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When the baby remains there for a long time, it is going to die so you have to hit her small for the baby to come out: Justification of disrespectful and abusive care during childbirth among midwifery students in Ghana

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Abstract

Despite global attention, high levels of maternal mortality continue to plague many low- and middle-income settings. One important way to improve the care of women in labour is to increase the proportion of women who deliver in a health facility. However, due to poor quality of care, including being disrespected and abused, women are reluctant to come to facilities for delivery care. The current study sought to examine disrespectful and abusive treatment towards labouring women from the perspective of midwifery students who were within months of graduation. For this study, we conducted focus groups with final year midwifery students at 15 public midwifery training colleges in all 10 of Ghana’s regions. Focus group discussions were recorded and transcribed. A multi-disciplinary team of researchers from the US and Ghana analysed the qualitative data. While students were able to talk at length as to why respectful care is important, they were also able to recount times when they both witnessed and participated in disrespectful and abusive treatment of labouring women. The themes which emerged from these data are: 1) rationalization of disrespectful and abusive care; 2) the culture of blame and; 3) no alternative to disrespect and abuse. Although midwifery students in Ghana’s public midwifery schools highlight the importance of providing high-quality, patient-centred respectful care, they also report many forms of disrespect and abuse during childbirth. Without better quality care, including making care more humane, the use of facility-based maternity services in Ghana is likely not to improve. This study provides an important starting point for educators, researchers, and policy makers to re-think how the next generation of healthcare providers needs to be prepared to provide high-quality, respectful care to women during labour and delivery in low-resource settings.

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... Scientific literature reveals that the factors that perpetuate OV include a lack of proper training for health professionals [1,23]. With respect to health science students, although the literature highlights the importance of providing high-quality woman-centred care, many forms of lack of respect and abuse during childbirth continue to be reported [24]. With all this, the negative obstetric practices and the existing literature make us think about an important public health problem: obstetric violence. ...
... For episiotomy without anaesthesia, midwives may feel that an episiotomy should only be performed if there is clinical need and that anaesthesia should only be administered in cases of emergency due to acute foetal compromise [29] based on the salutogenesis approach highlighted above. Finally, with regard to accompaniment in cases of instrumentation or caesarean section, it is known that nurses and midwives should be the guardians and guarantors of women's rights [12], but when these interventions are carried out, gynaecology and anaesthesia professionals become involved, shifting the role of the midwife and nurse to the background [24] and perhaps impacting the continuity of care and the woman's satisfaction with that care [41]. ...
... The fact that students are able to identify certain practices as OV does not mean that they are on track to addressing this type of violence. Although identification is a beginning, one must also be aware that students also learn how to justify this learned violence, lack of respect, and abuse in delivery and maternity wards [24]. This presents a broad field for future lines of research in this area, with a fundamental role being played by the development of strategies and learning plans related to any violence against women, for example, domestic violence during pregnancy [42]. ...
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Background: Obstetric violence could be defined as the dehumanized treatment or abuse of health professionals towards the body or reproductive process of women. Some practices associated with obstetric violence have been routinely standardized and do not include the woman in decision making. This type of violence has consequences for the health of both the mother and the baby and that of the professionals who practice or observed it. Methods: A questionnaire consisting of 33 items that measured perception through a Likert scale was developed. Some sociodemographic variables were collected. The instrument was applied to a sample of nursing, medicine and midwifery students to determine its psychometric properties. Results: The final sample consisted of 153 students. The Kaiser-Meyer-Olkin (p = 0.918) and Barlett tests (p ≤ 0.001) allowed for factor analysis, which explained 54.47% of the variance in two factors called protocolized-visible obstetric violence and non-protocolized-invisible obstetric violence. Conclusions: The PercOV-S (Perception of Obstetric Violence in Students) instrument was validated. The distribution and content of the two factors are closely related to obstetric violence against women. The existence of statistically significant relationships between the sociodemographic variables collected and the global measurements, domains and items of the PercOV-S scale highlight the normalization of obstetric violence as a central factor for future studies.
... The Respectful Maternity Care Charter has outlined the links between D&A and maternal health rights within human rights such as the right to be free from harm and ill treatment, and the right to dignity and respect (White Ribbon Alliance 2011). Studies have indicated interventions to reduce disrespectful and abusive maternity care (Abuya et al. 2015;Austad et al. 2017;Ratcliffe et al. 2016). For example, Kujawski et al. (2017) report on an intervention to reduce the D&A of women in two facilities in Tanzania using the Staha intervention. ...
... Qualitative and quantitative studies have focussed on women's experiences and perceptions of D&A during childbirth (Asefa and Bekele 2015;McMahon et al. 2014;Warren et al. 2017), but very few have explored this issue from the provider perspective (Burrowes et al. 2017;Rominski et al. 2017;Shimoda et al. 2018). In one study from Ghana, midwifery students reported witnessing and participating in various forms of D&A during childbirth and provided justifications for their perpetration of such practices (Rominski et al. 2017). ...
... Qualitative and quantitative studies have focussed on women's experiences and perceptions of D&A during childbirth (Asefa and Bekele 2015;McMahon et al. 2014;Warren et al. 2017), but very few have explored this issue from the provider perspective (Burrowes et al. 2017;Rominski et al. 2017;Shimoda et al. 2018). In one study from Ghana, midwifery students reported witnessing and participating in various forms of D&A during childbirth and provided justifications for their perpetration of such practices (Rominski et al. 2017). ...
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Objectives To explore healthcare providers’ perspectives of disrespect and abuse in maternity care and the impact on women’s health and well-being. Methods Qualitative interpretive approach using in-depth semi-structured interviews with sixteen healthcare providers in two public health facilities in Nigeria. Interviews were audio-recorded, transcribed, and analysed thematically. Results Healthcare providers’ accounts revealed awareness of what respectful maternity care encompassed in accordance with the existing guidelines. They considered disrespectful and abusive practices perpetrated or witnessed as violation of human rights, while highlighting women’s expectations of care as the basis for subjectivity of experiences. They perceived some practices as well-intended to ensure safety of mother and baby. Views reflected underlying gender-related notions and societal perceptions of women being considered weaker than men. There was recognition about adverse effects of disrespect and abuse including its impact on women, babies, and providers’ job satisfaction. Conclusions Healthcare providers need training on how to incorporate elements of respectful maternity care into practice including skills for rapport building and counselling. Women and family members should be educated about right to respectful care empowering them to report disrespectful practices.
... Studies on D&A are important to identify the gap and to recommend interventions based on the ndings. However, previous reports on D&A have mostly focused on subjective experience of D&A [14][15][16][17] and studies reporting observed incidents are limited. ...
... Subsequently, medical students performed procedures that were considered D&A. In contrast to previous studies that reported a shortage of human resources as a contributor to D&A [17,24,27,31,58]. ...
... Emergency caesarean sections were sometimes delayed after the decision and women stayed without beddings. These ndings agree with prior reports [4,15,17,46, 64] However, in our study, it did not result in detention and verbal abuse as prior ndings [16] In present study, women's passivity contributed to D&A. Women did not ask for information about procedures from the health care providers; rather, they complied with multiple providers' commands for procedures. ...
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Background: Disrespect and abuse during facility-based childbirth is a negative experience for women in developed and developing regions. Types and drivers of disrespect and abuse vary based on study settings. Few studies have explored disrespect and abuse in tertiary teaching hospitals settings. Therefore, the aim of this study was to explore women experience of disrespect and abuse in one of tertiary teaching hospitals in southwest part of Ethiopia. Method: Qualitative participant observation was used as a data collection method. Fieldwork was conducted in the labour ward, the normal postnatal ward, and the maternity recovery room for three consecutive months in Jimma University specialized teaching hospital. The participant observation units were selected purposively, and 53 episodes of women in labour and 33 episodes of post-partum women were observed. The data were organized and analysed using NVIVO qualitative analysis software.and we used the thematic analysis method. Results: Three categories of themes were identified: disrespect and abuse, contributor themes, and respectful themes. Disrespect and abuse themes were physical abuse, poor communication, non-consented care, lack of privacy, lack of confidentiality , neglected care, loss of autonomy and lack of companion,. Contributor themes for disrespect and abuse were provider-related, health system-related, and women-related themes. Provider-related themes were lack of respect among providers and lack of collaboration and communication. Health-system related themes were poor human resource management, scarcity of equipment and supplies, and wastage of supplies. A women-related contributor was women passivity. Respectful care themes were in two categories: respectful provider and respectful facility cultures. Respectful provider practice includes: timely evaluation at admission, being with women, supportive care, and teamwork during emergency. Respectful facility culture included postpartum companion and free delivery service. Conclusion: The findings of this study indicate that women experienced disrespect and abuse at a teaching health care facility. Policy makers, administrators, and quality improvement initiative activities need to address the identified contributors to improve women’s experience in health care facilities.
... Studies on midwives' experiences of disrespect and abuse of childbearing women during intrapartum care seem limited in sub-Saharan Africa [30][31][32][33]. The few evidence on the phenomenon have reported frequent cases of disrespect and abusive care during childbearing women's labour and delivery, with weak health systems and intent to save mother and baby from death commonly cited as reasons for engaging in D&AC practices [30,31,34,35]. For instance, a Ghanaian study involving student midwives revealed that although they understood what constituted D&AC, these student midwives mentioned that some forms of D&AC were justified when the intent was to save both mother and baby from dying during delivery [34]. ...
... The few evidence on the phenomenon have reported frequent cases of disrespect and abusive care during childbearing women's labour and delivery, with weak health systems and intent to save mother and baby from death commonly cited as reasons for engaging in D&AC practices [30,31,34,35]. For instance, a Ghanaian study involving student midwives revealed that although they understood what constituted D&AC, these student midwives mentioned that some forms of D&AC were justified when the intent was to save both mother and baby from dying during delivery [34]. ...
... Healthcare providers in other studies have given similar justifications for their engagement in D&AC on childbearing women during intrapartum care. They mentioned that inadequate clinical and support staff and weak health systems prevented them from translating their knowledge of respectful maternity care into practice [30,31,34,35]. For instance, student midwives and practicing midwives in Ghana and Ethiopia reported that huge workload, burnout from job due to unrealistic staff-to-childbearing women ratio and the pressure to save mother and child during delivery can compel skilled providers to engage in practices that are deemed D&AC [30,34]. ...
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Background Quality maternal health reduces maternal and neonatal mortality and morbidity. Healthcare professionals, including midwives, are significant agents for the promotion of quality maternal health. Frequents reports of disrespect and abuse of childbearing women by midwives during intrapartum care are becoming common, suggesting that many of these agents are engaging in care practices that compromise quality maternal health. Thus, understanding midwives’ descriptions and experiences of the phenomenon is critical to addressing the threat. This paper, therefore, explored the understanding of midwives on D&AC and their occurrence in professional practice in a tertiary health facility in Kumasi, Ghana.Methods An exploratory descriptive qualitative research design using an interpretative approach was employed in the study. Data were generated through individual in-depth interviews. Data saturation was reached with fifteen interviews. The interviews were audio-recorded and transcribed verbatim. Open Code 4.03 was used to manage and analyse the data.Results The midwives understood D&AC. They also confirmed meting out or witnessing colleagues engage in D&AC in their professional practice. The midwives described D&AC as the provision of inadequate care and the overlooking of patient-centred care, and verbal, physical, and psychological abuse. The themes revealed that socio-economic inequalities, provider perception and victim-blaming, and health system-related factors facilitate D&AC. It emerged that the following marginalized groups were at high risk for D&AC: the non-compliant, mentally ill, HIV/AIDs+, teenagers, poor, and childbearing women on admission at the general labour ward.Conclusion The midwives understood D&AC and revealed that it frequently occurred in their professional practice. Frequent in-service training on respectful maternity care and monitoring of care provision in healthcare facilities are needed to eliminate the incidence of D&AC. Keywords Disrespectful maternity care, childbearing women, midwives, Ghana, qualitative
... Several terms have been used to describe poor care and abusive, disrespectful, negligent or discriminatory treatment of women giving birth in facilities (hereafter referred to in short as 'mistreatment'). 1 10-12 These terms have been framed as a subset of the larger issues of violence against women, human rights violations, quality of care, health systems issues or a combination of these. 13 Bowser and Hill's landmark landscape analysis was the first to review existing evidence and convene an expert working group to develop a classification system for 'disrespect and abuse during facility-based childbirth 14 '. A global mixedmethods systematic review of mistreatment by Bohren et al. (2015) cited widespread mistreatment in 34 countries and resulted in the first evidence-based typology of mistreatment (the WHO typology), which included domains of physical abuse, verbal abuse, sexual abuse, stigma and discrimination, failure to meet professional standards of care, poor rapport and communication between women and providers, and health systems conditions and constraints. ...
... The latter may be due to health system deficiencies like inadequate resources, personnel or facility policies; they also may reflect norms in training around pragmatic strategies to establish professional distance or maintain control and compliance during birth in an effort to ensure expedient and/ or good birth outcomes. 13 49 53 72-75 Our measurement approach is consistent with measures operationalised in related research areas. Constructs of violence and abuse are measured using psychometric scales in prior research, [76][77][78][79] often through adaptations of the Conflict Tactics Scale. ...
... To assess consistency of items within a measure: the percent distributions of co-occurring mistreatment items were examined, whereby internally consistent measures would have higher proportions of items that occur with at least one or several other items in a measure (results available upon request). To determine consistency of measure scores: to determine if each item could distinguish between "high" and "low" scores of mistreatment, a binary variable was constructed where "high" scores included observations with scores higher than the country-specific mean, and "low" included those scoring at or below the country-specific mean (13,14). The proportion of women experiencing a mistreatment item who had "high" and "low" scores was then calculated; if scores were internally consistent and distinguished between these two groups, we would expect to see a higher proportion of women in the "high" score group experiencing each item (14). ...
