Disrespectful Maternity Care Research Articles

Multi-stakeholder Perspectives on the Maternal, Provider, Institutional, Community, and Policy Drivers of Disrespectful Maternity Care in South-East Nigeria.

PurposeUnderstanding the contextualized perspectives of stakeholders involved in maternal health care is critical to promoting respectful maternity care. This study explored maternal, provider, institutional, community, and policy level drivers of disrespectful maternity care in Southeast Nigeria. This study also identified multi-stakeholder perspectives on solutions to implementing respectful maternity care in health facilities.Materials and MethodsThis was a mixed-methods cross-sectional study conducted in two urban cities of Ebonyi State, South-eastern Nigeria. Data were collected using semi-structured questionnaires, focus group discussions, and key informant interviews with mothers, providers, senior facility obstetric decision-makers, ministry of health policymaker, and community members. Quantitative data and qualitative data were analysed using SPSS version 20 and manual thematic analysis, respectively.ResultsMaternal level drivers were poor antenatal clinic attendance, uncooperative clients, non-provision of birthing materials, and low awareness of rights. Provider factors included work overload/stress, training gaps, desire for good obstetric outcome, under-remuneration and under-appreciation. Institutional drivers were poor work environments including poorly designed wards for privacy, stressful hospital protocols, and non-provision of work equipment. Community-level drivers were poor female autonomy, empowerment, and normalization of disrespect and abuse during childbirth. The absence of targeted policies and the high cost of maternal health services were identified as policy-related drivers.ConclusionA variety of multi-level drivers of disrespectful maternity care were identified. A diverse and inclusive multi-stakeholder approach should underline efforts to mitigate disrespectful maternity care and promote respectful, equitable, and quality maternal health care.

Health Care Workers' Perspectives of the Influences of Disrespectful Maternity Care in Rural Kenya.

While disrespectful treatment of pregnant women attending health care facilities occurs globally, it is more prevalent in low-resource countries. In Kenya, a large body of research studied disrespectful maternity care (DMC) from the perspective of the service users. This paper examines the perspective of health care workers (HCWs) on factors that influence DMC experienced by pregnant women at health care facilities in rural Kisii and Kilifi counties in Kenya. We conducted 24 in-depth interviews with health care workers (HCWs) in these two sites. Data were analyzed deductively and inductively using NVIVO 12. Findings from HCWs reflective narratives identified four areas connected to the delivery of disrespectful care, including poor infrastructure, understaffing, service users’ sociocultural beliefs, and health care workers’ attitudes toward marginalized women. Investments are needed to address health system influences on DMC, including poor health infrastructure and understaffing. Additionally, it is important to reduce cultural barriers through training on HCWs’ interpersonal communication skills. Further, strategies are needed to affect positive behavior changes among HCWs directed at addressing the stigma and discrimination of pregnant women due to socioeconomic standing. To develop evidence-informed strategies to address DMC, a holistic understanding of the factors associated with pregnant women’s poor experiences of facility-based maternity care is needed. This may best be achieved through an intersectional approach to address DMC by identifying systemic, cultural, and socioeconomic inequities, as well as the structural and policy features that contribute and determine peoples’ behaviors and choices.

Quality of measures on respectful and disrespectful maternity care: A systematic review.

This systematic review aimed to critique the process of development and psychometric properties of tools measuring respectful or disrespectful maternity care experienced by women during labor and birth in low- and middle-income countries. The MEDLINE, Embase, CINAHL, Web of Science, PubMed, and Cochrane Library electronic databases were systematically searched from their inception to February 2020. Methodological quality was assessed using the COnsensus-based Standards for the selection of health Measurement INstruments checklist. Six tools measuring respectful maternity care during the intrapartum period were identified. Measurement error, cross-cultural validity, and responsiveness were not evaluated by any tool developers, while structural validity, internal consistency, and hypothesis testing were the most frequently assessed measurement properties. Interestingly, this review could not identify any measures of disrespectful care even though most included measures focused on disrespect and abuse. No measure was of sufficient quality to determine women's experiences of disrespectful and respectful maternity care in low- and middle-income countries. New valid and reliable measures using rigorous approaches to tool development are required.

