By Amanda Landrian (University of California, Los Angeles)
Reducing maternal mortality remains a public health priority in many low- and middle-income countries. Great efforts have been made globally to increase institutional deliveries (versus delivering at home) as a means of addressing maternal mortality by increasing women’s access to skilled birth attendants and emergency obstetric care. Indeed, the proportion of births taking place in institutional facilities, particularly in Africa and Asia, has increased dramatically in recent decades.
In India, nearly 80% of births now occur in health facilities compared to just 35% in 2000. In this same timeframe, the national maternal mortality ratio (MMR) has fallen from 370 to 150 deaths per 100,000 live births. Assuming these trends continue, India is on track to meet its Sustainable Development Goal of an MMR below 70 per 100,000 live births by 2030.
Still, with so many more women turning to facility deliveries, a shift is needed from focusing solely on getting women into a health facility to a deeper examination of the conditions women are met with once there and how these conditions may impede progress toward reductions in maternal mortality and morbidity.
(Mis)treatment of women during childbirth
In India, evidence suggests that physical and verbal abuse, stigma and discrimination, vaginal examinations or other treatments without consent, and neglect or abandonment are common experiences for women during delivery. In fact, one study found that all women surveyed experienced at least one indicator of mistreatment during childbirth.
Bribes and informal payment requests are another form of mistreatment commonly experienced, despite mandates that maternity care be provided for free in the country. Women and their families may be asked to make these payments to obtain medical tests or treatments, to receive better care, or to receive any care at all. But does the payment of a bribe actually translate to better, more timely care, and thus, better outcomes? This was a question that had yet to be explored in the research.
Bribes = quality maternity care?
We present data from 2,018 women who delivered in public facilities in Uttar Pradesh, India examining the association between bribes and informal payments and the experience of quality of care and maternal complications. We found that 43% of women were asked to pay a bribe, and that those who were asked to pay a bribe received poorer care. Specifically, women who were requested to pay a bribe were less likely to receive all or most health checks at every stage of labor and delivery (e.g., upon arrival to the facility, during and after labor and delivery) and more likely to experience maternal complications.
What might explain these surprising results? One possibility is that facilities where bribe requests are most common are also more likely to suffer from staff and equipment shortages that would influence quality of care. That is, bribe requests are symptoms of larger institutional problems that influence quality of care. It is also plausible that providers are more inclined to ask women for a bribe when the woman is experiencing problems or complications to recoup the costs associated with providing emergency care. Alternatively, our findings may be telling of a woman’s inability or refusal to pay a bribe, whereby quality of care diminishes, or care is refused altogether, when bribe requests are not fulfilled. Remaining questions around how bribe requests are related to poorer care for women during childbirth and maternal complications warrants further investigation. Collecting information on the timing of bribe requests during the various stages of labor and delivery and if/when these requests are fulfilled is essential to doing so.
Implications for programming and policy
Bribe requests during childbirth were a common experience among women in our study. While many questions remain, the results provide important direction for institutional policies and programs for addressing bribes. For example, facilities should develop clear guidelines around bribe requests, and providers and other facility staff members should receive training on these guidelines. Accountability mechanisms must also be developed, with clear punishments for facilities where bribes are common and rewards for those where the practice is not. Importantly, facilities must be sufficiently funded to ensure an adequate supply of essential medicines and supplies needed for every stage of labor and delivery. Well-stocked facilities and proper supply chains, coupled with improvements in the distribution and availability of the healthcare workforce and overall facility environment, may reduce the likelihood that women incur costs related to bribes or other informal payments. Finally, programs that target women’s expectations of care during childbirth, including knowledge on their rights as a patient, how to demand better care, and user fees not applying during pregnancy and delivery care in public facilities must be widespread.
The issue of bribes and informal payments during delivery is of significant concern in the region and globally, with gendered and cultural components as to who pays and to what ends. We hope this work propels additional research on not only the role of bribes in maternity care, but the effectiveness of policies and programs aimed at eliminating them altogether. Doing so would get us that much closer to ensuring a dignified and respectful childbirth experience for all women everywhere.