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Introduction Mistreatment of women during childbirth is increasingly recognised as a significant issue globally. Research and programmatic efforts targeting this phenomenon have been limited by a lack of validated measurement tools. This study aimed to develop a set of concise, valid and reliable multidimensional measures for mistreatment using labour observations applicable across multiple settings. Methods Data from continuous labour observations of 1974 women in Nigeria (n=407), Ghana (n=912) and Guinea (n=655) were used from the cross-sectional WHO’s multicountry study ‘How women are treated during facility-based childbirth’ (2016–2018). Exploratory factor analysis was conducted to develop a scale measuring interpersonal abuse. Two indexes were developed through a modified Organisation for Economic Co-operation and Development approach for generating composite indexes. Measures were evaluated for performance, validity and internal reliability. Results Three mistreatment measures were developed: a 7-item Interpersonal Abuse Scale, a 3-item Exams & Procedures Index and a 12-item Unsupportive Birth Environment Index. Factor analysis results showed a consistent unidimensional factor structure for the Interpersonal Abuse Scale in all three countries based on factor loadings and interitem correlations, indicating good structural construct validity. The scale had a reliability coefficient of 0.71 in Nigeria and approached 0.60 in Ghana and Guinea. Low correlations (Spearman correlation range: −0.06–0.19; p≥0.05) between mistreatment measures supported our decision to develop three separate measures. Predictive criterion validation yielded mixed results across countries. Both items within measures and measure scores were internally consistent across countries; each item co-occurred with other items in a measure, and scores consistently distinguished between ‘high’ and ‘low’ mistreatment levels. Conclusion The set of concise, comprehensive multidimensional measures of mistreatment can be used in future research and quality improvement initiatives targeting mistreatment to quantify burden, identify risk factors and determine its impact on health and well-being outcomes. Further validation and reliability testing of the measures in other contexts is needed.
... Studies on midwives' experiences of disrespect and abuse of childbearing women during intrapartum care seem limited in sub-Saharan Africa [30][31][32][33]. The few evidence on the phenomenon have reported frequent cases of disrespect and abusive care during childbearing women's labour and delivery, with weak health systems and intent to save mother and baby from death commonly cited as reasons for engaging in D&AC practices [30,31,34,35]. For instance, a Ghanaian study involving student midwives revealed that although they understood what constituted D&AC, these student midwives mentioned that some forms of D&AC were justified when the intent was to save both mother and baby from dying during delivery [34]. ...
... The few evidence on the phenomenon have reported frequent cases of disrespect and abusive care during childbearing women's labour and delivery, with weak health systems and intent to save mother and baby from death commonly cited as reasons for engaging in D&AC practices [30,31,34,35]. For instance, a Ghanaian study involving student midwives revealed that although they understood what constituted D&AC, these student midwives mentioned that some forms of D&AC were justified when the intent was to save both mother and baby from dying during delivery [34]. ...
... Healthcare providers in other studies have given similar justifications for their engagement in D&AC on childbearing women during intrapartum care. They mentioned that inadequate clinical and support staff and weak health systems prevented them from translating their knowledge of respectful maternity care into practice [30,31,34,35]. For instance, student midwives and practicing midwives in Ghana and Ethiopia reported that huge workload, burnout from job due to unrealistic staff-to-childbearing women ratio and the pressure to save mother and child during delivery can compel skilled providers to engage in practices that are deemed D&AC [30,34]. ...
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Background Quality maternal health reduces maternal and neonatal mortality and morbidity. Healthcare professionals, including midwives, are significant agents for the promotion of quality maternal health. Frequents reports of disrespect and abuse of childbearing women by midwives during intrapartum care are becoming common, suggesting that many of these agents are engaging in care practices that compromise quality maternal health. Thus, understanding midwives’ descriptions and experiences of the phenomenon is critical to addressing the threat. This paper, therefore, explored the understanding of midwives on D&AC and their occurrence in professional practice in a tertiary health facility in Kumasi, Ghana.Methods An exploratory descriptive qualitative research design using an interpretative approach was employed in the study. Data were generated through individual in-depth interviews. Data saturation was reached with fifteen interviews. The interviews were audio-recorded and transcribed verbatim. Open Code 4.03 was used to manage and analyse the data.Results The midwives understood D&AC. They also confirmed meting out or witnessing colleagues engage in D&AC in their professional practice. The midwives described D&AC as the provision of inadequate care and the overlooking of patient-centred care, and verbal, physical, and psychological abuse. The themes revealed that socio-economic inequalities, provider perception and victim-blaming, and health system-related factors facilitate D&AC. It emerged that the following marginalized groups were at high risk for D&AC: the non-compliant, mentally ill, HIV/AIDs+, teenagers, poor, and childbearing women on admission at the general labour ward.Conclusion The midwives understood D&AC and revealed that it frequently occurred in their professional practice. Frequent in-service training on respectful maternity care and monitoring of care provision in healthcare facilities are needed to eliminate the incidence of D&AC. Keywords Disrespectful maternity care, childbearing women, midwives, Ghana, qualitative
... Studies on midwives' experiences of disrespect and abuse of childbearing women during intrapartum care seem limited in sub-Saharan Africa [30][31][32][33]. The few evidence on the phenomenon have reported frequent cases of disrespect and abusive care during childbearing women's labour and delivery, with weak health systems and intent to save mother and baby from death commonly cited as reasons for engaging in D&AC practices [30,31,34,35]. For instance, a Ghanaian study involving student midwives revealed that although they understood what constituted D&AC, these student midwives mentioned that some forms of D&AC were justified when the intent was to save both mother and baby from dying during delivery [34]. ...
... The few evidence on the phenomenon have reported frequent cases of disrespect and abusive care during childbearing women's labour and delivery, with weak health systems and intent to save mother and baby from death commonly cited as reasons for engaging in D&AC practices [30,31,34,35]. For instance, a Ghanaian study involving student midwives revealed that although they understood what constituted D&AC, these student midwives mentioned that some forms of D&AC were justified when the intent was to save both mother and baby from dying during delivery [34]. ...
... Healthcare providers in other studies have given similar justifications for their engagement in D&AC on childbearing women during intrapartum care. They mentioned that inadequate clinical and support staff and weak health systems prevented them from translating their knowledge of respectful maternity care into practice [30,31,34,35]. For instance, student midwives and practicing midwives in Ghana and Ethiopia reported that huge workload, burnout from job due to unrealistic staff-to-childbearing women ratio and the pressure to save mother and child during delivery can compel skilled providers to engage in practices that are deemed D&AC [30,34]. ...
Preprint
Full-text available
Background: Quality maternal health reduces maternal and neonatal mortality and morbidity. Healthcare professionals, including midwives, are significant agents for the promotion of quality maternal health. Frequents reports of disrespect and abuse of childbearing women by midwives during intrapartum care are becoming common, suggesting that many of these agents are engaging in care practices that compromise quality maternal health. Thus, understanding midwives’ descriptions and experiences of the phenomenon is critical to addressing the threat. This paper, therefore, explored the understanding of midwives on D&AC and their occurrence in professional practice in a tertiary health facility in Kumasi, Ghana. Method: An exploratory descriptive qualitative research design using an interpretative approach was employed in the study. Data were generated through individual in-depth interviews. Data saturation was reached with fifteen interviews. The interviews were audio-recorded and transcribed verbatim. Open Code 4.03 was used to manage and analyse the data. Findings: The midwives understood D&AC. They also confirmed meting out or witnessing colleagues engage in D&AC in their professional practice. The midwives described D&AC as the provision of inadequate care and the overlooking of patient-centred care, and verbal, physical, and psychological abuse. The themes revealed that socio-economic inequalities, provider perception and victim-blaming, and health system-related factors facilitate D&AC. It emerged that the following marginalized groups were at high risk for D&AC: the non-compliant, mentally ill, HIV/AIDs+, teenagers, poor, and childbearing women on admission at the general labour ward. Conclusion: The midwives understood D&AC and revealed that it frequently occurred in their professional practice. Frequent in-service training on respectful maternity care and monitoring of care provision in healthcare facilities are needed to eliminate the incidence of D&AC. Keywords Disrespectful maternity care, childbearing women, midwives, Ghana, qualitative
... Studies on midwives' experiences of disrespect and abuse of childbearing women during intrapartum care seem limited in sub-Saharan Africa [30][31][32][33]. The few evidence on the phenomenon have reported frequent cases of disrespect and abusive care during childbearing women's labour and delivery, with weak health systems and intent to save mother and baby from death commonly cited as reasons for engaging in D&AC practices [30,31,34,35]. For instance, a Ghanaian study involving student midwives revealed that although they understood what constituted D&AC, these student midwives mentioned that some forms of D&AC were justified when the intent was to save both mother and baby from dying during delivery [34]. ...
... The few evidence on the phenomenon have reported frequent cases of disrespect and abusive care during childbearing women's labour and delivery, with weak health systems and intent to save mother and baby from death commonly cited as reasons for engaging in D&AC practices [30,31,34,35]. For instance, a Ghanaian study involving student midwives revealed that although they understood what constituted D&AC, these student midwives mentioned that some forms of D&AC were justified when the intent was to save both mother and baby from dying during delivery [34]. ...
... Healthcare providers in other studies have given similar justifications for their engagement in D&AC on childbearing women during intrapartum care. They mentioned that inadequate clinical and support staff and weak health systems prevented them from translating their knowledge of respectful maternity care into practice [30,31,34,35]. For instance, student midwives and practicing midwives in Ghana and Ethiopia reported that huge workload, burnout from job due to unrealistic staff-to-childbearing women ratio and the pressure to save mother and child during delivery can compel skilled providers to engage in practices that are deemed D&AC [30,34]. ...
Article
Full-text available
Background Quality maternal health reduces maternal and neonatal mortality and morbidity. Healthcare professionals, including midwives, are significant agents for the promotion of quality maternal health. Frequents reports of disrespect and abuse of childbearing women by midwives during intrapartum care are becoming common, suggesting that many of these agents are engaging in care practices that compromise quality maternal health. Thus, understanding midwives’ descriptions and experiences of the phenomenon is critical to addressing the threat. This paper, therefore, explored the understanding of midwives on D&AC and their occurrence in professional practice in a tertiary health facility in Kumasi, Ghana. Methods An exploratory descriptive qualitative research design using an interpretative approach was employed in the study. Data were generated through individual in-depth interviews. Data saturation was reached with fifteen interviews. The interviews were audio-recorded and transcribed verbatim. Open Code 4.03 was used to manage and analyse the data. Results The midwives understood D&AC. They also confirmed meting out or witnessing colleagues engage in D&AC in their professional practice. The midwives described D&AC as the provision of inadequate care and the overlooking of patient-centred care, and verbal, physical, and psychological abuse. The themes revealed that socio-economic inequalities, provider perception and victim-blaming, and health system-related factors facilitate D&AC. It emerged that the following marginalized groups were at high risk for D&AC: the non-compliant, mentally ill, HIV/AIDs+, teenagers, poor, and childbearing women on admission at the general labour ward. Conclusion The midwives understood D&AC and revealed that it frequently occurred in their professional practice. Frequent in-service training on respectful maternity care and monitoring of care provision in healthcare facilities are needed to eliminate the incidence of D&AC.
... A growing body of studies related to PCMC in African countries highlight context-specific enablers of and gaps in respectful and dignified care, communication and autonomy, and supportive maternity care. Midwives commonly reported verbal abuse, physical abuse, lack of visual privacy, poor record confidentiality, neglect, and non-dignified care [5,8,[22][23][24][25][26][27][28][29][30][31][32][33]. Disrespectful care of childbearing women results from lack of co-operation from women [8,22,23,26,31], lack of resources [5,22,23,28,29,34], midwives' normalisation of abuse [31], negative view of women [27,31], exertion of power and control over women [8,24,25,30,31], fear of being blamed for poor childbirth outcomes and medical necessity [5,8,22,23,26,31], high workload and tiredness [5,29,34], and use of moral judgement [24,35]. ...
... Midwives commonly reported verbal abuse, physical abuse, lack of visual privacy, poor record confidentiality, neglect, and non-dignified care [5,8,[22][23][24][25][26][27][28][29][30][31][32][33]. Disrespectful care of childbearing women results from lack of co-operation from women [8,22,23,26,31], lack of resources [5,22,23,28,29,34], midwives' normalisation of abuse [31], negative view of women [27,31], exertion of power and control over women [8,24,25,30,31], fear of being blamed for poor childbirth outcomes and medical necessity [5,8,22,23,26,31], high workload and tiredness [5,29,34], and use of moral judgement [24,35]. ...
... Midwives commonly reported verbal abuse, physical abuse, lack of visual privacy, poor record confidentiality, neglect, and non-dignified care [5,8,[22][23][24][25][26][27][28][29][30][31][32][33]. Disrespectful care of childbearing women results from lack of co-operation from women [8,22,23,26,31], lack of resources [5,22,23,28,29,34], midwives' normalisation of abuse [31], negative view of women [27,31], exertion of power and control over women [8,24,25,30,31], fear of being blamed for poor childbirth outcomes and medical necessity [5,8,22,23,26,31], high workload and tiredness [5,29,34], and use of moral judgement [24,35]. ...
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Background Person-centred maternity care (PCMC) is acknowledged as essential for achieving improved quality of care during labour and childbirth. Yet, evidence of healthcare providers’ perspectives of person-centred maternity care is scarce in Nigeria. This study, therefore, examined the perceptions of midwives on person-centred maternity care (PCMC) in Enugu State, South-east Nigeria. Materials and methods This study was conducted in seven public hospitals in Enugu metropolis, Enugu State, South-east Nigeria. A mixed-methods design, involving a cross-sectional survey and focus group discussions (FGDs) was used. All midwives (n = 201) working in the maternity sections of the selected hospitals were sampled. Data were collected from February to May 2019 using a self-administered, validated PCMC questionnaire. A sub-set of midwives (n = 56), purposively selected using maximum variation sampling, participated in the FGDs (n = 7). Quantitative data were entered, cleaned, and analysed with SPSS version 20 using descriptive and bivariate statistics and multivariate regression. Statistical significance was set at alpha 0.05 level. Qualitative data were analysed thematically. Results The mean age of midwives was 41.8 years ±9.6 years. About 53% of midwives have worked for ≥10 years, while 60% are junior midwives. Overall, the prevalence of low, medium, and high PCMC among midwives were 26%, 49% and 25%. The mean PCMC score was 54.06 (10.99). High perception of PCMC subscales ranged from 6.5% (dignity and respect) to 19% (supportive care). Midwives’ perceived PCMC was not significantly related to any socio-demographic characteristics. Respectful care, empathetic caregiving, prompt initiation of care, paying attention to women, psychosocial support, trust, and altruism enhanced PCMC. In contrast, verbal and physical abuses were common but normalised. Midwives’ weakest components of autonomy and communication were low involvement of women in decision about their care and choice of birthing position. Supportive care was constrained by restrictive policy on birth companion, poor working conditions, and cost of childbirth care. Conclusion PCMC is inadequate in public hospitals as seen from midwives’ perspectives. Demographic characteristics of midwives do not seem to play a significant role in midwives’ delivery of PCMC. The study identified areas where midwives must build competencies to deliver PCMC.