Prevalence and predictors of perceived disrespectful maternity care in postpartum Iranian women: a cross-sectional study

BackgroundDisrespectful maternity care is a key impediment to achieving a good quality care. Identifying predicting factors can be used in mitigating any potential risk in for disrespect and abuse in maternity care. The present study was conducted to determine prevalence and predictors of perceived disrespectful maternity care among Iranian women.MethodsA cross-sectional study was conducted in three public and three private hospitals in the city of Tabriz involving 334 postpartum women. Tools included socio-demographic, pregnancy, labour and birth characteristics questionnaires, and disrespect and abuse scales. Data were collected in 6 to 18 h after birth. Multivariate logistic regression was used to determine predictors of disrespectful maternity care.ResultsA majority of the women (253; 75.7%) reported one or several types of perceived disrespectful maternity care. The most frequent types related to not allowing women to choose labour positions (142; 44.3%) and not allowing them to move during labour (148; 42.5%). Nighttime childbirth (aOR 3.07; 95% CI 1.61 to 5.88) increased the likelihood of perceived disrespectful maternity care. However, presence of spouses to accompany their wives in waiting rooms (aOR 0.32; 95% CI 0.11 to 0.88), the attendance of private physicians (aOR 0.05; 95% CI 0.02 to 0.12), and midwives (aOR 0.22; 95% CI 0.11 to 0.45) decreased the likelihood of perceived disrespectful maternity care.ConclusionThe results showed high levels of perceived disrespectful maternity care in postpartum women. Therefore, appropriate interventions, such as encouraging spouses’ presence, increasing the number of night shift staff, and training obstetric residents and midwives by holding ethics classes, with particular emphasis on empathy with patients.

Respectful maternity care during childbirth in India: A systematic review and meta-analysis.

Background:Respectful maternity care is a rightful expectation of women. However, disrespectful maternity care is prevalent in various settings. Therefore, a systematic review and meta-analysis were conducted to identify various forms of ill-treatment, determinants, and pooled prevalence of disrespectful maternity care in India.Methods:A systematic review was performed in various databases. After quality assessment, seven studies were included. Pooled prevalence was estimated using the inverse variance method and the random-effects model using Review Manager Software.Results:Individual study prevalence ranged from 20.9% to 100%. The overall pooled prevalence of disrespectful maternity care was 71.31% (95% CI 39.84–102.78). Pooled prevalence in community-based studies was 77.32% (95% CI 56.71–97.93), which was higher as compared to studies conducted in health facilities, this being 65.38% (95% CI 15.76–115.01). The highest reported form of ill-treatment was non-consent (49.84%), verbal abuse (25.75%) followed by threats (23.25%), physical abuse (16.96%), and discrimination (14.79%). Besides, other factors identified included lack of dignity, delivery by unqualified personnel, lack of privacy, demand for informal payments, and lack of basic infrastructure, hygiene, and sanitation. The determinants identified for disrespect and abuse were sociocultural factors including age, socioeconomic status, caste, parity, women autonomy, empowerment, comorbidities, and environmental factors including infrastructural issues, overcrowding, ill-equipped health facilities, supply constraints, and healthcare access.Results:Individual study prevalence ranged from 20.9% to 100%. The overall pooled prevalence of disrespectful maternity care was 71.31% (95% CI 39.84–102.78). Pooled prevalence in community-based studies was 77.32% (95% CI 56.71–97.93), which was higher as compared to studies conducted in health facilities, this being 65.38% (95% CI 15.76–115.01). The highest reported form of ill-treatment was non-consent (49.84%), verbal abuse (25.75%) followed by threats (23.25%), physical abuse (16.96%), and discrimination (14.79%). Besides, other factors identified included lack of dignity, delivery by unqualified personnel, lack of privacy, demand for informal payments, and lack of basic infrastructure, hygiene, and sanitation. The determinants identified for disrespect and abuse were sociocultural factors including age, socioeconomic status, caste, parity, women autonomy, empowerment, comorbidities, and environmental factors including infrastructural issues, overcrowding, ill-equipped health facilities, supply constraints, and healthcare access.Conclusion:The high prevalence of disrespectful maternity care indicates an urgent need to improve maternity care in India by making it more respectful, dignified, and women-centered. Interventions, policies, and programs should be implemented that will protect the fundamental rights of women.

