------------

Medicines that satisfy the priority health-care needs of the population. Essential medicines are intended to be available at all times in adequate amounts, in the appropriate dosage forms, with assured quality, and at a price the individual and the community can afford.

Health

------------------- -------------------------------------------------------------------------------------------------------------

A state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. (WHO)

Right to health

------------------- -------------------------------------------------------------------------------------------------------------

Right to the enjoyment of a variety of facilities, goods, services, and conditions necessary for the realization of the highest attainable standard of health.

Health Workers

------------------- -------------------------------------------------------------------------------------------------------------

Physicians, nurses, dentists, or other health care providers.

Health care system

------------------- -------------------------------------------------------------------------------------------------------------

The organized provision of health care services.

Dual loyalty

------------------- -------------------------------------------------------------------------------------------------------------

Role conflict between professional duties to a patient and obligations— express or implied, real or perceived—to the interests of a third party such as an employer, insurer, or the state.

Informed consent

------------------- -------------------------------------------------------------------------------------------------------------

A process by which a patient participates in health care choices. A patient must be provided with adequate and understandable information on matters such as the treatment’s purpose, alternative treatments, risks, and side-effects.

Patient autonomy

------------------- -------------------------------------------------------------------------------------------------------------

The right of patients to make decisions about their medical care. Providers can educate and inform patients, but cannot make decisions for them.

Human dignity

------------------- -------------------------------------------------------------------------------------------------------------

There is no agreement on a definition, but most people have their own ideas of what it means. It is a central component of all human rights.

Medical ethics

------------------- -------------------------------------------------------------------------------------------------------------

A system of moral principles and rules that are used as standards for professional conduct. Many hospitals and other health care facilities have ethics committees that can help doctors, other healthcare providers, patients, and family members in making difficult decisions regarding medical care. This may vary with religious and cultural backgrounds.

Underlying determinants of health ------------------- -------------------------------------------------------------------------------------------------------------

Conditions necessary for good health, including safe and potable water, adequate food, housing, healthy occupational and environmental conditions, health-related education, non-discrimination, etc. This includes both social and economic and civil and political rights.

Concluding observations

------------------- -------------------------------------------------------------------------------------------------------------

Recommendations by a treaty’s monitoring mechanism on the actions a state should take in ensuring compliance with the treaty’s obligations. This generally follows both submission of a state’s country report and a constructive dialogue with state representatives.

General comments / recommendations

------------------- -------------------------------------------------------------------------------------------------------------

Interpretive texts issues by a treaty’s monitoring mechanism on the content of particular rights. Although these are not legally binding, they are widely regarded as authoritative and have significant legal weight.

Monitoring/ fact finding/ investigation

------------------- -------------------------------------------------------------------------------------------------------------

Terms often used interchangeably, generally intended to mean the tracking and/or gathering of information about government practices and actions related to human rights.

Patient confidentiality

------------------- -------------------------------------------------------------------------------------------------------------

Doctrine that holds that the physician has the duty to maintain patient confidences. This is to allow patients to make full and frank disclosure to their physician, enabling appropriate treatment and diagnosis.

Right to life

The right for anyone not to have their

life taken away; and to have the state

take reasonable steps to protect life.

Positive obligations

Duties which states are required

to discharge in relation to

upholding human rights

Convention/Treaty

An international agreement

between states.

Non-Discrimination

No one should be disadvantaged

because of sex, race, colour, age,

religion, disability, health status,

sexual orientation, socio-economic or

other status.

Domestic Law

The internal law of a

state.

International Bill of Rights

The collective term for the Universal

Declaration of Human Rights; the

International Covenant on Civil & Political

Rights; and the International Covenant

on Economic, Social and Cultural Rights.

Introduction to Human Rights – Day 1, Session 2

Slide 1

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 2

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 3

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 4

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 5

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 6

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 7

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 8

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 9

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 10

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 11

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Health as a Human Right – Day 1, Session 3

Slide 1

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 2

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 3

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 4

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 5

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 6

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 7

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 8

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 9

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 10

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 11

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

International Human Rights Instruments and Protected Rights and Fundamental Freedoms

relating to Health Care

UDHR ICCPR ICESCR CEDAW CERD CRC Banjul

Charter

Liberty and

Security

of Person

Art. 3

Art.