... Care and respectful care were addressed in 4 studies included in this review from the perspective of midwives, midwifery students, and clients; the studies discussed any disrespectful or abusive maternal care and respectful care during labor and childbirth from their perspective [34][35][36][37]. Denial of health care delivery, overlooking of patient-centered treatment, and low socioeconomic status were the usual problems with regard to care and respectful care. ...
... In this review, 14 studies originated from Africa, namely Ethiopia, Ghana, Nigeria, Burkina Faso, and South Africa [27][28][29]31,32,[34][35][36][37][40][41][42][43]45], and 5 studies were from other continents, in the countries of Iran, the United Kingdom, European countries, and China [26,30,33,39,44]. A qualitative approach was used by 10 of the studies [28,29,31,[33][34][35][36]41,43,44], 2 used a mixed approach [27,30], 5 were cross-sectional studies [32,37,40,42,45], 1 was a descriptive-analytical study [39], 1 was based on expert consensus [26], and 1 was an expert review [38]. ...
... In this review, 14 studies originated from Africa, namely Ethiopia, Ghana, Nigeria, Burkina Faso, and South Africa [27][28][29]31,32,[34][35][36][37][40][41][42][43]45], and 5 studies were from other continents, in the countries of Iran, the United Kingdom, European countries, and China [26,30,33,39,44]. A qualitative approach was used by 10 of the studies [28,29,31,[33][34][35][36]41,43,44], 2 used a mixed approach [27,30], 5 were cross-sectional studies [32,37,40,42,45], 1 was a descriptive-analytical study [39], 1 was based on expert consensus [26], and 1 was an expert review [38]. Of the 20 studies, one-half (10/20, 50%) of the studies were from the perspective of health workers [26,28,29,[35][36][37]41,43,44], 7 of the studies were from the perspectives of clients [27,30,32,33,39,40,42,45], and the other 3 studies were from both health workers' and clients' perspectives [31,34] ( Table 2). ...
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Background: A compassionate, respectful, and caring (CRC) health professional is very important for human-centered care, serving clients ethically and with respect, adhering to the professional oath, and serving as a model for young professionals. As countries try to achieve universal health coverage (UHC), quality delivery of health services is crucial. CRC health care is an initiative around the need to provide quality care services to clients and patients. However, there is an evidence gap on the status of CRC health care service delivery.
... Eleven papers were eligible for inclusion [35][36][37][38][39][40][41][42][43][44][45] and their study characteristics can be seen in Table 3. Two papers [39,40] were from the same study. ...
... The geographical spread of papers was: four from South Africa; two from each of Ghana and Mozambique; and one each from Benin, Ethiopia and The Gambia. Six papers had aims that were negatively framed: four explicitly focused on mistreatment or abuse [36,39,44,45]; one looked at the psychological stress of caring [40]; and another reported midwives' perceptions of barriers to quality perinatal care [43]. In contrast, Fujita et al. [37] reported on the implementation of a humanised care intervention. ...
... While some student midwives thought there was no justification for So sometimes, we just have to use a little bit of force, and then they will comply. (p.220) [44] Another trigger point was dealing with pain and its manifestations, which some midwives described as a trigger for women to become difficult to control [40] or driving them to physically lash out [36]. However, while pain was sometimes understood as an explanation for why women did not cooperate, it did not spare them from punishment. ...
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Background: In the past decade, the negative impact of disrespectful maternity care on women's utilisation and experiences of facility-based delivery has been well documented. Less is known about midwives' perspectives on these labour ward dynamics. Yet efforts to provide care that satisfies women's psycho-socio-cultural needs rest on midwives' capacity and willingness to provide it. We performed a systematic review of the emerging literature documenting midwives' perspectives to explore the broader drivers of (dis)respectful care during facility-based delivery in the sub-Saharan African context. Methods: Seven databases (CINAHL, PsychINFO, PsychArticles, Embase, Global Health, Maternity and Infant Care and PubMed) were systematically searched from 1990 to May 2018. Primary qualitative studies with a substantial focus on the interpersonal aspects of care were eligible if they captured midwives' voices and perspectives. Study quality was independently assessed by two reviewers and PRISMA guidelines were followed. The results and findings from each study were synthesised using an existing conceptual framework of the drivers of disrespectful care. Results: Eleven papers from six countries were included and six main themes were identified. 'Power and control' and 'Maintaining midwives' status' reflected midwives' focus on the micro-level interactions of the mother-midwife dyad. Meso-level drivers of disrespectful care were: the constraints of the 'Work environment and resources'; concerns about 'Midwives' position in the health systems hierarchy'; and the impact of 'Midwives' conceptualisations of respectful maternity care'. An emerging theme outlined the 'Impact on midwives' of (dis)respectful care. Conclusion: We used a theoretically informed conceptual framework to move beyond the micro-level and interrogate the social, cultural and historical factors that underpin (dis)respectful care. Controlling women was a key theme, echoing women's experiences, but midwives paid less attention to the social inequalities that distress women. The synthesis highlighted midwives' low status in the health system hierarchy, while organisational cultures of blame and a lack of consideration for them as professionals effectively constitute disrespect and abuse of these health workers. Broader, interdisciplinary perspectives on the wider drivers of midwives' disrespectful attitudes and behaviours are crucial if efforts to improve the maternity care environment - for women and midwives - are to succeed.
... Studies on midwives' experiences of disrespect and abuse of childbearing women during intrapartum care seem limited in sub-Saharan Africa [30][31][32][33]. The few evidence on the phenomenon have reported frequent cases of disrespect and abusive care during childbearing women's labour and delivery, with weak health systems and intent to save mother and baby from death commonly cited as reasons for engaging in D&AC practices [30,31,34,35]. For instance, a Ghanaian study involving student midwives revealed that although they understood what constituted D&AC, these student midwives mentioned that some forms of D&AC were justified when the intent was to save both mother and baby from dying during delivery [34]. ...
... The few evidence on the phenomenon have reported frequent cases of disrespect and abusive care during childbearing women's labour and delivery, with weak health systems and intent to save mother and baby from death commonly cited as reasons for engaging in D&AC practices [30,31,34,35]. For instance, a Ghanaian study involving student midwives revealed that although they understood what constituted D&AC, these student midwives mentioned that some forms of D&AC were justified when the intent was to save both mother and baby from dying during delivery [34]. ...
... Healthcare providers in other studies have given similar justifications for their engagement in D&AC on childbearing women during intrapartum care. They mentioned that inadequate clinical and support staff and weak health systems prevented them from translating their knowledge of respectful maternity care into practice [30,31,34,35]. For instance, student midwives and practicing midwives in Ghana and Ethiopia reported that huge workload, burnout from job due to unrealistic staff-to-childbearing women ratio and the pressure to save mother and child during delivery can compel skilled providers to engage in practices that are deemed D&AC [30,34]. ...
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Background Various aspects of disrespect and abusive maternity care have received scholarly attention because of frequent reports of the phenomenon in most healthcare facilities globally, especially in low- and middle-income countries. However, the perspectives of skilled providers on respectful maternal care have not been extensively studied. Midwives’ knowledge of respectful maternity care is critical in designing any interventive measures to address the menace of disrespect and abuse in maternity care. Therefore, the present study sought to explore the views of midwives on respectful maternity care at a Teaching Hospital in Kumasi, Ghana. Methods Phenomenological qualitative research design was employed in the study. Data were generated through individual in-depth interviews, which were audio-recorded and transcribed verbatim. Data saturation was reached with fifteen midwives. Open Code 4.03 was used to manage and analyse the data. Findings The midwives’ understanding of respectful maternity care was comprised of the following components: non-abusive care, consented care, confidential care, non-violation of childbearing women’s basic human rights, and non-discriminatory care. Probing questions to solicit midwives’ opinions on an evidenced-based component of respectful maternity care generated little information, suggesting that the midwives have a gap in knowledge regarding this component of respectful maternity care. Conclusion Midwives reported an understanding of most components of respectful maternity care, but their gap in knowledge on evidenced-based care requires policy attention and in-service training. To understand the extent to which this gap in knowledge can be generalized for midwives across Ghana to warrant a redesign of the national midwifery curriculum, the authors recommend a nationwide cross-sectional quantitative study.
... 11 Mistreatment of women during facility-based childbirth in Ghana has been documented, albeit in few studies. [12][13][14] D'Ambruoso et al. presented women's accounts of their interaction with birth attendants during facility-based childbirth in semi-urban suburbs of Accra. 12 Their findings showed that women were deeply concerned about health provider attitudes and refused to attend health facilities where they were not treated kindly. ...
... A study among student midwives across Ghana also confirmed occurrences of mistreatment during childbirth. 14 Similarly, a study by Moyer et al. 13 in rural northern Ghana noted that mistreatment during facility-based childbirth was pervasive, and could serve as a disincentive for attending health facilities in the future. These studies did not specifically assess views of acceptability of mistreatment during childbirth, or the perceived factors influencing mistreatment. ...
... Our findings are similar to the few previous studies in Ghana, which reported women experiencing physical abuse, scolding, shouting and abandonment during childbirth, as well as health facilities that are unresponsive to their needs, or unable to provide the necessary emotional and physical support during childbirth. [12][13][14]19,20 Failure to push, young age and inability to bring all items required for the birthing process were reported in our study as potential triggers for mistreatment, also echoing previous studies in Ghana. 13,14,20 Mistreatment during facility-based childbirth is increasingly recognised as a widespread problem. ...
Article
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Mistreatment of women during childbirth at health facilities violates their human rights and autonomy and may be associated with preventable maternal and newborn mortality and morbidity. In this paper, we explore women’s perspectives on mistreatment during facility-based childbirth as part of a bigger World Health Organization (WHO) multi-country study for developing consensus definitions, and validating indicators and tools for measuring the burden of the phenomenon. Focus group discussions (FGDs) and in-depth interviews (IDIs) were used to explore experiences of mistreatment from women who have ever given birth in a health facility in Koforidua and Nsawam, Ghana. Interviews were audio-recorded, transcribed and thematic analysis conducted. A total of 39 IDIs and 10 FGDs involving 110 women in total were conducted. The major types of mistreatment identified were: verbal abuse (shouting, insults, and derogatory remarks), physical abuse (pinching, slapping) and abandonment and lack of support. Mistreatment was commonly experienced during the second stage of labour, especially amongst adolescents. Inability to push well during the second stage, disobedience to instructions from birth attendants, and not bringing prescribed items for childbirth (mama kit) often preceded mistreatment. Most women indicated that slapping and pinching were acceptable means to “correct” disobedient behaviours and encourage pushing. Women may avoid giving birth in health facilities in the future because of their own experiences of mistreatment, or hearing about another woman’s experience of mistreatment. Consensus definitions, validated indicators and tools for measuring mistreatment are needed to measure prevalence and identify drivers and potential entry points to minimise the phenomenon and improve respectful care during childbirth.
... For instance, healthcare providers may control the way clients -including pregnant women -should interact during the decision-making process, sometimes disregarding their complaints and concerns [6]. Other times, healthcare providers become angry, yell at, verbally abuse and make derogatory remarks about clients when they perceive they are not adopting the 'appropriate' medical practices and behaviours [5,[7][8][9][10][11]. In addition, healthcare providers sometimes conduct care interactions in environments that do not take into consideration confidentiality of information clients provide them and their privacy needs [2,12]. ...
... Some of the healthcare providers in this study mentioned that part of their behaviour is influenced by the pressures on them from their superordinates' in the healthcare system to reduce maternal and neonatal mortalities to the barest minimum and meet targets like the millennium and sustainable development goals in a resource constrained context. Another study from Ghana describes healthcare providers' physical abuse of mothers in labour as a strategy for gaining mothers' cooperation and compliance to improve neonatal outcomes [10]. ...
... Another three of the women did not want the researcher's present at their baby's delivery. They cited embarrassments as reasons and five went into labour at times impossible for the researcher to be present 10 Research did not play any role in the study design, data collection, analysis and interpretations of data and writing of the manuscript. ...
Article
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Background: Pregnant women can misinform or withhold their reproductive and medical information from providers when they interact with them during care decision-making interactions, although, the information clients reveal or withhold while seeking care plays a critical role in the quality of care provided. This study explored 'how' and 'why' pregnant women in Ghana control their past obstetric and reproductive information as they interact with providers at their first antenatal visit, and how this influences providers' decision-making at the time and in subsequent care encounters. Methods: This research was a case-study of two public hospitals in southern Ghana, using participant observation, conversations, interviews and focus group discussions with antenatal, delivery, and post-natal clients and providers over a 22-month period. The Ghana Health Service Ethical Review Committee gave ethical approval for the study (Ethical approval number: GHS-ERC: 03/01/12). Data analysis was conducted according to grounded theory. Results: Many of the women in this study selectively controlled the reproductive, obstetric and social history information they shared with their provider at their first visit. They believed that telling a complete history might cause providers to verbally abuse them and they would be regarded in a negative light. Examples of the information controlled included concealing the actual number of children or self-induced abortions. The women adopted this behaviour as a resistance strategy to mitigate providers' disrespectful treatment through verbal abuses and questioning women's practices that contradicted providers' biomedical ideologies. Secondly, they utilised this strategy to evade public humiliation because of inadequate privacy in the hospitals. The withheld information affected quality of care decision-making and care provision processes and outcomes, since misinformed providers were unaware of particular women's risk profile. Conclusion: Many mothers in this study withhold or misinform providers about their obstetric, reproductive and social information as a way to avoid receiving disrespectful maternal care and protect their privacy. Improving provider client relationship skills, empowering clients and providing adequate infrastructure to ensure privacy and confidentiality in hospitals, are critical to the provision of respectful maternal care.