Disrespectful treatment in primary care in rural Tanzania: beyond any single health issue.

Knowing how patients are treated in care is foundational for creating patient-centred, high-quality health systems and identifying areas where policies and practices need to adapt to improve patient care. However, little is known about the prevalence of disrespectful treatment of patients in sub-Saharan Africa outside of maternity care. We used data from a household survey of 2002 women living in rural Tanzania to describe the extent of disrespectful care during outpatient visits, who receive disrespectful care, and determine the association with patient satisfaction, rating of quality and recommendation of the facility to others. We asked about women’s most recent outpatient visit to the local clinic, including if they were made to feel disrespected, if a provider shouted at or scolded them, and if providers made negative or disparaging comments about them. Women who answered yes to any of these questions were considered to have experienced disrespectful care. We report risk ratios with standard errors clustered at the facility level. The most common reasons for seeking care were fever or malaria (33.9%), vaccination (33.6%) and non-emergent check-up (13.4%). Disrespectful care was reported by 14.3% of women and was more likely if the visit was for sickness compared to a routine check-up [risk ratio (RR): 1.6, 95% confidence interval (CI): 1.1–2.2]. Women who did not report disrespectful care were 2.1 times as likely to recommend the clinic (95% CI: 1.6–2.7). While there is currently a lot of attention on disrespectful maternity care, our results suggest that this is a problem that goes beyond this single health issue and should be addressed by more horizontal health system interventions and policies.

Women who break the rules: Social exclusion and inequities in pregnancy and childbirth experiences in Zambia

Health inequities are a growing concern in low- and middle-income countries, but reducing them requires a better understanding of underlying mechanisms. This study is based on 42 semi-structured interviews conducted in June 2018 with women who gave birth in the previous year, across rural and urban clinic sites in Mansa district, Zambia. Findings show that health facility rules regulating women's behaviour during pregnancy and childbirth create inequities in women's maternity experiences. The rules and their application can be understood as a form of social exclusion, discriminating against women with fewer financial and social resources. This study extends existing frameworks of social exclusion by demonstrating that the rules do not only originate in, but also reinforce, the structural processes that underpin inequitable social institutions. Legitimising the rules supports a moral order where women with fewer resources are constructed as “bad women”, while efforts to follow the rules widen existing power differentials between socially excluded women and others. This study's findings have implications for the literature on reversed accountability and the unintended consequences of global and national safe motherhood targets, and for our understanding of disrespectful maternity care.

Respectful maternity care: A national landscape review.

Respectful maternity care is a fundamental right of every childbearing woman. It contributes to ensuring a positive outcome for mothers as well as newborns, and aims to address health inequalities. However, studies have reported a high prevalence of disrespect and abuse in India, and have shown that the quality of care has been overlooked at all levels including research, policy, programme and practice. The lack of respectful maternity care results in failure in accessing institutional services. Thus, it is essential to design context-specific and evidence-based interventions as well as formulate policies and programmes to reduce disrespectful maternity care.

