From “Obstetrical Violence” Complaints to “Respectful Maternity Care”: The Complaints Commissioner as Facilitator of Organizational Change

In this case study, we describe an approach to dealing with a complicated, systemic, and multifaceted organizational issue: perceptions of obstetrical violence in the continuum of maternal care from antepartum care, birthing, to post-natal care. Résumé Abstract Dans cette étude de cas, nous décrivons une approche visant à aborder un problème organisationnel compliqué, systémique et à multiples facettes : les perceptions de violences obstétricales dans le continuum des soins maternels, depuis les soins prénataux, jusqu’à l’accouchement et les soins postnataux. In this case study, we describe an approach to dealing with a complicated, systemic, and multifaceted organizational issue: perceptions of obstetrical violence in the continuum of maternal care from antepartum care, birthing, to post-natal care. Mots-clés


INTRODUCTION
In this case study, we describe how a Service Quality and Complaints Commissioner Office dealt with complaints regarding "obstetrical violence", and how these served as levers to improve the continuum of maternal care, from antepartum care, birthing, to post-natal care.

SOCIAL CONTEXT: DENUNCIATION OF "OBSTETRICAL VIOLENCE"
The denunciation of obstetrical violence is not a new phenomenon. In 1958, an American maternity ward nurse gathered testimonies from women and nurses about perceived mistreatment such as physical contention, delaying childbirth to a more convenient time for the physician, threatening women to have them stop crying loudly, and performing episiotomies without anesthetics (1). This was the first of many academic articles and books documenting mistreatment during childbirth over the decades. Various reforms were proposed, and advocacy organizations were created. Yet, women worldwide continue to experience mistreatment during childbirth (2). In recent years, the movement is receiving more attention and global recognition (3)(4)(5).
The term "obstetrical violence" was coined in the 2000s and is defined as: " [v]iolence exercised by health personnel on the body and reproductive processes of pregnant women, expressed through dehumanizing treatment, medicalization abuse, and the conversion of natural processes of reproduction into pathological ones…" (6). In addition to physical mistreatment, obstetrical violence also encompasses issues in fiduciary relationships and in the organization of care, such as disrespectful comments, lack of consent, lack of choice for procedures, and separating mothers and babies (6)(7)(8)(9). It includes issues that may occur at any stage of the maternal care continuum.
In Quebec, "obstetrical violence" generated media attention in 2019. The newspaper La Presse published a series of articles recounting the experience of patients and reporting on the popularity of the "StopVOG" website, an initiative to encourage women to share their experience with obstetrical violence so that the problem would no longer remain taboo and unaddressed (10,11).

COMPLAINTS COMMISSIONER'S INTERVENTION
In the weeks before and after the media exposure, the office of the Service Quality and Complaints Commissioner of the CIUSSS West-Central Montreal noticed an increase in the number of complaints pertaining to perceived mistreatment during maternal care and more specifically, using the term obstetrical violence (12). As women were encouraged to speak up about their experience (10,11), many were choosing the Commissioner as their interlocutor; some of the letters conveyed hope that the social movement would translate into organizational changes. Users complained about inappropriate comments, lack of explicit consent, babies being separated from mothers, and judgment of birthing choices such as natural birth, home birth, and midwifery. These aspects pertain to the quality of care, which is at the very core of the Commissioner's mandate. Therefore, the Commissioner sought a means to provide the CIUSSS West-Central Montreal with a reflection of the social movement to stop obstetrical violence inside the walls of their establishments. While Commissioners' main mandate is the treatment of individual complaints, they also hold the prerogative to conduct systemic interventions on topics that they deem preoccupying for patient rights or the quality of care and services (13). Based on the increased number of complaints as well as the evident social movement aiming to tackle the issue of obstetrical violence, the Commissioner launched an intervention on this topic in 2019.
This first part of the intervention was a report mapping of the issues arising during the maternal care continuum. It included a description of the social movement to stop obstetrical violence and a thematic analysis of the recent complaint. The report concluded by emitting the following recommendation: "The Commissioner recommends that practitioners and management identify organizational elements that hinder practitioners in their efforts to establish therapeutic relationships." More specifically, the Commissioner recommended improving the presentation protocol for practitioners, avoiding unnecessary comments, using explicit informed consent for all procedures, offering treatment alternatives, continuing efforts to help patients prepare for the experience of giving birth, and seeking opportunities for further training in communication and fiduciary relationships. The report also mentioned the necessity to improve users' decisional capacity concerning vaginal birth after cesarean delivery (VBAC), ensuring the right to be accompanied even in the context of the pandemic, and looking into the possibility of making the necessary structural and architectural changes to allow mothers and babies to be kept together at all times, even in the context of off-hour cesarean and NICU hospitalizations. In keeping with the Quebec Act Respecting Health Services and Social Services, the Commissioner submitted the report to the Vigilance Committee and the Board of Directors, along with the relevant clinical directorate and medical chiefs, to respond to the recommendations.

