Towards humanised and respectful childbirth in Togo: promoting women’s dignity and rights in obstetric settings

Towards Humanised and Respectful Childbirth in Togo: Promoting Women’s Dignity and Rights in Obstetric Settings

*¹Wankpaouyare GMAKOUBA, ²Salaraga BANTAKPA, ²Mazabalo BINI

¹Ministry of Health and Public Hygiene, Lomé, Togo, Public Health specialist, PhD Candidate, Bircham International University

²Public Health specialist, Ministry of Health and Public Hygiene, Lomé, Togo 

^*Correspondence Author

DOI: https://dx.doi.org/10.47772/IJRISS.2024.8120360

Received: 18 December 2024; Accepted: 26 December 2024; Published: 24 January 2025

ABSTRACT

Introduction

Childbirth, a critical and vulnerable phase in women’s lives, is often marred by dehumanizing practices in regions such as Togo, where inadequate healthcare infrastructure and a lack of training in respectful care exacerbate the challenges. While the WHO advocates for care centered on women’s rights and dignity, local realities reveal significant gaps, particularly regarding the choice of birthing positions and respect for cultural preferences [1]. Promoting humanized childbirth emerges as a key solution to improving patient experiences, strengthening their trust in the healthcare system, and reducing maternal mortality. This article highlights initiatives supporting this approach in Togo, exploring the progress made, persistent challenges, and recommendations for mainstreaming practices that place women at the center of obstetric care.

Methodology

The study is based on a literature review and semi-structured interviews with local stakeholders: women, health care providers, traditional chiefs, community health workers and members of management committees. Data were drawn from institutional reports, care monitoring documents and testimonies collected in May 2024.

Results

The results show that several respectful and humanised birth practices, such as the use of squatting, sitting or standing positions, promote a better birth experience. A significant improvement has been observed in the number of births attended by skilled personnel, which has doubled in three years in certain peripheral care units (USP) in Togo. These changes correlate with an increase in women’s satisfaction and better adherence to postpartum family planning and newborn care.

Discussion

The study highlights the importance of respecting women’s cultural preferences, such as their preference for traditional birthing positions (squatting, sitting), which are often considered more natural and comfortable. This respect for cultural beliefs not only promotes trust in the health system, but also improves obstetric outcomes.

Conclusion

Promoting humane, respectful childbirth in Togo requires systematic reform of obstetric practices, commitment from local communities and adaptation to cultural norms. By placing women’s rights and dignity at the centre of care, it is possible to improve the quality of maternal health care and services, and increase client adherence and satisfaction with health facilities.

Keywords: Humanised childbirth, women’s rights, Togo

INTRODUCTION

Childbirth, a critical and vulnerable phase in a woman’s life, is often associated with dehumanizing practices in regions such as Togo, where inadequate healthcare infrastructure and a lack of training in respectful care exacerbate the challenges. Although the WHO advocates for care that prioritizes women’s rights and dignity, local realities reveal significant gaps, particularly regarding the choice of birthing positions and respect for cultural preferences [1]. In many sub-Saharan African countries, including Togo, obstetric care is often associated with dehumanizing practices such as poor reception, verbal abuse, physical mistreatment, or neglect [2]. These practices violate the fundamental rights of patients and contradict the World Health Organization’s recommendations for respectful maternal care [1]. Promoting humanized childbirth is a key solution to improving patients’ experiences, rebuilding their trust in the healthcare system, and reducing maternal mortality.

Training obstetric staff, designing delivery rooms appropriately, and providing adequate equipment to enable women to choose their preferred birthing position are crucial factors in promoting respectful and harmonious childbirth.

This article highlights initiatives supporting this approach in Togo by examining the progress made, persistent challenges, and recommendations for embedding practices that place women at the center of obstetric care.

METHODOLOGY

This study is based on a qualitative review, including an analysis of scientific publications, institutional reports and national policies on maternal health in Togo. It also draws on epidemiological data and testimonies collected during previous obstetric care projects.

In addition, semi-structured interviews were conducted with various key stakeholders, including traditional chiefs, beneficiaries, maternal and child health service providers (midwives, doctors, nurses), community health workers and members of management committees. This approach aims to provide multiple perspectives for an in-depth understanding of

Definition of terms

Respectful maternity care (RMC) includes care that is kind, free from abuse, timely, non-discriminatory and respectful of local cultural values, which are fundamental to ensuring a positive and dignified birth experience.

Study sites

Peripheral Care Units (PCUs), which are first-level health centres in the Kara and Central regions, were randomly selected.

Data collection methods and tools

Data were collected through archives and interviews with local stakeholders using a pre-tested, validated semi-structured interview guide and data collection grid. The grid included six key headings: layout of the labour and delivery room, preferred position for delivery, level of customer satisfaction, use of other health services, barriers to service use, while the questionnaire included questions under three headings: training of health staff, information management tools and system administration, and equipment and layout of obstetric services. This approach allowed an in-depth evaluation of the humanised approach to childbirth.