Providing postpartum care with limited resources: Experiences of nurse-midwives and obstetricians in urban Tanzania

BackgroundTanzania has high maternal and neonatal mortality rates. Comprehensive guidelines for postpartum care have been developed by the government as a means to improve health outcomes during the perinatal period. Despite the creation of these guidelines and the government’s commitment to universal perinatal care for women and neonates, there is concern that the delivery of postpartum services may not be meeting the needs of mothers and neonates. AimThe purpose of this feminist poststructuralist study was to explore nurse-midwives’ and obstetricians’ experiences of providing postpartum care in Tanzania. MethodsThis qualitative study used feminist poststructuralism to explore the personal, social, and institutional discourses of postpartum care. We individually interviewed ten nurse-midwives and three obstetricians in Dar es Salaam, Tanzania. Feminist poststructuralist discourse analysis was used to analyze the transcribed interviews after their translation from Kiswahili to English. FindingsFour main themes were identified. In this paper, we present the main theme of availability of resources, and its four corresponding subthemes; (1) space, (2) equipment, (3) staffing, and (4) government responsibility. DiscussionThe findings from our study illustrate the need for health workforce planning to be addressed in a comprehensive manner that accounts for context, required resources and systemic challenges. These findings are consistent with findings from other studies. ConclusionUnderstanding the resource challenges that nurse-midwives and obstetricians are facing in one low-and-middle-income-country will assist researchers, decision makers, and politicians as they address issues of mortality, morbidity, and disrespectful maternity care.

Home deliveries in the capital: a qualitative exploration of barriers to institutional deliveries in peri-urban areas of Lusaka, Zambia

BackgroundA shortage of skilled birth attendants and low quality of care in health facilities along with unattended home deliveries contribute to the high maternal and neonatal mortality in sub Saharan Africa. Identifying and addressing context-specific reasons for not delivering at health care facilities could increase births assisted by skilled attendants who, if required, can provide life-saving interventions.MethodsWe conducted 22 in-depth interviews (IDIs) with midwives at three health facilities in peri-urban communities and 24 semi-structured surveys with mothers in two areas served by health facilities with the highest number of reported home deliveries in Lusaka, Zambia. Both IDIs and surveys were audio-recorded, transcribed and coded to identify themes around delivery and birthing experience.ResultsWe found that most women preferred institutional deliveries to home deliveries, but were unable to utilize these services due to inability to recognize labour symptoms or lack of resources. Midwives speculated that women used herbal concoctions to reduce the duration of delivery with the result that women either did not present in time or endangered themselves and the baby with powerful contractions and precipitous labour. Respondents suggested that disrespectful and abusive maternity care dissuaded some women from delivering at health facilities. However, some midwives viewed such tactics as necessary to ensure women followed instructions and successfully delivered live babies.ConclusionDifference in beliefs and birthing practices between midwives and mothers suggest the need for open dialogue to co-design appropriate interventions to increase facility usage. Further examination of the pharmaceutical properties and safety of herbal concoctions being used to shorten labour are required. Measures to reduce the economic burden of care seeking within this environment, increase respectful and patient-centred care, and improve the quality of midwifery could increase institutional deliveries.

Prevalence of Disrespectful Maternity Care and Abuse among Women Seeking Maternity Care Services at the Kenyatta National Hospital, Nairobi: A Cross-Sectional Descriptive Study

Background: Respectful Maternity Care (RMC) is a basic human right for every childbearing woman. Acts of disrespectful maternity care and abuse are commonly reported worldwide and are recognized as a powerful deterrence to facility based childbirth than the traditionally known accessibility. In Kenya, acts of disrespect and abuse are frequently reported. Objectives of the study: To assess the prevalence of disrespectful maternity care and abuse among women seeking maternity care services at the Kenyatta National Hospital, Nairobi. Methods: This study was conducted at the Kenyatta National Hospital maternity wards. A descriptive study design was employed and targeted 164 respondents. The study utilized an interviewer administered questionnaire and an observational checklist to collect required data. Participants were sampled using simple random sampling method. Data was collected between July 15th and July 30th 2017 and was entered, cleaned and analyzed using SPSS 20. Results were presented in descriptive form, figures and tables. Results: Out of the targeted 164 participants, 152 (93%) women were interviewed during the study. The study found that women experienced at least some form of disrespect and abuse while seeking maternity care services at the Kenyatta National hospital. In general, prevalence of disrespectful maternity care and abuse ranged from 9% for discriminatory care to as high as 32% for non-privacy of care. Untimely care/abandonment of care was 22%, similar to non-consensual care (22%). Prevalence for non-confidential care was 28%. Majority of the women who experienced disrespect and abuse chose to resort to acquiescence whereby they just complied or kept quiet. The study found a strong association between marital status and physical abuse of women in labor 95% CI (P < 0.000) and level of education was found to be strongly associated with right to information 95% CI (P = 0.029). Conclusion: There are significant levels of disrespect and abuse among women seeking maternity care services at the Kenyatta National Hospital. The hospital management and the reproductive health department of the ministry of health should work towards ensuring that women seeking maternity care services at the facility do not endure disrespect and abuse.