... In a previous qualitative paper, we reported the occurrence of major types of mistreatments experienced by women in Ghana including verbal abuse (shouting, insults), physical abuse (pinching, slapping) and neglect [6]. Similar reports indicate that, mistreatment and disrespectful care are pervasive in the country [5,13,14]. These events were more prevalent during the second stage of labor, and amongst adolescent mothers [4,6]. ...
... In total, 9 midwives/nurses, 11 doctors and 4 administrators were interviewed. Majority of the respondents (18) were between the ages of 25-39 years, single (12) and female (14). Most respondents had been working in their respective health facilities for a period of 1-4 years. ...
Article
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Background: Globally, mistreatment of women during facility-based childbirth continues to impact negatively on the quality of maternal healthcare provision and utilization. The views of health workers are vital in achieving comprehensive understanding of mistreatment of women, and to design evidence-based interventions to prevent it. We explored the perspectives of health workers and hospital administrators on mistreatment of women during childbirth to identify opportunity for improvement in the quality of maternal care in health facilities. Methods: A qualitative study comprising in-depth interviews (IDIs) with 24 health workers and hospital administrators was conducted in two major towns (Koforidua and Nsawam) in the Eastern region of Ghana. The study was part of a formative mixed-methods project to develop an evidence-based definition, identification criteria and two tools for measuring mistreatment of women in facilities during childbirth. Data analysis was undertaken based on thematic content via the inductive analytic framework approach, using Nvivo version 12.6.0. Result: Health workers and hospital administrators reported mixed feelings regarding the quality of care women receive. Almost all respondents were aware of mistreatment occurring during childbirth, describing physical and verbal abuse and denial of preferred birthing positions and companionship. Rationalizations for mistreatment included limited staff capacity, high workload, perceptions of women's non-compliance and their attitudes towards staff. Health workers had mixed responses regarding the acceptability of mistreatment of women, although most argued against it. Increasing staff strength, number of health facilities, refresher training for health workers and adequate education of women about pregnancy and childbirth were suggestions to minimize such mistreatment. Conclusion: Health workers indicated that some women are mistreated during birth in the study sites and provided various rationalizations for why this occurred. There is urgent need to motivate, retrain or otherwise encourage health workers to prevent mistreatment of women and promote respectful maternity care. Further research on implementation of evidence-based interventions could help mitigate mistreatment of women in health facilities.
... While research has sought to understand the drivers of this complex issue [10][11][12], respectful maternity care has only recently begun to be studied through the lens of behavioral science globally [13,14]. Bringing the insights of behavioral science to bear on respectful maternity care can shed light on the psychological dimensions of provider behavior, such as the instinct to justify disrespectful care and perceptions of what respectful care encompasses, and identify how providers' micro-level context could trigger disrespect and abuse. ...
... Our research supports the findings of other literature around the importance of ensuring that providers concretize an intention to change the way they provide care in alignment with best practices of respectful care [13,[26][27][28][29]. We highlight that initial on-site training, observed behavior of other providers, and ongoing feedback and supervision all emphasize the importance of death avoidance, and either actively support harsh treatment as a means to achieve client cooperation or justify this behavior. ...
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Background: Recently, a growing body of literature has established that disrespect and abuse during delivery is prevalent around the world. This complex issue has not been well studied through the lens of behavioral science, which could shed light on the psychological dimensions of health worker behavior and how their micro-level context may be triggering abuse. Our research focuses on the behavioral drivers of disrespect and abuse in Zambia to develop solutions with health workers and women that improve the experience of care during delivery. Methods: A qualitative study based on the behavioral design methodology was conducted in Chipata District, Eastern Province. Study participants included postpartum women, providers (staff who attend deliveries), supervisors and mentors, health volunteers, and birth companions. Observations were conducted of client-provider interactions on labor wards at two urban health centers and a district hospital. In-depth interviews were audio recorded and English interpretation from these recordings was transcribed verbatim. Data was analyzed using thematic analysis and findings were synthesized following the behavioral design methodology. Results: Five key behavioral barriers were identified: 1) providers do not consider the decision to provide respectful care because they believe they are doing what they are expected to do, 2) providers do not consider the decision to provide respectful care explicitly since abuse and violence are normalized and therefore the default, 3) providers may decide that the costs of providing respectful care outweigh the gains, 4) providers believe they do not need to provide respectful care, and 5) providers may change their mind about the quality of care they will provide when they believe that disrespectful care will assist their clinical objectives. We identified features of providers' context - the environment in which they live and work, and their past experiences - which contribute to each barrier, including supervisory systems, visual cues, social constructs, clinical processes, and other features. Conclusions: Client experience of disrespectful care during labor and delivery in Chipata, Zambia is prevalent. Providers experience several behavioral barriers to providing respectful maternity care. Each of these barriers is triggered by one or more addressable features in a provider's environment. By applying the behavioral design methodology to the challenge of respectful maternity care, we have identified specific and concrete contextual cues that targeted solutions could address in order to facilitate respectful maternity care.
... Roder-Dewan et al. [18] even seem to question the rationale for a gatekeeper system for maternal healthcare in their recent call for redesigning healthcare models in LMICs to shift all child births to higher level facilities such as hospitals. The call attributed global inequities in maternal health outcomes to current healthcare models requiring that substantial deliveries be made at PHC facilities and argues that emerging evidence demonstrates that such PHC facilities lack the capacity to provide quality basic emergency obstetric and newborn care [18][19][20][21]. However, Hanson et al. [22] argued that local needs, contextual peculiarities, human resource availability and the need for a strengthened local health system should determine the fitness of recommended healthcare models. ...
... By implication, the findings of this study question the practical feasibility of implementing the Ghana healthcare gatekeeper and referral policy. Existing studies have revealed that a lot of PHC facilities in Northern Ghana [21] and elsewhere [19,20] are less attractive to women seeking maternal care because of lack of midwives, maltreatment of clients, and poor experience of women with the existing healthcare referral system. It is against this background that some scholars have argued that bypassing PHC to higher level facilities may be important for women to obtain quality maternal healthcare [18]. ...
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Background: Bypassing primary health care (PHC) facilities for maternal health care is an increasing phenomenon. In Ghana, however, there is a dearth of systematic evidence on bypassing PHC facilities for maternal healthcare. This study investigated the prevalence of bypassing PHC facilities for maternal healthcare, and the socio-economic factors and financial costs associated with bypassing PHC facilities within two municipalities in Northwestern Ghana. Methods: A quantitative cross-sectional design was implemented between December 2019 and March 2020. Multistage stratified sampling was used to select 385 mothers receiving postnatal care in health facilities for a survey. Using STATA 12 software, bivariate analysis with chi-square test and binary logistic regression models were run to determine the socio-economic and demographic factors associated with bypassing PHC facilities. The two-sample independent group t-test was used to estimate the mean differences in healthcare costs of those who bypassed their PHC facilities and those who did not. Results: The results revealed the prevalence of bypassing PHC facilities as 19.35 % for antenatal care, 33.33 % for delivery, and 38.44 % for postnatal care. The municipality of residence, ethnicity, tertiary education, pregnancy complications, means of transport, nature of the residential location, days after childbirth, age, and income were statistically significantly (p < 0.05) associated with bypassing PHC facilities for various maternal care services. Compared to the non-bypassers, the bypassers incurred a statistically significantly (P < 0.001) higher mean extra financial cost of GH₵112.09 (US$19.73) for delivery, GH₵44.61 (US$7.85) for postnatal care and ₵43.34 (US$7.65) for antenatal care. This average extra expenditure was incurred on transportation, feeding, accommodation, medicine, and other non-receipted expenses. Conclusions: The study found evidence of bypassing PHC facilities for maternal healthcare. Addressing this phenomenon of bypassing and its associated cost, will require effective policy reforms aimed at strengthening the service delivery capacities of PHC facilities. We recommend that the Ministry of Health and Ghana Health Service should embark on stakeholder engagement and sensitization campaigns on the financial consequences of bypassing PHC facilities for maternal health care. Future research, outside healthcare facility settings, is also required to understand the specific supply-side factors influencing bypassing of PHC facilities for maternal healthcare within the study area.
... Mistreatment during childbirth is an issue across the globe, yet its occurrence is particularly prevalent in low-income settings [4]. Factors such as frustration among healthcare personnel and unequal patient-provider relations can help to explain why women are being mistreated during childbirth; however, intrinsically good motives among healthcare staff might play a role as well [5]. This can be well understood through the words of an Ethiopian midwife. ...
... Our finding that observation of mistreatment during education was significantly related to positive appraisal of mistreatment, confirms findings of Rominski et al. [5], who proposed that observation of mistreatment during education might cause midwifery students to rationalize disciplinary measures against patients through victim-blaming. While students might understand the importance of respectful and patient-centered care, observation of mistreatment during education appears to put them at risk of internalizing such behaviors. ...
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The maternal mortality ratio and neonatal mortality rate remain high in Ethiopia, where few births are attended by qualified healthcare staff. This is partly due to care providers’ mistreatment of women during childbirth, which creates a culture of anxiety that decreases the use of healthcare services. This study employed a cross-sectional design to identify risk factors for positive appraisal of mistreatment during childbirth. We asked 391 Ethiopian final year midwifery students to complete a paper-and-pen questionnaire assessing background characteristics, prior observation of mistreatment during education, self-esteem, stress, and mistreatment appraisal. A multivariable linear regression analysis indicated age (p = 0.005), stress (p = 0.019), and previous observation of mistreatment during education (p < 0.001) to be significantly associated with mistreatment appraisal. Younger students, stressed students, and students that had observed more mistreatment during their education reported more positive mistreatment appraisal. No significant association was observed for origin (p = 0.373) and self-esteem (p = 0.445). Findings can be utilized to develop educational interventions that counteract mistreatment during childbirth in the Ethiopian context.
... The views of midwives were sought on situations where force should be applied during intrapartum care. This question was informed by findings from previous work by the first, third, and fifth authors involving midwifery students who justified the application of force or hitting childbearing women during labour [34]. The midwives who responded to the questions mentioned that hitting the thighs of the childbearing women in the second stage of labour helps them push and deliver babies safely. ...
... Other studies in healthcare facilities in Ghana have revealed that childbearing women are usually mistreated, and the midwives in our study and in others justified mistreatment by arguing that childbearing women should not be overly pampered as this may lead to non-compliance and death of their babies [6,26,28]. The repetitiveness of this finding in our study involving practising midwives and that of previous work by the lead author [34] involving student midwives suggest that this belief of engaging in mistreatment with a life-saving goal in mind is pervasive and deserve to be immediately addressed. Given the goal of this sub-study to inform intervention, we emphasised the disrespectful and abusive nature of such a belief and its dangers on the dignity and welfare of childbearing women in our training manual and during the intervention. ...
Article
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Background Various aspects of disrespect and abusive maternity care have received scholarly attention because of frequent reports of the phenomenon in most healthcare facilities globally, especially in low- and middle-income countries. Experiences of disrespect and abuse during childbirth may dissuade women from returning for facility-based postpartum services, for antenatal care, and delivery for future pregnancies and births. Midwives’ knowledge of respectful maternity care is critical in designing any interventive measures to address the menace of disrespect and abuse in maternity care. However, the perspectives of skilled providers on respectful maternal care have not been extensively studied. Therefore, the present study sought to explore the views of midwives on respectful maternity care at a teaching hospital in Kumasi, Ghana. Methods We employed an exploratory descriptive qualitative research design using an interpretative approach. Data were generated through individual in-depth interviews of fifteen midwives, which were audio-recorded and transcribed verbatim. Open Code 4.03 was used to manage and analyse the data. Findings The midwives demonstrated some degree of awareness of respectful maternity care that comprised of the following components: non-abusive care, consented care, confidential care, non-violation of childbearing women’s basic human rights, and non-discriminatory care. However, midwives’ support for disrespectful and abusive practices such as hitting, pinching, and implicitly blaming childbearing women for mistreatment suggests that midwives awareness of respectful maternity care is disconnected from its practice. Conclusion In view of these findings, we recommend frequent in-service training for midwives and the institutionalization of regular supervision of intrapartum care services in the healthcare facility.
... Twelve research studies 17,20,21,32-40 addressed views of both women and care providers; three [41][42][43] focused only on care providers perspectives and another two studies from Ghana involved final year midwifery students. 44,45 Two studies from Kenya 46 and Mali 47 used mixed methods. No systematic review or registered protocol to date has been identified that specifically addresses how care providers' view D&A of women during facility-based childbirth in Africa. ...
Article
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Objective: The objective of this review is to identify and synthesize the best available qualitative evidence to understand healthcare providers' views on disrespect and abuse of women during facility-based childbirth in Africa. Introduction: Everyday, approximately 800 women die from preventable pregnancy and childbirth-related causes worldwide; poorer women living in developing countries comprise 99% of these deaths. Maternal mortality has no single cause or solution, but the most effective preventive strategy is ensuring that every woman gives birth in an equipped health facility with the help of skilled providers. Yet, many women are dissatisfied and decline to attend facility-based delivery, often due to disrespect and abuse during childbirth. Inclusion criteria: This systematic review will consider studies that include views of care providers regarding disrespect and abuse of women in birthing facilities, including verbal, physical and sexual abuse; stigma; discrimination; substandard care; neglect; and trust and communication problems. Qualitative studies that relate to Africa published in English from 1990 will be included. Methods: PubMed, CINAHL, Embase, Scopus, African Index Medicus and Web of Science, and selected gray literature sources, will be searched for eligible papers. Titles and abstracts of obtained documents will be assessed by the lead reviewer against the inclusion criteria. Identified documents will then be appraised for relevance and rigor by two independent reviewers. Data will be extracted by two independent reviewers and graded according to the ConQual approach.
... At the individual level, providers state that disrespect and abuse are unintended and are justified as necessary to help women in the birthing process (Bohren et al., 2016;Burrowes et al., 2017;Warren et al., 2017). Others blame women's disobedience and lack of co-operation (Bohren et al., 2016;Rominski et al., 2017). In a study in Nigeria on acceptability of mistreatment during childbirth, Bohren et al. (2016) found that while some respondents viewed scenarios such as slapping, verbal abuse and physical restraint as abuse, others thought these were acceptable means of gaining compliance to ensure a good outcome. ...