Data sources

Local health system stakeholders and documents such as ANC and birth registers, Expanded Programme on Immunisation (EPI) records and tally sheets were the main sources of data. Stakeholders include beneficiaries, spouses, traditional chiefs, SMCs, health providers, etc.

Sampling

The approach is being implemented in 02 of Togo’s 05 regions. Six (06) peripheral care units were randomly selected, 03 per region. All stakeholders who were present at the time of the survey and gave their consent were selected for interview. In addition, all available documents recording service delivery data at health centre level were used.

RESULTS

People interviewed

A total of 21 people were interviewed, including 8 birth attendants, 03 pregnant women, 02 traditional chiefs, 04 service providers, 02 CHWs and 02 members of COGES.

Humanised birthing practices: autonomy, respect and comfort for clients

The ability to choose positions during labour, where possible and safe, increases patient autonomy and involvement.

Several birthing approaches, such as sitting, standing and squatting, are recognised as humanised and respectful practices. These methods offer women greater autonomy and greater consideration for their preferences and comfort during childbirth.

By allowing women to choose their position, these approaches promote a more inclusive and participatory environment, reduce stress and pain, and improve the overall birth experience. They are part of a woman-centred approach where care is provided with empathy, respect for individual needs and without discrimination.

These practices, combined with respectful and appropriate care, help to improve maternal satisfaction and encourage more women to give birth in health facilities.

Humanised” assisted deliveries by health workers doubled in three yearsDoubling of “humanized” assisted deliveries by care staff in three years

According to data from the DHIS2, over the last three years (2020-2023), the number of births attended by healthcare personnel has doubled, marking a clear improvement in access to obstetric care. Unlike previous births, these deliveries are now described as “humanized and respectful”, taking into account not only clients’ medical needs, but also their cultural and customary preferences. This increase underlines a more inclusive approach, where traditional practices and modern care meet, offering women a more positive and respectful birthing experience.

These results show positive progress against initial targets, with coverage exceeding expectations in both regions. Table I below shows the increase in assisted “humanized” childbirths.

Table I: Improved coverage of births attended by skilled personnel

Source: DHIS2.

Increased uptake of postpartum family planning and newborn care services: a direct impact on client satisfaction

In recent years, there has been a significant increase in women’s uptake of postpartum family planning services and supportive newborn care, such as child protection through follow-up care and immunisation. This development reflects a growing awareness of the benefits of family planning and quality medical follow-up, supported by greater commitment on the part of health care providers.

Women now benefit from more continuous and personalised support, facilitating the use of postpartum contraceptive methods and ensuring more complete immunisation coverage for their newborns. This success is also the result of targeted awareness-raising strategies, improved access to health services, and ongoing training for health care providers.

This improvement in women’s retention is directly linked to client satisfaction with humanised childbirth. Respectful practices that integrate the preferences and needs of the mother have increased women’s confidence in health services. This increased confidence has had a positive impact on their commitment to continue with postnatal care and to use services to care for their newborns. In this way, humanised childbirth not only improves the birth experience but also promotes continuity of care, contributing to the long-term health of mothers and babies.

Inequalities in access to maternity care persist: geographical, financial and information challenges

Obstetric care is characterised by persistent inequalities in access to information, financial resources and health services. Women in rural areas or from disadvantaged backgrounds are particularly affected, facing barriers related to the high cost of care, distance from health facilities and lack of information about available services. These geographical and socio-economic disparities limit their access to quality care, exacerbating maternal and neonatal mortality. The lack of adequate infrastructure, qualified personnel and awareness of the benefits of modern care perpetuates these disparities, highlighting the need for targeted interventions to reduce these gaps and improve equitable access to obstetric care.

DISCUSSION

Limits of the study

Although this study provides valuable information, it has certain weaknesses. Firstly, the sample size of only 21 participants is relatively small, which may limit the scope and generalisability of the results. In addition, the lack of in-depth statistical analysis is another limitation, as the findings are based primarily on qualitative data, with a lack of robust quantitative comparisons to support them further.

The role of ‘daddy champions’ in promoting respectful childbirth: a corroborated approach

Promoting respectful childbirth requires the active involvement of men as ‘champion dads’ or role models in their communities, playing a key role in raising awareness among their peers of the importance of humanised care [1]. These male role models, trained in good practices and issues related to respectful childbirth, can break cultural taboos, encourage emotional and practical support for women, and influence decisions in favour of respectful care [2]. My findings corroborate those of other authors, who also emphasise that involving men helps to transform social norms, strengthen family dialogue and mobilise communities for an environment where women’s needs and choices are respected [3]. In addition, these inclusive approaches are all the more effective when they are supported by sensitised healthcare providers and appropriate community campaigns.

