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When Dr. Samina Khalid gave birth about two decades ago in Pakistan, her firstborn baby nearly died. At the time, she wished that her doctor would just listen to her.

鈥淭he doctors did not realize [the umbilical cord] was around my daughter鈥檚 neck. I was going through labor, but the baby was not coming down,鈥� Khalid says. 鈥淚 [felt] so helpless, and I kept telling my obstetrician that I am having pain. [But] she just said, 鈥榊ou are having false pains, these are not real pains.鈥欌�� After the baby鈥檚 heartbeat plummeted, Khalid says, it was a miracle her daughter survived.

This harrowing experience stayed with her and  motivated Khalid to oversee a large-scale survey of a quarter-million Pakistani women, centered around a single open-ended question: 鈥淲hat do you want for your maternal and reproductive health care?鈥�

This was part of a worldwide effort conducted by the White Ribbon Alliance, a grassroots nonprofit focused on decreasing maternal and newborn deaths. The global survey, called 鈥�,鈥� collected the voices of 1.2 million women and girls age 15 and above in 114 countries, from the villages of Pakistan鈥檚 Sindh province to Kenya鈥檚 nomadic Maasai communities. Survey collectors visited women in their homes, at colleges, churches, health clinics, and even at a music festival in the United Kingdom. Remarkably, almost half of the total responses came from India and Pakistan.

So, what do women want? The most common answers, with more than 100,000 responses were respect and dignity. They asked for doctors and nurses to be kind, to not dismiss their opinions, and to listen to their needs. The desire for running water, sanitation, and hygiene in health care facilities were next on the list, with basic medicine and supplies a close third.

Learning what women and girls actually want

The survey collectors鈥攁 mix of women and men鈥攔eceived a set of guidelines before they set off. The most important rule was that women and adolescent girls have to give informed consent and fully understand that their answers might be presented to policymakers. The surveyors asked the participants to write their responses on paper, with the option to record their answers if they were illiterate.

In many areas, the survey collectors served their own communities. 鈥淚nstead of sending strangers, we involved people from the same area, so [women and girls] could confide in them, and they felt there is someone to listen to them at last,鈥� Khalid says.

Winfred Ongom, a 26-year-old nutritionist in Uganda, personally collected responses from 8,000 women and girls in the northern part of her country. She joined this project, in part, because of her own sister鈥檚 experience of getting insulted in a hospital while giving birth.

The staff told Ongom鈥檚 sister she was 鈥渢oo lazy to push鈥� when she requested a cesarean section after a full day of intense labor. They refused the C-section and Ongom鈥檚 sister was in labor for two days, facing major complications. 鈥淚 realized no woman should go through this,鈥� Ongom says.

In Kenya, Angela Nguku traveled across her country to interview women. 鈥淣o one had ever asked them 鈥榳hat is your top-most request for quality reproductive health services?鈥� They thought they have no power, no right, and here we are giving them power to be able to say these things,鈥� says Nguku, a former midwife who oversaw the survey in Kenya. She says they opened up when they realized they could talk about their needs freely.

Nguku says her midwifery training never touched on what she ultimately discovered in the survey results. 鈥淣o one told me that respect and dignity was the most important thing that women needed when they come for health care. But, see, it鈥檚 topping the list,鈥� she says. 鈥淚 was told drugs, medicines, supplies, ultrasounds, ambulances [are the most important] when I was in school,鈥� she says. 鈥淪o, it was like everything toppled, the pyramid changed.鈥�

Persuading policymakers to take real action

The survey idea originated in India, and then grew into a larger campaign. 鈥淭hings were looking up in our country, we had a lot of good stuff happening, but we knew there was something missing,鈥� says Dr. Aparajita Gogoi, who co-chaired the campaign and directs the Centre for Catalyzing Change in India. 鈥淲hat was missing was the voices of women.鈥�

To persuade policymakers to take real action, Gogoi says, 鈥渨e wanted to take [those voices] to the highest levels of power.鈥� So, on India鈥檚 National Safe Motherhood Day, 150 women from the survey stood in front of the country鈥檚 health minister and presented a list of their demands. He listened, and India is already starting to see changes. After hearing from the women, the health minister launched a new national initiative to improve labor rooms in hospitals, and included respectful care as a central priority.