Article
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Disrespect and abuse during childbirth are violations of women's human rights and an indicator of poor-quality care. Disrespect and abuse during childbirth are widespread, yet data on providers' perspectives on the topic are limited. We examined providers' perspectives on the frequency and drivers of disrespect and abuse during facility-based childbirth in a rural county in Kenya. We used data from a mixed-methods study in a rural county in Western Kenya with 49 maternity providers (32 clinical and 17 non-clinical) in 2016. Providers were asked structured questions on disrespect and abuse, followed by open-ended questions on why certain behaviours were exhibited (or not). Most providers reported that women were often treated with dignity and respect. However, 53% of providers reported ever observing other providers verbally abuse women and 45% reported doing so themselves. Observation of physical abuse was reported by 37% of providers while 35% reported doing so themselves. Drivers of disrespect and abuse included perceptions of women being difficult, stress and burnout, facility culture and lack of accountability, poor facility infrastructure and lack of medicines and supplies, and provider attitudes. Provider bias, training and wom-en's empowerment influenced how different women were treated. We conclude that disrespect and abuse are driven by difficult situations in a health system coupled with a facilitating sociocul-tural environment. Providers resorted to disrespect and abuse as a means of gaining compliance when they were stressed and feeling helpless. Interventions to address disrespect and abuse need to tackle the multiplicity of contributing factors. These should include empowering providers to deal with difficult situations, develop positive coping mechanisms for stress and address their biases. We also need to change the culture in facilities and strengthen the health systems to address the system-level stressors.
... Caregivers must learn appropriate skills to communicate effectively with the mother at various stages of the labour, how to inform the mother and her companion, and help the mother participate actively in childbirth. Professionals and midwives must understand the importance of focusing on the mothers' mental and emotional needs from the start of their education and get to know that they directly affect the longterm experiences of mother's birth [23,24]. In order for training interventions to lead to change in the behavior of clinicians and maternity experts, continuous training, monitoring and feedback, participation of supervisors, academic literacy and periodic reminders should be utilized [25]. ...
Article
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Background: Psychological birth trauma (PBT), mainly due to overlooking maternal mental health, is a common and high prevalence public health problem in low-resource settings. Preventing PBT is a good indicator of the realization of human rights in healthcare. This work reports the results of a qualitative study that aimed to identify perceived strategies of PBT prevention among childbearing women in Iran. Methods: We conducted semi-structured in-depth interviews with 22 mothers with history of traumatic childbirth, two mothers with positive childbirth experience, two spouses, and eight health professionals between April and June 2017. We used purposive sampling method to recruit traumatized mothers, while health experts were selected based on their relevant expertise and experience. Our initial literature review identified eight categories, using which we developed our interview guide and conducted the content analysis approach. Results: With the maximum possible purification, we reached 50 thematic codes. The strategies to prevent PBT are generally summarized in four major themes and 13 categories: 1) skill-builder knowledge [Birth preparedness, Mothers' empowerment in maintaining mental health, Understanding the importance of mental care in maternity services], 2) responsible caregiving [Support loop, Good behavior of the caregivers, Deepening trust, Struggle with medicalization of childbirth, Labour pain relief, Special services for maternal mental health], 3) the alliance of prenatal and antenatal care [Continuity of care, Coordination of prenatal and antenatal caregivers], and 4) reconstruction of the structures [Efficient management, Rebuilding physical structures]. Conclusions: This is a comprehensive approach towards PBT prevention, which can guide future efforts to reduce PBT at the clinical level and open further avenues for future studies. We recommend policy makers to consider the integration of multilevel and multidimensional PBT prevention interventions, simultaneously within maternity care services packages for promotion of mental health.
... The different types of OV detected in the literature refer to verbal violence, physical violence, sexual violence, social discrimination, neglect of care and inappropriate use of procedures and technologies [8]. The structural characteristic of such violence [9] often means that the professionals who exercise it are unaware that they do so, and even consider it to be normal [10,11]. Another factor to bear in mind is institutional violence. ...
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The decentralization of health systems can have direct repercussions on maternity care. Some inequalities can be noted in outcomes, like neonatal and child mortality in Spain. This study aimed to make the presence of obstetric violence in Spain visible as an interterritorial equity criterion. A descriptive, restrospective and cross-sectional study was conducted between January 2018 and June 2019. The sample comprised 17,541 questionnaires, which represented all Spanish Autonomous Communities. Of our sample, 38.3% perceived having suffered obstetric violence; 44.4% perceived that they had undergone unnecessary and/or painful procedures, of whom 83.4% were not requested to provide informed consent. The mean satisfaction with the attention women received obtained 6.94 points in the general sample and 4.85 points for those women who viewed themselves as victims of obstetric violence. Spain seems to have a serious problem with public health and respecting human rights in obstetric violence. Offering information to women and requesting their informed consent are barely practiced in the healthcare system, so it is necessary to profoundly reflect on obstetric practices with, and request informed consent from, women in Spain.
... Women's birthing experience was often sub-optimal because of midwives' professional interest in ensuring a live birth. Disrespect and abuse towards mothers in labour did not present a significant barrier in this study, unlike that conducted in Ghana [35]. Nonetheless, as reported by other studies, disrespect, abuse and otherwise negative attitudes of midwives towards women seeking delivery services could hamper efforts to increase facility deliveries in peri-urban Lusaka [36,37]. ...
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Background: A 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. Methods: We 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. Results: We 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. Conclusion: Difference 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.
... In Spain, the existence of obstetric violence is still not accepted by the majority of the healthcare community and even by society in general, because its structural characteristics mean that the professionals who perform it are frequently unaware of it, and this sort of behaviour has become commonplace [12,13]. Obstetric violence is a taboo and hidden practice in Spanish health care, and the normalisation of this sort of violence can occur among healthcare professionals and health sciences students, such as nursing or medical students [14,15]. ...
Article
Background Obstetric violence appears to be a worldwide concern and is defined as a type of gender-based violence perpetrated by health professionals. This violence undermines and harms women’s autonomy. In Spain, 38.3 % of women have identified themselves as victims of this type of violence. Aim To explore current information and knowledge about obstetric violence within the Spanish healthcare context, as well as to develop a theoretical model to explain the concept of obstetric violence, based on the experiences of healthcare professionals (midwives, registered nurses, gynaecologists and paediatricians) and nursing students. Methods A constructivist grounded theory study was conducted at Jaume I University in Spain between May and July 2021, including concurrent data collection and interpretation through constant comparison analysis. An inductive analysis was carried out using the ATLAS.ti 9.0 software to organise and analyse the data. Results Twenty in-depth interviews were conducted, which revealed that healthcare professionals and students considered obstetric violence a violation of human rights and a serious public health issue. The interviews allowed them to describe certain characteristics and propose preventive strategies. Three main categories were identified from the data analysis: (i) characteristics of obstetric violence in the daily routine, (ii) defining the problem of obstetric violence and (iii) strategies for addressing obstetric violence. Participants identified obstetric violence as structural gender-based violence and emphasised the importance of understanding its characteristics. Our results indicate how participants’ experiences influence their process of connecting new information to prior knowledge, and they provide a connection to specific micro- and macro-level strategic plans. Discussion Despite the lack of consensus, this study resonates with the established principles of women and childbirth care, but also generates a new theoretical model for healthcare students and professionals to identify and manage obstetric violence based on contextual factors. The term ‘obstetric violence’ offers a distinct contribution to the growing awareness of violence against women, helps to regulate it through national policy and legislation, and involves both structural and interpersonal gender-based abuse, rather than assigning blame only to care providers. Conclusions Obstetric violence is the most accurate term to describe disrespect and mistreatment as forms of interpersonal and structural violence that contribute to gender and social inequality, and the definition of this term contributes to the ongoing awareness of violence against women, which may help to regulate it through national policy and legislation.
... A number of explanations have been forwarded for disrespectful or aggressive care by health workers in sub-Saharan Africa, such as it being part of a process of status positioning (Jewkes et al., 1998;Andersen, 2004), to force patients to cooperate (Rominski et al., 2017) or because senior management were reluctant to sanction nurses who behaved in a disrespectful way (Jewkes et al., 1998). Likewise, the influence of personal connections on access to public services is common across West Africa, and has been remarked upon extensively (see Blundo et al., 2006;Smith, 2006). ...
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We examined the views of providers and users of the surgical system in Freetown, Sierra Leone on processes of care, job and service satisfaction and barriers to achieving quality and accessible care, focusing particularly on the main public tertiary hospital in Freetown and two secondary and six primary sites from which patients are referred to it. We conducted interviews with health care providers (N = 66), service users (n = 24) and people with a surgical condition who had chosen not to use the public surgical system (N = 13), plus two focus groups with health providers in primary care (N = 10 and N = 10). The overall purpose of the study was to understand perceptions on processes of and barriers to care from a variety of perspectives, to recommend interventions to improve access and quality of care as part of a larger study. Our research suggests that providers perceive their relationships with patients to be positive, while the majority of patients see the opposite: that many health workers are unapproachable and uncaring, particularly towards poorer patients who are unable or unwilling to pay staff extra in the form of informal payments for their care. Many health care providers note the importance of lack of recognition shown to them by their superiors and the health system in general. We suggest that this lack of recognition underlies poor morale, leading to poor care. Any intervention to improve the system should therefore consider staff–patient relations as a key element in its design and implementation, and ideally be led and supported by frontline healthcare workers.
... 6 Failure to cooperate with or adhere to instructions given during childbirth or antenatal care (such as the provision of required items) could lead to frustration and provocation of the health provider unto deviation from the ideal compassionate and polite treatment of parturients to maltreatments such as verbal, physical abuse, neglect or any other form of D&A during childbirth. 21,32,[47][48][49][50][51] Community-level drivers of D&A during childbirth in this study were the normalization of disrespectful care, poor awareness of fundamental rights and redress mechanisms, lack of autonomy and empowerment of women. 40 Normalization of mistreatment during childbirth in a bid to assist childbirth was the most-mentioned driver from the qualitative arm of the study and also recurred in the questionnaire-based survey. ...
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Purpose: Understanding 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 methods: This 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. Results: Maternal 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. Conclusion: A 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.
... In two studies, maternity staff stated that respectful and quality care is provided when healthcare worker communicate without shouting to the clients [54] [82]. in another study, one maternity healthcare staff narrated that if client does not want something to be done during the delivery, instead of abusing the women, the provider can document what happened [74]. ...
... Too often, research has confirmed the presence of both verbal and physical abuse directed at patients in maternity wards. This phenomenon has been reported in the Congo (Hunt, 2013), Tanzania (Allen, 2002;Kujawski et al, 2015;Kruk et al, 2018), Kenya (Abuya et al, 2015;Afulani et al, 2019), Nigeria (Bohren et al, 2016;Ishola et al, 2017), Ghana (Moyer et al, 2014;Rominski et al, 2017) and Guinea (Blade et al, 2017). Four studies in Kenya, Tanzania, Ethiopia and Nigeria analysed women's experiences during childbirth and estimated prevalence of disrespect and abuse to be 20%, 20-28%, 78% and 98% respectively (Abuya et al, 2015;Okafor et al, 2015). ...
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Background The World Health Organization includes women's experiences of care and person-centred outcomes as primary components in their quality-of-care framework for maternal and newborn health. Patients' perceptions of quality of care indicate how well health systems meet patients' expectations, as well as their level of trust in the system. Methods This study was a cross-sectional examination of person-centred maternal care service delivery, from the perspective of women who used the services of the Princess Christian Maternity Hospital in Sierra Leone. The care was measured using the person-centred maternity care survey, which was administered to 100 women at the hospital. Results Person-centred maternal care was found to be lacking in patient–provider interactions, especially in the areas of communication, autonomy and dignity and respect. Conclusions This study provides evidence regarding the extent to which person-centred maternity care is delivered at the Princess Christian Maternity Hospital. The findings could be used to target interventions to improve patient satisfaction and quality of care at the Princess Christian Maternity Hospital.
... According to these personal relationships and social links, it is something that is vital and indivisible of a person and, therefore, of the autonomy capacity (Busquets Gallego, 2019). Students are capable of justifying disrespectful and abusive care while women give birth (Rominski et al., 2017). By considering this relational autonomy, research should be conducted into how health sciences students' learning impacts obstetric violence with their tutors, teachers and/or superiors. ...
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Background Obstetric violence is a problem that has grown worldwide, and a particularly worrying one in Spain. Such violence has repercussions for women, and for the professionals who cause them. Preventing this problem seems fundamental. Objective This study evaluated how health sciences students perceived obstetric violence. Design A cross-sectional study conducted between October 2019 and November 2020. Participants A sample of Spanish health sciences students studying degrees of nursing, medicine, midwifery, and psychology. Methods A validated questionnaire was used: Perception of Obstetric Violence in Students (PercOV-S). Socio-demographic and control variables were included. A descriptive and comparative multivariate analysis was performed with the obtained data. Results 540 questionnaires were completed with an overall mean score of 3.83 points (SD ± 0.63), with 2.83 points (SD ± 0.91) on the protocolised-visible dimension and 4.15 points (SD ± 0.67) on the non-protocolised-invisible obstetric violence dimension. Statistically significant differences were obtained for degree studied (p < 0.001), gender (p < 0.001), experience (p < 0.001), ethnic group (p < 0.001), the obstetric violence concept (p < 0.001) and academic year (p < 0.005). There were three significant multivariate models for the questionnaire's overall score and dimensions. Conclusions Health sciences students perceived obstetric violence mainly as non-protocolised aspects while attending women. Degree studied and academic year might be related to perceived obstetric violence.
... Globally, some studies have shown that non-use or delayed use of health facilities for childbirth have been reported due to poor quality of care and D&A received in health facilities alongside other social determinants of health [13][14][15][16][17]. Occurrence of D&A during childbirth has been explored by mostly qualitative studies, but few have used a mixed-methods approach to compare experiences of women in public and private health facilities [7, 10,15,[18][19][20][21][22][23][24][25][26][27]. The objective of this study was to compare prevalence and forms of D&A during childbirth in public and private specialized healthcare settings in Southeast Nigeria. ...