Women’s cultural preferences for birthing positions in Togo: a call for adapted care

In Togo, women’s cultural preferences for birthing positions highlight the importance of respecting local beliefs, practices and perceptions in maternal health care. Respecting these choices not only builds women’s trust in the health system, but also improves their birth experience and obstetric outcomes. This model of care, based on autonomy and respect for women’s preferences, is confirmed by studies such as the one conducted by the Liverpool School of Tropical Medicine [4] and the University of Lomé on respectful maternity care (SMR) in Lomé.

Togolese women do not always adopt the classic birthing position, such as lithotomy, because it is incompatible with their cultural traditions and beliefs. In many communities, squatting or sitting positions are considered more natural and effective. For example, some women prefer the squatting position for its spiritual connection and ability to facilitate childbirth, while others prefer the sitting position, which is often symbolically associated with strength and the natural use of gravity.

Studies, including one by Diawara [5], show that Mossi and Peul women in West Africa prefer the squatting position for its spiritual significance and perceived role in facilitating childbirth. Conversely, Bantu communities in southern Africa generally prefer the sitting position, which symbolises strength and makes optimal use of natural gravity.

The lithotomy position, widely used in modern hospitals, is often perceived as intrusive and uncomfortable. It exposes women’s privacy to multiple caregivers, which is contrary to the norms of modesty in many African cultures [6]. In contrast, local traditions value active postures in which the woman plays a central role in the birth process, favouring the opening of the pelvis and the use of gravity [7].

The influence of matrons[1], key figures in rural communities, also reinforces the attachment to these traditional practices, often in opposition to modern medical standards [8]. Spiritual considerations also add an important dimension: among the Luo of Kenya, for example, squatting is associated with symbolic rooting in the earth, perceived as the source of life. Conversely, lying down is seen as passive and disconnected from this vital energy [9].

These observations highlight the importance of a culturally respectful and appropriate approach to maternity care. Incorporating women’s beliefs and preferences into medical practice can not only improve their comfort and satisfaction, but also encourage greater use of maternal health services.

Satisfaction with antenatal care influences uptake of vaccines

Our findings highlight the critical importance of women’s satisfaction with antenatal and postnatal care in improving uptake of immunisation services. This link is illustrated by examples from countries such as South Africa, India, Niger and Vietnam, where high-quality, respectful and well-explained care promotes mothers’ adherence to health services, including immunisation of their children [10, 11]. Clear communication, continuity of care and attention to cultural specificities play an essential role in women’s satisfaction and help improve immunisation coverage [12,13]. The integration of high-quality antenatal and postnatal care, focused on patients’ needs, is fundamental to improving long-term child health [14, 15].

Ensuring the Sustainability of Maternal Health Interventions in Togo: Diversification of Financing and Integration of Humanised Deliveries

The financing of this approach depends on external funding. To ensure the long-term sustainability of interventions, it is essential to diversify funding sources by mobilising local resources, building the capacity of institutions and local teams, and integrating initiatives into national policies with realistic budget plans. The creation of innovative financing mechanisms, such as public-private partnerships and social investment funds, should be encouraged. Rigorous monitoring and evaluation enables strategies to be adjusted in line with results, while the active involvement of communities and local players promotes ownership and co-financing of interventions, thereby reducing dependence on external funding. A policy dependent on external funding can have several negative consequences, such as financial vulnerability due to fluctuations in donor priorities, a lack of autonomy in programme management, and delays in local capacity building [15-16].

It can also generate instability and contingencies in the event of a sudden withdrawal of funding, create inequities in access to interventions, and encourage a welfare effect by discouraging local efforts to mobilise internal resources [17-18]. To avoid these impacts, it is essential to diversify funding sources and promote local ownership and sustainability [19].

In the Togolese context, it is imperative to integrate the culture of humanised childbirth into national health policy and to allocate adequate funding to ensure equitable, high-quality coverage. This includes the training of health workers, the development of national standards for safe and respectful childbirth practices, and the commitment of communities to promote maternity care practices centred on women’s dignity and rights.

CONCLUSION

Promoting humanised and respectful childbirth in Togo requires a profound change in obstetric practices. To ensure the success of this approach, investment in equipping health facilities, setting up birthing areas and providing ongoing training for health staff in humanised childbirth is essential. This includes providing adequate facilities to respect women’s dignity, as well as specific training for caregivers in respectful and personalised childbirth practices that promote a positive experience for both mother and child. By putting women’s rights and dignity at the centre of care, Togo can significantly improve maternal health outcomes and build confidence in its health system.

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FOOTNOTES

[1] designates community maternity health assistants or companions experienced in maternity care