Post on 02-Aug-2018
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
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Health as a Human Right – Day 1, Session 3
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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
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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?