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Background Disrespect and Abuse (D&A) during childbirth represents an important barrier to skilled birth utilization, indicating a problem with quality of care and a violation of women‘s human rights. This study compared prevalence of D&A during childbirth in a public and a private hospital in Southeast Nigeria. Methods This study was a cross-sectional study among women who gave birth in two specialized health facilities: a public teaching and a private-for-profit faith-based hospital in Southeast Nigeria. In each facility, systematic random sampling was used to select 310 mothers who had given birth in the facility and were between 0-14 weeks after birth. Study participants were recruited through the immunization clinics. Semi-structured, interviewer-administered questionnaires using the Bowser and Hills classification of D&A during childbirth were used for data collection. Data were analyzed using SPSS version 20 at 95% significance level. Results Mean age of the participants in the public hospital was 30.41 ± 4.4 and 29.31 ± 4.4 in the private hospital. Over three-fifths ( 191; 61.6%) in the public and 156 women (50.3%) in the private hospital had experienced at least one form of D&A during childbirth [cOR1.58; 95% CI 1.15, 2.18]. Abandonment and neglect [Public153 (49.4%) vs. Private: 91 (29.4%); cOR2.35; 95% CI. 1.69, 3.26] and non-consented care [Public 45 (14.5%) vs. Private 67(21.6%): cOR0.62; 95% CI. 0.41, 0.93] were the major types of D&A during childbirth. Denial of companionship was the most reported subtype of D&A during childbirth in both facilities [Public 135 (43.5%) vs. Private66 (21.3%); cOR2.85; 95% CI. 2.00, 4.06]. Rural residents were less likely to report at least one form of D&A during childbirth (aOR 0.53; CI 0.35-0.79). Conclusion Although prevalence was high in both facilities, overall prevalence of D&A during childbirth and most subtypes were higher in the public health facility. There is a need to identify contextual factors enabling D&A during childbirth in public and private health care settings.
... Numerous studies worldwide emphasize that women often experience disrespect and abuse during childbirth [15][16][17][18][19][20][21][22][23]. Studies report that 20%, 20%-28%, 78%, and 98% of women in Kenya, Tanzania, Ethiopia, and Nigeria experience childbirth violence [15,[24][25][26]. ...
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Background Violation of mothers' rights during childbirth is a global problem that often silently torments women in many parts of the world. The aim of this study was to explore negative health consequences due to childbirth violence based on mothers' perceptions and experiences. Methods To achieve rich data, an exploratory qualitative study was carried out in 2019 on 26 women with childbirth violence experience who had given birth in hospitals of Ilam, Iran. Data were collected using semi‑structure in‑depth interviews (IDIs) and a purposive sampling. Participants were asked about their experiences and perceptions of negative health consequences due to childbirth violence. Data were analyzed by conventional content analysis based on Graneheim and Lundman approach. MAXQDA (v.18) software was used for better data management. Results Final codes were classified into 9 sub-categories and 3 main categories including maternal and newborn injuries, weakening of family ties, sense of distrust and hatred. These findings emerged the theme: negative health consequences. Conclusions This study broke the silence of abused mothers during childbirth and expressed the perspective of mothers who suffered childbirth violence as a routine phenomenon in maternal care, and a serious threat to the health of mothers, newborns and families. Findings of this study can be a warning for maternity health system, monitoring and support structures as well as health policy-makers to seriously plan to prevent and eliminate this problem.
... When women have their expectations of labor and birth met, they are likely to be satisfied with care. A study in the United States of America (USA) found that personal control during childbirth was an important childbirth care requirement amongst participating women (Rominski-Danielson et al., 2016). A similar study in Australia found that having familiar faces engaging in the care process was important to satisfaction with birth care (Goodman et al., 2004). ...
... Moreover, healthcare professionals reacted after a scientific publication in Italy that described the OV phenomenon as unrealistic [21]. Actually, the structural characteristics of such violence [9] means that professionals frequently exercise it without realizing it, and it has even become a standard practice [22,23]. This means that without actually perceiving it, some healthcare professionals have acquired an authoritarian role marked by pseudoscientific guidelines (not based on up-to-date evidence), and one based on unequal treatment to stick to comply with the protocols established by health centers. ...
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Background: Obstetric violence is a worldwide public health problem, which seems greater in Spain. As no studies were found that identify the most representative healthcare professionals, times, and areas involved in obstetric violence, the objective of this work was to study at what time of maternity, with which professionals, and in what areas women identified obstetric violence. Methods: This descriptive, retrospective, and cross-sectional study was performed from January 2018 to June 2019. The main variables were the area (hospital, primary care, both), the time (pregnancy, birth, puerperium), and the professionals attending to women. Results: Our sample comprised 17,541 participants. The area identified with the most obstetric violence for the different studied variables was hospitals. Women identified more obstetric violence at time of birth. Findings such as lack of information and informed consent (74.2%), and criticism of infantile behavior and treatment (87.6%), stood out. The main identified healthcare professionals were midwives and gynecologists, and "other" professionals repeatedly appeared. Conclusions: Having identified the professionals, times, and areas of most obstetric violence in Spain, it seems necessary to reflect on not only the Spanish National Health System's structure and management but also on healthcare professionals' training.
... During this time in Ghana there was an excess of new graduate nurses and midwives who could not get jobs as there was no funding to pay them (Asamani et al., 2020). Recent studies of midwives perspectives in Ghana also point to an underresourced health system, and they are under immense pressure in trying to do their jobs (Dzomeku et al., 2020;Rominski et al., 2017;Yakubu et al., 2014). While the Sustainable Development Goals are taking a multisectoral approach to end poverty, without an equitable distribution of resources globally, it is hard to have hope for the future. ...
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BACKGROUND The purpose of this metasynthesis is to analyze women's lived experiences of giving birth in Ghana during and after the Millennium Development Goals (MDGs), when health policy in Ghana was changed to urge women to birth in health services with skilled attendants. METHOD An interpretive phenomenological framework guided the review of the literature. Three electronic databases were searched as well as reference lists and author searches. Articles that met the screening criteria for inclusion were coded and thematically analyzed, then drawn together to construct the essence of women's experiences of giving birth in Ghana. RESULTS Seven themes were constructed from the data and these were poor quality health services, maltreatment by midwives, mixed emotions about pregnancy and childbirth, supernatural fears, women wanting safe births with skilled birth attendants, uncertainty about reaching a health facility, and decision-making hierarchy. There were three counter themes and these were women wanting a home birth with a traditional midwife, defiance against dominant decision-makers by some women, and a belief that “not all nurses are bad.” CONCLUSION Ghanaian women have heeded the MDGs and health policy messages to birth with skilled attendants, but in reality, they are not always accessible, available, appropriate, or of high quality. Maternal health services still need much improvement including more resources such as staff, essential services, medicines, and quality assurance standards.
... Many quantitative studies on D&A have been published from African countries, including Ethiopia. 9,11,19,[26][27][28][29][30] Unlike in other African countries, where many qualitative studies on D&A have been conducted, [31][32][33][34] there have been limited qualitative studies in Ethiopia exploring D&A during childbirth. 35,36 Furthermore, past research has demonstrated that D&A differs based on the circumstances of the study setting. ...
Article
There is evidence that women in Ethiopia often face disrespect and abuse in health care facilities during childbirth. Disrespect and abuse (D&A) violate women's right to dignified, respectful health care and decrease their trust in health care facilities. There is a need for more insight into women's perspectives on D&A during childbirth in different contexts. Therefore, this study aimed to explore women's perspectives on D&A during childbirth in a teaching hospital in SouthWest Ethiopia. A qualitative study was conducted from November 2017 to February 2018 using in-depth interviews and focus group discussions. Postnatal women were purposively chosen and scheduled for interviews six weeks postpartum. Data saturation occurred once 32 women were interviewed, and four focus group discussions were conducted. A thematic analysis method was used to analyse the data using MAXQDA qualitative analysis software. Three main themes emerged from the data: disrespect and abuse, its contributors, and perceived consequences. The subthemes of D&A include neglected care, non-consented care, physical abuse, lack of privacy, loss of autonomy, objectification, lack of companionship, and verbal abuse. The subthemes of contributors include health care provider-related, health care system-related, and women-related contributors. The subthemes of perceived consequences include the fear of using health care facilities. Women in Ethiopia experienced D&A. Health system factors, such as the teaching environment and scarcity of supplies, contribute the most to the identified D&A. Therefore, providers, administrators, training institutions, and researchers must collaborate to address these health system factors to reduce disrespect and abuse during childbirth in teaching hospitals.
Article
Mistreatment with women during childbirth is prevalent in many in low- and middle-income countries. There is dearth of evidence that informs development of health system interventions to promote supportive and respectful maternity care in facility-based settings. We examined health systems bottlenecks that impedes provision of supportive and respectful maternity care in secondary-level public healthcare system of Pakistan. Using a qualitative exploratory design, forty in-depth interviews conducted with maternity care staff of six public health facilities in southern Pakistan. Development of interview guide and data analyses were guided by the WHO’s six health system building blocks. A combination of inductive and deductive approach was used for data analyses. Our study identified range of bottlenecks impeding provision of RMC. In terms of leadership/governance, there was lack of institutional guidelines, supervision and monitoring, and patient feedback mechanism. No systematic mechanism existed to screen and record patient psychosocial needs. Health workforce lacked training opportunities on RMC that resulted in limited knowledge and skills; there were also concerns about lack of recognition from leadership for good performers, and poor relationship and coordination between clinical and non-clinical staff. Regarding the domain of service delivery, we found that patients were perceived as un-cooperative, non-RMC manifestations were acceptable and normalized under certain conditions, and restrictive policies for active engagement of companions. Finally, lack of cleanliness, curtains for privacy, seating arrangement for companion were the identified issues infrastructural issues. A service-delivery intervention package is needed that effectively uses all six components of the health system: from investments in capacity building of maternity teams to creating a conducive facility environment via proper governance and accountability mechanisms. Such interventions should not only focus on provision of maternity care in a respectful and dignified manner, but also ensure that care is responsive to the psychosocial needs of pregnant women without any discrimination.
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Background Student nurses are expected to implement a caring practice in order to become professional nurses. Caring has remained the art and science of nursing, which student nurses learn from professional nurses during clinical practice. The South African Nursing Council mandates professional nurses to teach and supervise student nurses to master the art of caring during clinical practice. Caring is taught through role-modelling of daily nursing activities. Research purpose This study was performed to gain an understanding of South African student nurses' experiences of professional nurses' role-modelling of caring. Methods Phenomenological, qualitative research. Purposive sampling of fourth-year student nurses. Data collection: focus groups, observations and field notes. The data were analysed using Giorgi's modified Husserlian five-step method. Ethical principles were respected. Results Three themes were identified. Theme 1: inconsistency in the clinical environment; Theme 2: effective and ineffective role-modelling of caring and Theme 3: carelessness cascading. Conclusions The study facilitated an understanding of student nurses' experiences of professional nurses' role-modelling of caring. Recommendations to facilitate professional nurses' role-modelling of caring in a public hospital were formulated: Mentorship training, recognition system for professional nurses, clinical support for student nurses, open channels of communication, random nurse leader rounds, employee wellness program, workshops and positive learning environment promotion.
Article
Background Disrespect and Abusive Care (DA&C) of women in health facilities during childbirth is a topic of growing concern globally. Given that DA&C is a violation of women’s basic rights and a deterrent to facility-based maternity services for women. In Nigeria, limited evidence exists on barriers to the provision of Respectful Maternity Care (RMC), especially in South-West, Nigeria. Aim This study aimed to explore the barriers to the provision of Respectful Maternity Care (RMC) during childbirth by midwives in selected health facilities in Lagos State, Nigeria. Methodology The research used an Exploratory Descriptive Research Design. Data was collected through semi-structured individual interviews. Data analysis was done following Burns and Clarke’s thematic method. Twenty midwives were purposively selected from two public secondary health facilities. Findings The findings of this study revealed the barriers to the provision of RMC are diverse and interwoven. The study highlighted health system factors, health provider factors and client factors as barriers challenging the provision of RMC. Health system factors include physical structure of the labour ward, work overload due to shortage of staff, shortage of resources, lack of motivation, hospital policy and poor working conditions. Health provider factors identified were midwives’ personal beliefs, individual personalities, the poor orientation of professional staff, and poor collaborations among professionals. The client factors were women’s/relations attitudes and unmet expectations. Conclusion Training midwives and others on RMC without addressing deficiencies in the health care system will not achieve the desired goals of RMC. Encouraging teamwork, trust-building, collaboration, accountability and effective communication among health workers, policymakers, stakeholders and women will further promote RMC.
Article
Background Childbearing women's relationship with maternity care providers enhance childbirth outcomes. Students need to understand and offer respectful care. Objective Evaluate effectiveness and impact of an online education intervention on nursing students' perceptions towards respectful maternity care during labour and childbirth in Nepal. Design A quasi-experimental pre-post design was used. Participants A total of 89 Third Year Bachelor of Nursing students (intervention n = 40; control n = 49) from three participating colleges. Methods Students completed online pre and post-test surveys using the Students' Perceptions of Respectful Maternity Care scale and questions about impact of the intervention. The intervention group received six hours of education delivered online (three sessions x three weeks). ANCOVA and non-parametric Wilcoxon signed-rank tests measured effects. Results Compared to controls, students in the intervention group reported a significant increase in perceptions towards respectful maternity care (F (1, 86) = 28.19, p < 0.001, ηp² = 0.25). Participants reported a good understanding of respectful maternity care (75%), positive views about providing such care (82.5%), and a desire to use their new knowledge in practice (65%). Conclusion Relatively few intervention studies to promote respectful maternity care in students have been published. This brief online intervention improved students' perceptions. The intervention package can be integrated into nursing or midwifery curricula and in-service training. A larger study with longer follow-up is needed to support current findings.