9(1)

Art.

5(b)

Art. 6

Privacy Art. 12 Art. 17 Art. 16

Expression and

Information

Art. 19

Art.

19(2)

Art. 12,

Art.13,

Art. 17

Art. 9

Life Art. 3 Art.

6(1)

Art.

6(1)

Art. 4

Health Art. 25 Art. 12 Art. 12 Art.

5(e)(iv)

Art. 24 Art. 16

Torture or

Cruel, Inhuman

or Degrading

Treatment

Art. 5

Art. 7

Art.

37(a)

Art. 5

Participate in

Public Policy

Art. 21 Art. 25 Art. 7 Art.

5(c)

Art. 13

Non-

Discrimination

and Equality

Art. 1,

2

Art.

2(1),

Art. 3

Art. 2(2),

Art. 3

Art. 2,

All

Art. 2,

Art. 5,

All

Art. 2 Art. 2,

Art. 19

Links to the treaties are provided on the following page.

UDHR: Universal Declaration of Human Rights

http://www.un.org/en/documents/udhr/

ICCPR: International Covenant on Civil and Political

Rights http://www.ohchr.org/en/professionalinterest/pages/ccpr.aspx

ICESCR: International Covenant on Economic, Social and Cultural

Rights http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx

CEDAW: Convention on the Elimination of All Forms of Discrimination against Women

http://www.un.org/womenwatch/daw/cedaw/cedaw.htm

CERD: Convention on the Elimination of All Forms of Racial Discrimination

http://www.ohchr.org/EN/ProfessionalInterest/Pages/CERD.aspx

CRC: Convention on the Rights of the Child

http://www.ohchr.org/en/professionalinterest/pages/crc.aspx

Banjul Charter: African Charter on Human and Peoples' Rights

http://www.achpr.org/instruments/achpr/

The PANEL Approach and FAIR Flowchart – Day 2

Slide 1

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 2

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 3

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 4

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 5

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 6

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 7

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 8

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 9

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 10

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Case Scenarios

Below are several case scenarios. Participants should use these situations to apply

the PANEL principles and FAIR flowchart in practice. Participants can reflect on their

own experiences of similar situations to assist in this exercise.

The first case study provides an example of how to extract and discuss the relevant

information.

Grace

Grace is 30 year old mother of three, on her fourth pregnancy. Grace is

attended by a Traditional Birth Attendant (TBA) in her community, instead of

the Community Midwife Assistant (CMA), whom she feels is better than the

CMAs.

How can mothers like Grace be made more confident to seek the advice and

support of CMAs and not the TBAs?

Could a human rights based approach be helpful here?

Facts:

Attended by TBA not CMA

Believes TBA will provide better care than CMA

Analysis of Human Rights at Stake:

Right to health (attended by unskilled TBA)

Discrimination

Right to life (ultimately)

Identification of Shared Responsibilities:

Empower women to seek skilled help

Reinforce the roles of the TBA and CMA

Penalty for TBAs if identified as providing care

Work with village community to highlight role of CMA

CMAs should record all BBAs (Born Before Arrival)

Health Surveillance Assistants should conduct home visits for post natal mothers

Review Actions:

Record BBAs

Home visits conducted and recorded

Information provided regarding optimal care

Asmaa

Asmaa lives in a rural village. She is in the first trimester of her pregnancy and

has been suffering from nausea. A woman in her village has given Asmaa a

traditional herbal remedy which she claims will ease the symptoms.

A community midwife is involved in Asmaa’s care and when she learns that

Asmaa has taken the herbal remedy she disapproves and tells Asmaa to refrain

from taking any more. Asmaa is unhappy about this as she thinks the remedy

has eased her feelings of nausea.

What rights come into play in this scenario?

How would this conflict of interests be approached from a human rights based

approach?

Mphatso

Mphatso lives in a remote village and is in her eight month of pregnancy. She

has presented herself to the nearest community health facility suffering severe

abdominal pain.