The survey results also prompted India鈥檚 nursing association to fix the root cause of the problem: They鈥檙e  writing a new chapter on respectful care for textbooks that every nurse across the country will read in school.

鈥淭his is the national body of nurses, so whatever they do impacts all the nurses in all the states,鈥� Gogoi says. The updated textbooks will cover the main principles of respectful care: treating patients with dignity, patients鈥� rights, the importance of patient consent, and confidentiality. While these may seem like basic health care tenets, it鈥檚 not the case everywhere.

In India, women from poorer areas are commonly physically slapped by health providers, Gogoi says. Sometimes medical practitioners even begin invasive physical procedures without telling the patient. In the new textbook, nurses will learn about the importance of respectful care before they can graduate and get jobs.

In the sub-Saharan nation of Malawi, many women made another simple, but very important request: hygienic maternity wards. The local survey team used the data to lobby for better sanitation in health centers. In northern Malawi鈥檚 Chitipa District, local leaders committed to building a new maternity wing with renovated plumbing systems, new toilets, and running water in four health facilities.

In the countries that got the most survey responses (Mexico, Nigeria, Uganda, Kenya, Tanzania, Malawi, India, and Pakistan), White Ribbon Alliance will organize town-hall style forums for women and girls to speak directly to decision-makers.

The most important voice

鈥淭he simplicity of the messages was pretty profound and moving,鈥� says Dr. Dilys Walker, who leads the Global Maternal and Newborn Child Health Research Cooperative at the University of California San Francisco (UCSF) Institute for Global Health Sciences. 鈥淸The campaign was] remarkably successful at keeping the story very personal, and keeping it very clearly the voices of women around the world,鈥� she adds.

Walker and other global health experts say the survey presents already-known information, but it has the power to create policy change by sending a strong message to leaders. 鈥淚t鈥檚 the most important voice if we鈥檙e able to hear it,鈥� says Walker, who has worked in this field for decades. 鈥淪ome of the approaches my colleagues and I use may document and uncover things, but they may not necessarily change things, because they tend not to provide messages that policymakers can grab onto,鈥� she adds.

The gender equality experts at Ladysmith, Dr. Tara Cookson and Dr. Lorena Fuentes, commended the survey鈥檚 emphasis on women speaking for themselves. 鈥淢aking sure women鈥檚 accounts of their own lives 鈥榗ount鈥� as evidence is so important,鈥� they say.

Ladysmith says asking an open-ended question can help women explain their needs within their own geographic and cultural context. 鈥淸This survey] can do this in a way that standard surveys just can鈥檛,鈥� Cookson and Fuentes say.

鈥淚t鈥檚 significant that [this] initiative went beyond simply collecting data鈥攖hey connected it to pathways for action,鈥� Cookson and Fuentes say. However, they also note that What Women Want did not delve into how to finance health care upgrades. 鈥淸These changes] require adequate public financing, and the report comes short of highlighting pathways for states to take action at a high-level.鈥�

Dr. Walker from the University of California in San Francisco is also concerned some policy-makers will think there鈥檚 an easy fix to these problems. 鈥淚t鈥檚 not about going to a two-hour training on respectful care and things will get better,鈥� Walker says, adding that it has to be a 鈥渕ore integrated, comprehensive behavior change approach.鈥�

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In Pakistan, Dr. Samina Khalid鈥檚 Islamabad office is packed with boxes full of survey answers. 鈥淲hen I look at these boxes, I realize these are not boxes. These are voices of women, these are expectations of women,鈥� she says. 鈥淚 don鈥檛 want to bury these. I want them to be heard, and I want them to be implemented.鈥�

She pulls out the story of a young bride who took a break from her own wedding to answer the survey. Wearing her traditional red bridal dress and jewelry, she said she wants to see more trained community midwives. 鈥淭his was so important for her, that she had to take the time out of her wedding and share what she wants for health services,鈥� Khalid says.

鈥淲e cannot even imagine what kind of problems women go through in their communities. There is no one to hear them,鈥� she adds. Khalid says they have taken the survey results to parliamentarians, because 鈥渨e want to ensure that these stories are not going down the drain.鈥