Article
Objectives To develop and test a tool to measure Bachelor of Nursing students’ perceptions towards respectful maternity care in Nepal, a low-income country. Design A cross-sectional design was used. Phases of tool development included item generation, expert review for content validity testing, and psychometric testing. The draft tool had 42 items on a 5-point Likert response scale of 1 = strongly disagree to 5 = strongly agree. Psychometric testing included dimensionality, internal consistency, and test-retest reliability. A t-test assessed mean score differences between students who had witnessed or not witnessed disrespect and abuse. Settings Two medical colleges in Chitwan, Nepal Participants Undergraduate Bachelor of Nursing students (n = 171) undertaking their midwifery clinical practicum were invited to complete the online survey. Findings Principal component analysis generated three factors: Respectful Care, Safety and Comfort, and Supportive Care and explained 37.44% of the variance. The 18-item tool demonstrated good internal reliability (Cronbach's alpha of 0.81). The mean total scale score was 71.23 (SD 7.47, range 52-88 out of 90). Pearson's correlation coefficient confirmed test-retest reliability at one week (r = 0.91, p <0.001). The magnitude of difference in mean scores between those who had witnessed or not witnessed disrespectful and abusive care was very small (η² = 0.04). Key conclusion The new Student Perceptions of Respectful Maternity Care tool is the first valid and reliable measure of students’ perceptions of respectful maternity care. Validation of the newly developed tool in other low and middle income countries is recommended. Implications for practice Measuring students’ perceptions provides information to educators on how best to enhance students’ understanding and provision of respectful care to women.
Article
https://issuu.com/chalg/docs/algarve_medico_8 When did the concept of obstetric violence arise? What is it about? What consequences does it have? Factors that favor the presence of obstetric violence? What about in Portugal, is there obstetric violence? What measures can be implemented to improve delivery care?
Article
Background: A compassionate, respectful, and caring (CRC) health professional is very important for human-centered care, serving clients ethically and with respect, adhering to the professional oath, and serving as a model for young professionals. As countries try to achieve universal health coverage (UHC), quality delivery of health services is crucial. CRC health care is an initiative around the need to provide quality care services to clients and patients. However, there is an evidence gap on the status of CRC health care service delivery. Objective: This scoping review aimed to map global evidence on the status of CRC health service delivery practice. Methods: An exhaustive literature review and Delphi technique were used to answer the 2 research questions: "What is the current status of CRC health care practices among health workers?" and "Is it possible for health professionals, health managers, administrators, and policy makers to incorporate it into their activity while designing strategies that could improve the humanistic and holistic approach to health care provision?" The studies were searched from the year 2014 to September 2020 using electronic databases such as MEDLINE (PubMed), Cochrane Library, Web of Science, Hinari, and the World Health Organization (WHO) library. Additionally, grey literature such as Google, Google Scholar, and WorldWideScience were scrutinized. Studies that applied any study design and data collection and analysis methods related to CRC care were included. Two authors extracted the data and compared the results. Discrepancies were resolved by discussion, or the third reviewer made the decision. Findings from the existing literature were presented using thematic analysis. Results: A total of 1193 potentially relevant studies were generated from the initial search, and 20 studies were included in the final review. From this review, we identified 5 thematic areas: the status of CRC implementation, facilitators for CRC health care service delivery, barriers to CRC health care delivery, disrespectful and abusive care encountered by patients, and perspectives on CRC. The findings of this review indicated that improving the mechanisms for monitoring health facilities, improving accountability, and becoming aware of the consequences of maltreatment within facilities are critical steps to improving health care delivery practices. Conclusions: This scoping review identified that there is limited CRC service provision. Lack of training, patient flow volume, and bed shortages were found to be the main contributors of CRC health care delivery. Therefore, the health care system should consider the components of CRC in health care delivery during in-service training, pre-service training, monitoring and evaluation, community engagement, workload division, and performance appraisal.
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Mistreatment during childbirth occurs across the globe and endangers the well-being of pregnant women and their newborns. A gender-sensitive approach to mistreatment during childbirth seems relevant in Ethiopia, given previous research among Ethiopian midwives and patients suggesting that male midwives provide more respectful maternity care, which is possibly mediated by self-esteem and stress. This study aimed a) to develop a tool that assesses mistreatment appraisal from a provider’s perspective and b) to assess gender differences in mistreatment appraisal among Ethiopian final-year midwifery students and to analyze possible mediating roles of self-esteem and stress. First, we developed a research tool (i.e. a quantitative scale) to assess mistreatment appraisal from a provider’s perspective, on the basis of scientific literature and the review of seven experts regarding its relevance and comprehensiveness. Second, we utilized this scale, the so-called Mistreatment Appraisal Scale, among 390 Ethiopian final-year midwifery students to assess their mistreatment appraisal, self-esteem (using the Rosenberg Self-Esteem Scale), stress (using the Perceived Stress Scale) and various background characteristics. The scale’s internal consistency was acceptable (α = .75), corrected item-total correlations were acceptable (.24 - .56) and inter-item correlations were mostly acceptable (.07 - .63). Univariable (B = 3.084, 95% CI [-.005, 6.173]) and multivariable (B = 1.867, 95% CI [-1.472, 5.205]) regression analyses did not show significant gender differences regarding mistreatment appraisal. Mediation analyses showed that self-esteem (a1b1 = -.030, p = .677) and stress (a2b2 = -.443, p = .186) did not mediate the effect of gender on mistreatment appraisal. The scale to assess mistreatment appraisal appears to be feasible and reliable. No significant association between gender and mistreatment appraisal was observed and self-esteem and stress were not found to be mediators. Future research is needed to evaluate the scale’s criterion validity and to assess determinants and consequences of mistreatment during childbirth from various perspectives.
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Introduction Globally, mistreatment during childbirth remains a powerful deterrent to skilled birth utilization. Aim We determined the perpetrated and witnessed experiences of mistreatment and Respectful Maternity Care (RMC) among maternal health providers in a tertiary hospital in Nigeria. Methods A cross-sectional study was conducted among 156 maternal health providers in a tertiary hospital in Nigeria. Information was collected using semi-structured, self-administered questionnaires, and 3 focus group discussions. Quantitative and qualitative data analyses were performed using SPSS version 20 and thematic analysis respectively. Findings Most respondents were males (64.1%) and doctors (74.4%) with mean age of 31.97 ± 6.82. Two-fifths (39.1%) and 73.1% of the respondents had ever meted out or witnessed disrespectful and abusive care to women during childbirth respectively. Verbal abuse and denial of companionship in labour were major mistreatments reported qualitatively and quantitatively. About a third of the respondents mistreated women 1–2 times in a week. Younger respondents had 64% lower odds of reporting mistreatment during childbirth (AOR = 0.36, 95% CI = 0.14−0.96). The most and least frequently practiced RMC element were provision of consented care (62.8%) and allowing birth position of choice respectively (3.8%). Poor hospital patronage and reputation were the perceived consequences of mistreatment during childbirth. Conclusion Witnessed rather than self-perpetrated mistreatment during childbirth was more reported in addition to poor RMC practices Self-perpetrated mistreatment during childbirth was less reported among younger providers. We recommend intensification of provider capacity building on RMC with special focus on older practitioners and the provision of supportive work environments that encourage respectful maternal care practices.
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Globally, the widespread occurrence of disrespect and abuse (D&A) on maternity wards is well-documented. Using ethnography and cultural consensus analysis we explore how the practice of midwives hitting women who are in the second stage of labor (pushing) has become a locally accepted form of care in Tanzania if a baby’s life appears to be at risk. This analysis interrogates the deep uncertainty of birth outcomes in this setting that may motivate abuse during this time. Seriously engaging with local discourses on abuse and care sheds light on hegemonic norms and power dynamics and is critical for improving maternity services.
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Background The interest of the global community in improving women’s experiences with childbirth has led to interventions such as facility-based childbirth and the use of skilled birth attendants. However, reports of low facility and skilled birth attendants use continue to exist in literature because of disrespectful and abusive care directed at women during childbirth. The present systematic review examined the question “What are the understanding and justification for disrespect and abuse directed at women by Health Professionals during childbirth or intrapartum care?” Methods Electronic search was conducted from January 2000 to January 2021 across CINAHL, OVID, PUBMED, PSYINFO databases. The retrieved studies were then filtered through a stringent inclusion and exclusion criteria. Thirteen studies were included in this review; extracted and synthesized using Thomas and Harden’s (2008) thematic synthesis method. Results Three key themes were identified- providers related factors, women related factors, health system related factors. Sub-themes included classification and description, authority and control, reciprocity, providers attitude, rationalization, socio-economic inequalities, lack of assertiveness and inadequate resources. Conclusion The study demonstrated that HPs were aware and understood the various forms of D&AC. However, they provided justifications such as an act to save mother and baby’s life, lack of assertiveness from labouring women and inadequate work resources for their actions. This highlights the need for various stakeholders involved in care during childbirth to reignite commitments to international standards on respectful maternity care and patient safety, such as training of staff and education of women on the process of labour and birth.
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Profissionalismo em Ginecologia e Obstetrícia: O caso da Violência Obstétrica
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Background Quality midwifery care through respectful maternity care is the key to reducing maternal mortality rate. Several literatures implicated midwives as meting out disrespectful maternity care to women during childbirth, thus discouraging women from accessing facility-based childbirth. Hence, this study’s aim was to explore provision of respectful maternity care by midwives during childbirth in selected health facilities in Lagos State, Nigeria. Methodology This study adopted an exploratory descriptive research design. As a result, the collection of data was through semi-structured individual interviews. The purposive selection of 20 midwives was from two health facilities. Findings The study showed the adequate provision of confidentiality, availability of showers and water, availability of meals and drinks to women, and pain relief in labour and delivery. Findings further revealed other aspects of respectful maternity care poorly provided by midwives, included physical abuse, privacy, use of dignified tone/language/threat/neglect, obtaining consent for procedures during labour and delivery, discrimination, allowing birth companion, detention, mobility, positioning and availability of commodities. All the midwives claimed to be providing respectful maternity care and showed willingness to support provision of respectful maternity care. Conclusion To foster provision, RMC requires an enabling environment where staff are highly motivated, there is adequate staff strength, reduced workload, continuous in-service training on evidence-based practices, training and support of midwives on RMC, adequate provision of supplies, commodities and modern equipment, and restructuring the ward to private delivery suites to accommodate birth companions and provide privacy.
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Background Quality of care is essential for further progress in reducing maternal and newborn deaths. The integration of educated, trained, regulated and licensed midwives into the health system is associated with improved quality of care and sustained decreases in maternal and newborn mortality. To date, research on barriers to quality of care for women and newborns has not given due attention to the care provider’s perspective. This paper addresses this gap by presenting the findings of a systematic mapping of the literature of the social, economic and professional barriers preventing midwifery personnel in low and middle income countries (LMICs) from providing quality of care. Methods and Findings A systematic search of five electronic databases for literature published between January 1990 and August 2013. Eligible items included published and unpublished items in all languages. Items were screened against inclusion and exclusion criteria, yielding 82 items from 34 countries. 44% discussed countries or regions in Africa, 38% in Asia, and 5% in the Americas. Nearly half the articles were published since 2011. Data was extracted and presented in a narrative synthesis and tables. Items were organized into three categories; social; economic and professional barriers, based on an analytical framework. Barriers connected to the socially and culturally constructed context of childbirth, although least reported, appear instrumental in preventing quality midwifery care. Conclusions Significant social and cultural, economic and professional barriers can prevent the provision of quality midwifery care in LMICs. An analytical framework is proposed to show how the overlaps between the barriers reinforce each other, and that they arise from gender inequality. Links are made between burn out and moral distress, caused by the barriers, and poor quality care. Ongoing mechanisms to improve quality care will need to address the barriers from the midwifery provider perspective, as well as the underlying gender inequality.
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Background: Disrespect and abuse (D & A) during labor and delivery are important issues correlated with human rights, equity, and public health that also affect women's decisions to deliver in facilities, which provide appropriate management of maternal and neonatal complications. Little is known about interventions aimed at lowering the frequency of disrespectful and abusive behaviors. Methods: Between 2011 and 2014, a pre-and-post study measured D & A levels in a three-tiered intervention at 13 facilities in Kenya under the Heshima project. The intervention involved working with policymakers to encourage greater focus on D & A, training providers on respectful maternity care, and strengthening linkages between the facility and community for accountability and governance. At participating facilities, postpartum women were approached at discharge and asked to participate in the study; those who consented were administered a questionnaire on D & A in general as well as six typologies, including physical and verbal abuse, violations of confidentiality and privacy, detainment for non-payment, and abandonment. Observation of provider-patient interaction during labor was also conducted in the same facilities. In both exit interview and observational studies, multivariate analyses of risk factors for D & A controlled for differences in socio-demographic and facility characteristics between baseline and endline surveys. Results: Overall D & A decreased from 20-13 % (p < 0.004) and among four of the six typologies D & A decreased from 40-50 %. Night shift deliveries were associated with greater verbal and physical abuse. Patient and infant detainment declined dramatically from 8.0-0.8 %, though this was partially attributable to the 2013 national free delivery care policy. Conclusion: Although a number of contextual factors may have influenced these findings, the magnitude and consistency of the observed decreases suggest that the multi-component intervention may have the potential to reduce the frequency of D & A. Greater efforts are needed to develop stronger evaluation methods for assessing D & A in other settings.
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Background Despite growing recognition of neglectful, abusive, and disrespectful treatment of women during childbirth in health facilities, there is no consensus at a global level on how these occurrences are defined and measured. This mixed-methods systematic review aims to synthesize qualitative and quantitative evidence on the mistreatment of women during childbirth in health facilities to inform the development of an evidence-based typology of the phenomenon. Methods and Findings We searched PubMed, CINAHL, and Embase databases and grey literature using a predetermined search strategy to identify qualitative, quantitative, and mixed-methods studies on the mistreatment of women during childbirth across all geographical and income-level settings. We used a thematic synthesis approach to synthesize the qualitative evidence and assessed the confidence in the qualitative review findings using the CERQual approach. In total, 65 studies were included from 34 countries. Qualitative findings were organized under seven domains: (1) physical abuse, (2) sexual abuse, (3) verbal abuse, (4) stigma and discrimination, (5) failure to meet professional standards of care, (6) poor rapport between women and providers, and (7) health system conditions and constraints. Due to high heterogeneity of the quantitative data, we were unable to conduct a meta-analysis; instead, we present descriptions of study characteristics, outcome measures, and results. Additional themes identified in the quantitative studies are integrated into the typology. Conclusions This systematic review presents a comprehensive, evidence-based typology of the mistreatment of women during childbirth in health facilities, and demonstrates that mistreatment can occur at the level of interaction between the woman and provider, as well as through systemic failures at the health facility and health system levels. We propose this typology be adopted to describe the phenomenon and be used to develop measurement tools and inform future research, programs, and interventions.