The community facility does not have the equipment and expertise to assist

her and recommends she goes to the hospital in the nearest town but it will

take several hours to get there. The local facility cannot guarantee Mphatso an

ambulance and suggest she may be better getting a taxi there herself.

Mphatso is reluctant to embark on the journey and is uncertain as to whether

she would be better staying at the community facility.

What are the issue involved in this scenario?

How would a human rights based approach deal with this situation?

Chiwa

Chiwa is mid-way through her pregnancy and is experiencing some bleeding.

Her previous two pregnancies were unproblematic and her children are

healthy. Chiwa is anxious and asks her community midwife for advice who

recommends she be admitted to hospital for observation.

Chiwa’s husband disagrees with this as he needs Chiwa at home looking after

the other children in order for him to be able to work and earn money outside

the home.

What are the conflicting rights in this case?

How could the midwife rely on a human rights based approach to help resolve

this situation?

Njemile

Njemile is a midwife in a rural health facility. The facility is under-resourced in

terms of staff, equipment and medicines. This is having a detrimental effect on

Njemile’s and her colleagues’ morale.

A rise in the number of patients is placing greater strain on this already over-

stretched facility. Njemile becomes increasingly concerned having witnessed

incidents in which some of her colleagues have given vent to their frustration

by being abrupt or dismissive of their patients.

How could this situation be addressed through a human rights based

approach?

Lucy

Lucy is a 14 year girl raped by her neighbour, a man in his thirties married with

a family. She has been admitted to the maternity waiting home awaiting

delivery of her baby.

Lucy goes into premature labour and alerts the midwife on duty of abdominal

pain. The midwife ignores Lucy and tells her pain is due to something she ate

and that she's not in labour.

Lucy's pain worsens with family members intervening but still the midwife

ignores Lucy. After 24 hours of labouring with no assistance from the midwife

family members intervene to help Lucy deliver the baby however, both Lucy

and baby die.

How would a human rights based approach come into play in this scenario?

Mrs Benda

Mrs Benda is a 38yr old with a ruptured membrane (37 weeks). She arrives at

her local district hospital. She's taken to the labour room and thereafter left

without assistance.

Finally, the midwife arrives to find Mrs Benda has delivered a baby with the

cord around its neck. The baby has asphyxiated.

What human rights come into play in this case?

Martha

Martha is a woman in her final stages of labour. She has a tear and delivers a

live baby. However, the hospital has no anaesthetic to numb the site. As she is

stitched up she screams in pain and the midwife shouts abuse and slaps her to

be quiet.

What human rights are violated in this situation?

How could a human rights based approach support both Martha and the

midwife?

Ante-Natal Ward

Several women arrive on the ante-natal ward of a hospital but there are no

beds on the female ward. The women are told to make their beds on the

concentrate floor until ward beds become available. No mattresses are

provided because the hospital cannot afford to purchase them for the hospital.

As a member of the management team of this facility how could you rely on a

human rights based approach to improve this situation?

Jessie

Jessie is HIV positive. She is in labour and has been referred from a rural health

centre to a hospital. Jessie has been told that the reason for transfer is that she

is HIV positive. She tells the hospital staff that the health workers at the health

facility are refusing to care for her because of her HIV status.

What human rights are being violated here?

How could a human rights based approach help to deal with this situation?

Ruth

Ruth is 18 years old. She is pregnant and is severely anaemic. However her

guardians (mother and husband) have refused to let her have a blood

transfusion due to their religious beliefs. Ruth dies 4 hours after admission to

hospital.

How could a human rights based approach have helped to find a resolution to

this situation?

Sally

Sally, a 24 year old woman, was admitted to a community hospital in labour

and was taken to theatre because of failure to progress. There it was decided

Sally should have a Caesarean Section. However it was then discovered that

Sally had a ruptured uterus. The clinician felt he could not continue with the

Caesarean Section and abandoned the procedure, leaving Sally unsutured. She

was referred to the district hospital with an open abdomen.

What human rights come into play in this case?

How could a human rights based approach have helped?