“This poor woman, it's her first birth and this is her experience. And I’m a part of it!” Reconciling advocacy in the face of disrespectful maternity care

“This poor woman, it's her first birth and this is her experience. And I’m a part of it!” Reconciling advocacy in the face of disrespectful maternity care

Disrespectful Maternity Care: A Threat to the Maternal Health 2030 Agenda in Jamaica

Amidst advance action to increase positive pregnancy outcomes globally, sufficient focus and considerations have not being given to the human element, specifically the interpersonal relationships between care providers and the childbearing family.

Informal cash payments for birth in Hungary: Are women paying to secure a known provider, respect, or quality of care?

BackgroundIn Central and Eastern Europe, many women make informal cash payments to ensure continuity of provider, i.e., to have a “chosen” doctor who provided their prenatal care, be present for birth. High rates of obstetric interventions and disrespectful maternity care are also common to the region. No previous study has examined the associations among informal payments, intervention rates, and quality of maternity care. MethodsWe distributed an online cross-sectional survey in 2014 to a nationally representative sample of Hungarian internet-using women (N = 600) who had given birth in the last 5 years. The survey included items related to socio-demographics, type of provider, obstetric interventions, and experiences of care. Women reported if they paid informally, and how much. We built a two-part model, where a bivariate probit model was used to estimate conditional probabilities of women paying informally, and a GLM model to explore the amount of payments. We calculated marginal effects of the covariates (provider choice, interventions, respectful care). ResultsMany more women (79%) with a chosen doctor paid informally (191 euros on average) compared to 17% of women without a chosen doctor (86 euros). Based on regression analysis, the chosen doctor's presence at birth was the principal determinant of payment. Intervention and procedure rates were significantly higher for women with a chosen doctor versus without (cesareans 45% vs. 33%; inductions 32% vs. 19%; episiotomy 75% vs. 62%; epidural 13% vs. 5%), but had no direct effect on payments. Half of the sample (42% with a chosen doctor, 62% without) reported some form of disrespectful care, but this did not reduce payments. ConclusionDespite reporting disrespect and higher rates of interventions, women rewarded the presence of a chosen doctor with informal payments. They may be unaware of evidence-based standards, and trust that their chosen doctor provided high quality maternity care.

The Mothers on Respect (MOR) index: measuring quality, safety, and human rights in childbirth

BackgroundAbuse of human rights in childbirth are documented in low, middle and high resource countries. A systematic review across 34 countries by the WHO Research Group on the Treatment of Women During Childbirth concluded that there is no consensus at a global level on how disrespectful maternity care is measured. In British Columbia, a community-led participatory action research team developed a survey tool that assesses women's experiences with maternity care, including disrespect and discrimination. MethodsA cross-sectional survey was completed by women of childbearing age from diverse communities across British Columbia. Several items (31/130) assessed characteristics of their communication with care providers. We assessed the psychometric properties of two versions of a scale (7 and 14 items), among women who described experiences with a single maternity provider (n=2514 experiences among 1672 women). We also calculated the proportion and selected characteristics of women who scored in the bottom 10th percentile (those who experienced the least respectful care). ResultsTo demonstrate replicability, we report psychometric results separately for three samples of women (S1 and S2) (n=2271), (S3, n=1613). Analysis of item-to-total correlations and factor loadings indicated a single construct 14-item scale, which we named the Mothers on Respect index (MORi). Items in MORi assess the nature of respectful patient-provider interactions and their impact on a person's sense of comfort, behavior, and perceptions of racism or discrimination. The scale exhibited good internal consistency reliability. MORi- scores among these samples differed by socio-demographic profile, health status, experience with interventions and mode of birth, planned and actual place of birth, and type of provider. ConclusionThe MOR index is a reliable, patient-informed quality and safety indicator that can be applied across jurisdictions to assess the nature of provider-patient relationships, and access to person-centered maternity care.

