Dr France Donnay is currently an independent consultant, with a focus on women’s health policies, programs and practices. She has worked with UNICEF, UNFPA, Medicins Sans Frontieres, MSD for Mothers and the Bill and Melinda Gates Foundation. A specialist in obstetrics and gynaecology by training, she has visited and worked in many countries in all regions of the world.
Q: Having worked for many years in the area of maternal health, what do you see as the major issues currently facing women and threatening a safe motherhood experience?
I would say there are two opposing trends. One positive thing is the progress that many countries have made regarding maternal mortality over the last 25 years, since 1992 and 2015 when the development goals were assessed, nine countries have achieved the goals, many other countries have partially achieved the goals, but overall globally the progress was really striking with something like a 40 per cent reduction in maternal deaths over those years.
The main challenge now is really the quality of the care that women receive. Many women, even poor women, decide to give birth in clinics and small hospitals, but the quality of the care they receive is very poor in general.
Q: One of Safe Motherhood Week’s goals is to address the gaps in care and inequalities with regard to maternal rights/care. Having worked in many countries you will have seen these huge variations in the standard of care, particularly in relation to vulnerable groups. How do you think this can be addressed?
The main trend that we have seen over the last 10 years maybe, relatively recently, is the trend towards facility-based births, as opposed to home births. What is happening in those hospitals and clinics is that you have either over-medicalization with a lot of C-sections for instance, so you have good quality care but the birth process is being over-medicalized, and also the extreme opposite of under-medicalisation – women who go to clinics and there is hardly any equipment, there are no drugs, no midwife, and women are attended by people who are not really competent.
Over-medicalisation happens in rich countries, but also more and more in poor countries where women who are wealthy go to private hospitals to deliver their babies, but often poor women are also subjected to unnecessary C-sections in public and private hospitals – in India for example I see that a lot. The main problem however is under-medicalisation, so to address that challenge we have work on many fronts. We need more qualified people such as midwives nurses and doctors, who are competent, who are motivated and who are proud of what they do. The second is the infrastructure of the hospitals and clinics; the cleanliness, the equipment and the supplies that are needed. The third one is financing.
Q: You have been heavily involved in the development of public health policy, in relation to safety of mothers and newborns. What in your view are the most important aspects of the development and the implementation of this policy?
The main policy advances that we have been promoting in the last two years have been quality of care relating to childbirth, trained and skilled providers, clean hospitals, and equitable access to care – poor women as well as rich women. Many countries have instituted policies for improving access to care, for example, by removing user’s fees and by making care for pregnant women and their children free, in theory. Of course in many cases, the policy is not applied exactly as it should be, and poor women still have to pay something. There are many policies to improve access to care for poor people so the situation is better but not ideal and there is a long way to go. What is being discussed now is universal health coverage which is a type of health insurance for everybody – that is the future I think and that will help with equitable access to care.
Yet, about 800 women still die every day in pregnancy and childbirth, including from unsafe abortion and unsafe delivery. Many thousands of newborns die every day but there are also morbidities, babies who are alive but are disabled for life.
There is a lot of work to do to really improve the way that people attend to women and to make sure that all women rich and poor receive good quality of care which is also important during that process of delivery.
Q: You have written extensively on family planning advice and guidance – how important is this and why?
I think that family planning is one of the most important interventions to reduce maternal mortality – it is estimated that with good access to contraception we could reduce maternal mortality by one-third.
Access is not good enough in many places and often that is because family planning and antenatal care are usually implemented in a vertical fashion, separate from each other, there is little integration between the two. So the idea of this article and many other papers is that the care that is provided and the counselling should be integrated – they should receive advice on family planning during pregnancy and immediately after birth. Family planning is key also to limit the number of unwanted pregnancies and unsafe abortions, which is one part of the maternal deaths issue of course.
Q: Our theme for Safe Motherhood Week this year is: Motherhood is our power to shape the future. It is everyone’s responsibility to make it safe. What are your thoughts on this statement?
It is a good theme – it is true that the birthing event is very important for the future of that child but also the future of that family and the community. There are a lot of discussions now about communities of practice making sure that everyone contributes. It is also important for the fathers, the husbands, the partners, to actually support the mothers. In many places, particularly low income countries, the pregnancy is a family affair, it is not the woman’s individual issue. The family is really involved and engaged in the care in countries like India, and in Africa. The more that family members know the risks and opportunities for getting good care, the better. There’s really a community and family responsibility to make motherhood safe.
Q: Tell us about a project you are involved in that you think is relevant to the Safe Motherhood Week campaign?
France: I would like to highlight one programme that is being implemented by the University of California at San Francisco, working mostly in Kenya and India. This is a programme to improve respectful care because this is a universal problem across the world and Europe, particularly for poor women and migrant women. It is not only the clinical care – it is respect for women that we need to improve. We will ask women in India and Kenya how they have been treated during their pregnancies and in their deliveries, how they think they should be, what they want and talk to them about what they should expect and also what they can demand.
Another project which is interesting because it is managed in Europe, by a Finnish institution, is a user-centric design project. This involves improving the labour room itself – the infrastructure, the walls, the colours, the furniture, the way women are admitted are welcomed in the hospital and how they can know what to expect and that their birth companion can know what to do and what not to do. This is really a user-centric design approach to safe motherhood being pioneered by European institutions and design agencies and I think that’s a very effective way of improving care at childbirth.
Find out more about Safe Motherhood Week 2016 here.
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