COMPLAINTS COMMISSIONER: MOBILIZER OF KEY STAKEHOLDERS TO FACILITATE ORGANIZATIONAL CHANGE
The report aimed to shed light on this issue through the angle of complaints to contribute to mobilizing key stakeholders and to support the ongoing efforts toward quality improvement demonstrated by medical chiefs, directors, and clinicians. To ensure that the report would be a lever to mobilize key stakeholders, the following elements were considered.
When writing the report, the Complaints Commissioner and her team paid particular attention to remaining neutral about the controversial term "obstetrical violence." They made sure to acknowledge the perspective of clinicians who rightfully do not see themselves as perpetrators of violence when they aim to provide the best medical standard of care and eventually, save the life of a mother or baby. The Complaints Commissioner's team thought it was important to highlight that the report was a response to a social movement, as well as a response to increasing complaint numbers, and so did not aim to cast blame but rather to contribute to improvement in practices.
Numerous discussions occurred with the managers of the clinical directorates and the medical chiefs during the examination process. A presentation was done during the Grand Rounds to share preliminary analysis and stimulate discussions with clinicians. The recommendations were evidence-based as they followed a scoping analysis of the social context and best practices, as well as a thematic analysis of the complaints received. The consultation process ensured that the recommendations were also realistic based on local considerations. Complaints are a useful tool to shed light on areas needing improvement through the perceptions and experience of users. However, they only represent users' perspectives and do not capture the constraints under which managers operate as they strive to offer a positive user experience.
The report was received positively by clinical directorates and medical chiefs. In response to the report, a Respectful Maternity Care Committee was put in place to gather representatives from obstetrics, family medicine, nursing, midwifery, and Quality & Risk Management to discuss respectful maternity care on a monthly basis. The Commissioner was invited to take part in the meetings to provide her insight. This committee also solicits feedback from patient-partners. The Committee rapidly identified a central narrative for their work: making a strong position statement on Respectful Maternity care, including shared decisionmaking, patient-centered care, and maintaining excellent care. As recommended by the Commissioner, communication workshops were set up and as a group, the various teams started to work toward improving their clinical practices concerning communication, information, and consent. While part of the work to improve users' experience in obstetrics remains ahead, numerous initiatives are ongoing to improve the information offered for users, create a stronger collaborative work environment, formalize organizational communication strategies, and overcome structural environmental obstacles. This strong engagement of key stakeholders, such as clinical directorates and medical chiefs, is essential so that the culture change percolates in all aspects of practice, both organizationally and clinically.

BARRIERS AND FACILITATORS TO QUALITY-BASED INTERVENTIONS
Many barriers and facilitators can influence the sustainability of quality-based interventions in a healthcare setting. As per Cowie et al. (14), barriers include failure to consider social and political contexts and a human resources consideration such Page 76 as workload pressures, shortages, and high turnover. In this case, the social context was well accounted for. Given the pandemic, it is anticipated that human resources considerations may make it more difficult, although not impossible, for the Respectful Maternity Care Committee to implement and sustain improved practices. Facilitators to implementation and sustainability include clear accountability of roles and responsibilities, strong leadership/champions, and adequate organizational support (14). In this case, the Complaints Commissioner's intervention empowered key leaders/champions from each team involved in the maternal care continuum within the CIUSSS, and roles and responsibilities were clarified. The success of the ongoing improvement projects will depend largely on the maintenance of organizational support as some improvements would require changes in the organization of work and space that go beyond clinical best practices at the micro level.

CONCLUSION
Being an independent and impartial office, the very nature of the Complaints Commissioner's mandate makes it challenging, yet essential, to find allies within an organization. This case study exemplifies how the Complaints Commissioner was able to act as a powerful tool to mobilize stakeholders and support endeavors to improve practices. Sharing such success stories amongst Complaints Commissioners in practice communities could contribute to solidifying the role of Complaints' Commissioners as agents for improved care.