Globally, women are often on the receiving end of violence, and painfully, the history of Rwanda’s 1994 Genocide against the Tutsi paints a graphic and tragic picture of the horrors faced by women in any society in turmoil. Fast forward 29 years later, we see Rwanda transformed, into a land of peace and tourism, attracting the world. The role of the woman in the rebuilding of this nation — from its politics to its economy — is evident.

As a trailblazer and a positive outlier in the prioritisation of women’s rights, Rwanda boasts more women in political positions than any other country. These women in leadership deserve respect, and so does the waddling, often tired but hopeful, pregnant woman from the remote rural village in Rwanda. Respect is a core part of Rwandan culture and shapes many traditional social interactions. Extending this respect into the process of childbearing is critical for amplifying the investments of Rwandan women and mothers, in nation-building. Campaigns and programmes on respectful maternity care are underway across the country, and as a health professional, I must add my voice to promoting this critical next frontier for maternal health.

Strides made in maternal health care provision have been captured by the Rwanda Demographic Health Survey (RDHS) 2014-2015, which records that the maternal mortality ratio in Rwanda has decreased from 2,000 to 210 per 100,000 between 2000 and 2015. Deliveries in healthcare facilities have also increased from 27% to 91% mostly due to strong political will.

Respectful maternity care in the healthcare system has demonstrated that quality maternity care is not just limited to physical well-being but involves emotional and psychological aspects. Long-term national plans and policies, strong implementation frameworks, solid-tiered healthcare structures, and a committed workforce at every healthcare level have helped positively shape maternity care in the land of a thousand hills (Maternal Newborn and Child Health Strategic Plan (2018–2024).

Yet, more can be done to dignify and respect the woman during pregnancy, and childbirth.

Recently, during my bedside teaching with students in an obstetrics and gynaecology ward, I had a sad experience that brought back many other similar scenarios from the past 10 years of my medical career. Alice (not her true name), a 28-year-old pregnant mother with five children walked in and requested to be attended to by the healthcare provider in the admission room.

Sadly, instead of a respectful response, she was told, "With your age, how many babies do you think you will have? Are you a pig? They are the ones giving birth to many piglets like you!” Alice stood there in disbelief, shocked, and unable to respond to the dehumanising line of questioning. I was equally shocked to hear this and waited for the appropriate moment to counsel her. Alice just looked down and cried. The nurse’s motives were right, but the methods were wrong.

After Alice gave birth, she experienced postpartum depression. This made it challenging for her to nurse the baby because of her traumatic experience while seeking care. Her baby suffered from not being breastfed and was eventually taken to the hospital for over two weeks. Fortunately, Alice and the baby recovered.

Regrettably, this was not an isolated incident. I have witnessed several pregnant women receive similar or worse treatment. The reality is that not every "Alice” recovers. Maternal and child healthcare systems still fail to adequately provide respectful care which focuses on the humane and dignified treatment of childbearing women throughout pregnancy, birth, and the period following childbirth.

This kind of care champions maternal health care that safeguards the dignity, privacy, and confidentiality of women and girls and ensures freedom from harm and mistreatment while enabling informed choice and continuous support during labour and childbirth (WHO, 2018). The Ministry of Health must double its efforts to strengthen these systems by investing in human and capital resources, training healthcare workers in these concepts, and monitoring the implementation of care that reflects respectful values and standards.

Additionally, given the complex drivers of mistreatment during facility-based childbirth, interventions in healthcare and interpersonal relationships between women and healthcare providers at all levels of healthcare are crucial.

All relevant stakeholders, including mothers, healthcare professionals, hospital management, and the public, must gather to address respectful maternity care. We must create awareness, train, and build capacity. By investing in the professional development of healthcare providers and a national advocacy programme, the Ministry of Health in Rwanda can further enhance the quality of care and further reduce maternal mortality and morbidity, saving costs for the economy in line with Rwanda’s transformative agenda.

Through strengthening knowledge and skills in respectful maternity care both in medical and nursing schools and through continuous professional development (CPD) of the health workforce, these capacity-building initiatives can foster a culture of change and help establish trust between healthcare professionals and expectant mothers, resulting in improved health outcomes and reduced maternal mortality rates.

Rwanda has recorded significant progress in maternal health outcomes in record time, and Universal Health Coverage for maternal care is inspiring. The Rwandan government through the Ministry of Health has created the enabling environment for respectful maternity care, as it is committed to strengthening policy and legal frameworks, engaging communities and empowering women, continuous training of health care providers, leveraging technology for accessible quality care; and addressing socio-economic barriers.

However, there is still work to be done as occasionally, there is an Alice, a Benitha, and a Francoise who does not enjoy respectful care during pregnancy. Our collective ‘Umuganda’ should be to promote awareness of the concepts of respectful maternity care in rural areas of Rwanda and advocate for every "Alice”.

As part of the Global Surgery Advocacy Fellowship by Operation Smile, the University of Global Health Equity, and the Nkafu Policy Institute, my focus is on seeing every Rwandan mother respected during pregnancy, labour, childbirth, and recovery. By raising awareness and best practices towards respectful maternal health care at the community level and among health care providers.

Simon-Pierre Bigirimana is a medical doctor currently serving as a faculty member at the University of Global Health Equity.