Experiences of and responses to disrespectful maternity care and abuse during childbirth; a qualitative study with women and men in Morogoro Region, Tanzania.

BackgroundInterventions to reduce maternal mortality have focused on delivery in facilities, yet in many low-resource settings rates of facility-based birth have remained persistently low. In Tanzania, rates of facility delivery have remained static for more than 20 years. With an aim to advance research and inform policy changes, this paper builds on a growing body of work that explores dimensions of and responses to disrespectful maternity care and abuse during childbirth in facilities across Morogoro Region, Tanzania.MethodsThis research drew on in-depth interviews with 112 respondents including women who delivered in the preceding 14 months, their male partners, public opinion leaders and community health workers to understand experiences with and responses to abuse during childbirth. All interviews were recorded, transcribed, translated and coded using Atlas.ti. Analysis drew on the principles of Grounded Theory.ResultsWhen initially describing birth experiences, women portrayed encounters with providers in a neutral or satisfactory light. Upon probing, women recounted events or circumstances that are described as abusive in maternal health literature: feeling ignored or neglected; monetary demands or discriminatory treatment; verbal abuse; and in rare instances physical abuse. Findings were consistent across respondent groups and districts. As a response to abuse, women described acquiescence or non-confrontational strategies: resigning oneself to abuse, returning home, or bypassing certain facilities or providers. Male respondents described more assertive approaches: requesting better care, paying a bribe, lodging a complaint and in one case assaulting a provider.ConclusionsMany Tanzanian women included in this study experienced unfavorable conditions when delivering in facilities. Providers, women and their families must be made aware of women’s rights to respectful care. Recommendations for further research include investigations of the prevalence and dimensions of disrespectful care and abuse, on mechanisms for women and their families to effectively report and redress such events and on interventions that could mitigate neglect or isolation among delivering women. Respectful care is a critical component to improve maternal health.

P.6.a.004 The effect of naltrexone and acamprosate on cue-induced craving and fysiological cue-reactivity in alcoholics

In Central and Eastern Europe, many women make informal cash payments to ensure continuity of provider, i.e., to have a “chosen” doctor who provided their prenatal care, be present for birth. High rates of obstetric interventions and disrespectful maternity care are also common to the region. No previous study has examined the associations among informal payments, intervention rates, and quality of maternity care.We distributed an online cross-sectional survey in 2014 to a nationally representative sample of Hungarian internet-using women (N = 600) who had given birth in the last 5 years. The survey included items related to socio-demographics, type of provider, obstetric interventions, and experiences of care. Women reported if they paid informally, and how much. We built a two-part model, where a bivariate probit model was used to estimate conditional probabilities of women paying informally, and a GLM model to explore the amount of payments. We calculated marginal effects of the covariates (provider choice, interventions, respectful care).Many more women (79%) with a chosen doctor paid informally (191 euros on average) compared to 17% of women without a chosen doctor (86 euros). Based on regression analysis, the chosen doctor's presence at birth was the principal determinant of payment. Intervention and procedure rates were significantly higher for women with a chosen doctor versus without (cesareans 45% vs. 33%; inductions 32% vs. 19%; episiotomy 75% vs. 62%; epidural 13% vs. 5%), but had no direct effect on payments. Half of the sample (42% with a chosen doctor, 62% without) reported some form of disrespectful care, but this did not reduce payments.Despite reporting disrespect and higher rates of interventions, women rewarded the presence of a chosen doctor with informal payments. They may be unaware of evidence-based standards, and trust that their chosen doctor provided high quality maternity care.