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Background: Poor quality of care including fear of disrespect and abuse (D&A) perpetuated by health workers influences women's decisions to seek maternity care. Key manifestations of D&A include: physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination, abandonment, and detention in facilities. This paper describes manifestations of D&A experienced in Kenya and measures their prevalence. Methods: This paper is based on baseline data collected during a before-and-after study designed to measure the effect of a package of interventions to reduce the prevalence of D&A experienced by women during labor and delivery in thirteen Kenyan health facilities. Data were collected through an exit survey of 641 women discharged from postnatal wards. We present percentages of D&A manifestations and odds ratios of its relationship with demographic characteristics using a multivariate fixed effects logistic regression model. Results: Twenty percent of women reported any form of D&A. Manifestations of D&A includes: non-confidential care (8.5%), non-dignified care (18%), neglect or abandonment (14.3%), Non-consensual care (4.3%) physical abuse (4.2%) and, detainment for non-payment of fees (8.1). Women aged 20-29 years were less likely to experience non-confidential care compared to those under 19; OR: [0.6 95% CI (0.36, 0.90); p=0.017]. Clients with no companion during delivery were less likely to experience inappropriate demands for payment; OR: [0.49 (0.26, 0.95); p=0.037]; while women with higher parities were three times more likely to be detained for lack of payment and five times more likely to be bribed compared to those experiencing there first birth. Conclusion: One out of five women experienced feeling humiliated during labor and delivery. Six categories of D&A during childbirth in Kenya were reported. Understanding the prevalence of D&A is critical in developing interventions at national, health facility and community levels to address the factors and drivers that influence D&A in facilities and to encourage clients' future facility utilization.
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In 2015, as we review progress towards Millennium Development Goals (MDGs), despite significant progress in reduction of mortality, we still have unacceptably high numbers of maternal and newborn deaths globally. Efforts over the past decade to reduce adverse outcomes for pregnant women and newborns have been directed at increasing skilled birth attendance.1, 2 This has resulted in higher rates of births in health facilities in all regions.3 The proportion of deliveries reportedly attended by skilled health personnel in developing countries rose from 56% in 1990 to 68% in 2012.4 With increasing utilisation of health services, a higher proportion of avoidable maternal and perinatal mortality and morbidity have moved to health facilities. In this context, poor quality of care (QoC) in many facilities becomes a paramount roadblock in our quest to end preventable mortality and morbidity.
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PerspectivesIn the field of maternal and newborn health, there have been calls to prioritize the intra-partum period and promote facility delivery to meet maternal and newborn mortality reduction goals. This aim is based on a decade of epide-miological work identifying causes of death, systematically reviewing effective interventions, and modelling the impact of intervention coverage on mortality.
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Background Interventions 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. Methods This 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. Results When 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. Conclusions Many 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.
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Achieving the Millennium Development Goal (MDG) of improving maternal health has become a focus in recent times for the majority of countries in sub-Saharan Africa. Ghana's maternal mortality is still high indicating that there are challenges in the provision of quality maternal health care at the facility level. This study examined the implementation challenges of maternal health care services in the Tamale Metropolis of Ghana. Purposive sampling was used to select study participants and qualitative strategies, including in-depth interviews, focus group discussions and review of documents employed for data collection. The study participants included midwives (24) and health managers (4) at the facility level. The study revealed inadequate in-service training, limited knowledge of health policies by midwives, increased workload, risks of infection, low motivation, inadequate labour wards, problems with transportation, and difficulties in following the procurement act, among others as some of the challenges confronting the successful implementation of the MDGs targeting maternal and child health in the Tamale Metropolis. Implementation of maternal health interventions should take into consideration the environment or the context under which the interventions are implemented by health care providers to ensure they are successful. The study recommends involving midwives in the health policy development process to secure their support and commitment towards successful implementation of maternal health interventions.
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Summary This study aimed to explore pregnant women's attitudes towards the inclusion of a lay companion as a source of social support during labour and delivery in rural central Ghana. Quantitative demographic and pregnancy-related data were collected from 50 pregnant women presenting for antenatal care at a rural district hospital and analysed using STATA/IC 11.1. Qualitative attitudinal questions were collected from the same women through semi-structured interviews; data were analysed using NVivo 9.0. Twenty-nine out of 50 women (58%) preferred to have a lay companion during facility-based labour and delivery, whereas 21 (42%) preferred to deliver alone with the nurses in a facility. Women desiring a companion were younger, had more antenatal care visits, had greater educational attainment and were likely to be experiencing their first delivery. Women varied in the type of companion they prefer (male partner vs female relative). What was expected in terms of social support differed based upon the type of companion. Male companions were expected to provide emotional support and to 'witness her pain'. Female companions were expected to provide emotional support as well as instrumental, informational and appraisal support. Three qualitative themes were identified that run counter to the inclusion of a lay helper: fear of an evil-spirited companion, a companion not being necessary or helpful, and being 'too shy' of a companion. This research challenges the assumption of a unilateral desire for social support during labour and delivery, and suggests that women differ in the type of companion and type of support they prefer during facility deliveries. Future research is needed to determine the direction of the relationship - whether women desire certain types of support and thus choose companions they believe can meet those needs, or whether women desire a certain companion and adjust their expectations accordingly.
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While the most important factors associated with facility-based delivery (FBD) have been explored within individual countries in Africa, no systematic review has explored the factors associated with FBD across sub-Saharan Africa. A systematic search of the peer-reviewed literature was conducted to identify articles published in English from 1/1995-12/2011 that reported on original research conducted entirely or in part in sub-Saharan Africa and included a primary outcome variable of FBD, delivery location, or skilled birth attendance (SBA). Out of 1,168 citations identified, 65 met inclusion criteria. 62 of 65 were cross-sectional, and 58 of 65 relied upon household survey data. Fewer than two-thirds (43) included multivariate analyses. The factors associated with facility delivery were categorized as maternal, social, antenatal-related, facility-related, and macro-level factors. Maternal factors were the most commonly studied. This may be a result of the overwhelming reliance on household survey data -- where maternal sociodemographic factors are likely to be well-represented and non-maternal factors may be less consistently and accurately represented. Multivariate analysis suggests that maternal education, parity / birth order, rural / urban residence, household wealth / socioeconomic status, distance to the nearest facility, and number of antenatal care visits were the factors most consistently associated with FBD. In conclusion, FBD is a complex issue that is influenced by characteristics of the pregnant woman herself, her immediate social circle, the community in which she lives, the facility that is closest to her, and context of the country in which she lives. Research to date has been dominated by analysis of cross-sectional household survey data. More research is needed that explores regional variability, examines longitudinal trends, and studies the impact of interventions to boost rates of facility delivery in sub-Saharan Africa.
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Background In Burkina Faso, Ghana and Tanzania strong efforts are being made to improve the quality of maternal and neonatal health (MNH) care. However, progress is impeded by challenges, especially in the area of human resources. All three countries are striving not only to scale up the number of available health staff, but also to improve performance by raising skill levels and enhancing provider motivation. Methods In-depth interviews were used to explore MNH provider views about motivation and incentives at primary care level in rural Burkina Faso, Ghana and Tanzania. Interviews were held with 25 MNH providers, 8 facility and district managers, and 2 policy-makers in each country. Results Across the three countries some differences were found in the reasons why people became health workers. Commitment to remaining a health worker was generally high. The readiness to remain at a rural facility was far less, although in all settings there were some providers that were willing to stay. In Burkina Faso it appeared to be particularly difficult to recruit female MNH providers to rural areas. There were indications that MNH providers in all the settings sometimes failed to treat their patients well. This was shown to be interlinked with differences in how the term ‘motivation’ was understood, and in the views held about remuneration and the status of rural health work. Job satisfaction was shown to be quite high, and was particularly linked to community appreciation. With some important exceptions, there was a strong level of agreement regarding the financial and non-financial incentives that were suggested by these providers, but there were clear country preferences as to whether incentives should be for individuals or teams. Conclusions Understandings of the terms and concepts pertaining to motivation differed between the three countries. The findings from Burkina Faso underline the importance of gender-sensitive health workforce planning. The training that all levels of MNH providers receive in professional ethics, and the way this is reinforced in practice require closer attention. The differences in the findings across the three settings underscore the importance of in-depth country-level research to tailor the development of incentives schemes.
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We introduce the ‘active patient’ model, which we claim is a better way to describe health-seeking behaviour in low-income countries. Active patients do not automatically seek health care at the closest or lowest cost provider, but rather seek high-quality care (even at higher cost) when they estimate that such care will significantly improves outcomes. We show how the active patient can improve his or her health even when access to adequate quality care is insufficient and that the empirical literature supports this model, particularly in Africa. Finally, we demonstrate the importance, in analysing health care policy, of recognizing patients’ efforts to improve health outcomes by seeking quality care.
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The scarcity of resources in poorer countries means that ensuring health care is evidence based is particularly important A group of workers active in the field describe their experiences of trying to do just that.
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Maternal death reviews is a tool widely recommended to improve the quality of obstetric care and reduce maternal mortality. Our aim was to explore the challenges encountered in the process of facility-based maternal death review in Malawi, and to suggest sustainable and logically sound solutions to these challenges. SWOT (strengths, weaknesses, opportunities and threats) analysis of the process of maternal death review during a workshop in Malawi. Strengths: Availability of data from case notes, support from hospital management, and having maternal death review forms. Weaknesses: fear of blame, lack of knowledge and skills to properly conduct death reviews, inadequate resources and missing documentation. Opportunities: technical assistance from expatriates, support from the Ministry of Health, national protocols and high maternal mortality which serves as motivation factor. Threats: Cultural practices, potential lawsuit, demotivation due to the high maternal mortality and poor planning at the district level. Solutions: proper documentation, conducting maternal death review in a blame-free manner, good leadership, motivation of staff, using guidelines, proper stock inventory and community involvement. Challenges encountered during facility-based maternal death review are provider-related, administrative, client related and community related. Countries with similar socioeconomic profiles to Malawi will have similar 'pull-and-push' factors on the process of facility-based maternal death reviews, and therefore we will expect these countries to have similar potential solutions.
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Randomised controlled trials are widely accepted as the most reliable method of determining effectiveness, but most trials have evaluated the effects of a single intervention such as a drug. Recognition is increasing that other, non›pharmacological interventions should also be rigorously evaluated. 1-3 This paper examines the design and execution of research required to address the additional problems resulting from evalua› tion of complex interventions—that is, those "made up of various interconnecting parts." 4 The issues dealt with are discussed in a longer Medical Research Council paper (www.mrc.ac.uk/complex_packages.html). We focus on randomised trials but believe that this approach could be adapted to other designs when they are more appropriate.
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The Prevention of Maternal Mortality Program is a collaborative effort of Columbia University's Center for Population and Family Health and multidisciplinary teams of researchers from Ghana, Nigeria and Sierra Leone. Program goals include dissemination of information to those concerned with preventing maternal deaths. This review, which presents findings from a broad body of research, is part of that activity. While there are numerous factors that contribute to maternal mortality, we focus on those that affect the interval between the onset of obstetric complication and its outcome. If prompt, adequate treatment is provided, the outcome will usually be satisfactory; therefore, the outcome is most adversely affected by delayed treatment. We examine research on the factors that: (1) delay the decision to seek care; (2) delay arrival at a health facility; and (3) delay the provision of adequate care. The literature clearly indicates that while distance and cost are major obstacles in the decision to seek care, the relationships are not simple. There is evidence that people often consider the quality of care more important than cost. These three factors--distance, cost and quality--alone do not give a full understanding of decision-making process. Their salience as obstacles is ultimately defined by illness-related factors, such as severity. Differential use of health services is also shaped by such variables as gender and socioeconomic status. Patients who make a timely decision to seek care can still experience delay, because the accessibility of health services is an acute problem in the developing world. In rural areas, a woman with an obstetric emergency may find the closest facility equipped only for basic treatments and education, and she may have no way to reach a regional center where resources exist. Finally, arriving at the facility may not lead to the immediate commencement of treatment. Shortages of qualified staff, essential drugs and supplies, coupled with administrative delays and clinical mismanagement, become documentable contributors to maternal deaths. Findings from the literature review are discussed in light of their implications for programs. Options for health programs are offered and examples of efforts to reduce maternal deaths are presented, with an emphasis on strategies to mobilize and adapt existing resources.
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This study examines violence against women in Ghana and how it affects and is perceived by them. It looks at violence as experienced by Ghanaian women of varying ages, socio-economic status and professional standing. It defines domestic violence as violence intentionally perpetrated by husbands or male partners--people known to be intimate associates. Domestic violence is approached from a multidimensional perspective by examining the multiple facets of violence against women: sexual, socio-economic, cultural, pseudo-religious and mental torture. Women's perceptions of their rights, responsibilities, duties and abuses or violations are evaluated using open-ended qualitative questions in two major cities in Ghana: Accra and Kumasi. Policy responses to domestic violence are then examined by first reviewing what provisions exist in the country's constitution to address the problem and then the specific steps the government itself has taken. Civil society's response in the form of activities by non-governmental organizations is also reviewed. Finally, the effects of domestic violence on women's health and well-being are examined and suggestions for addressing the problem are made.
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We summarize and comment on the available literature on the effectiveness of interventions designed to change professional behaviour in order to bring evidence into practice in developing countries. We used a strategy adapted from the Effective Practice & Organization Care (EPOC) Cochrane group. Forty-four studies met pre-defined selection criteria. Controlled and uncontrolled trials of interventions were included. Studies measured either professional compliance with agreed standards or patients' clinical outcomes. Data extraction. Data were extracted using a pre-defined extraction tool and studies were appraised accordingly. Data were synthesized and categorized according to different types of intervention. Audit and feedback was found to be effective, at least in the short term, when combined with other approaches. Similarly, educational interventions were more effective when designed to address local educational needs and organizational barriers. We found insufficient evidence to assess the effectiveness of educational outreach, local opinion leaders, use of mass media, and reminders. Educational materials alone are unlikely to influence change. However, the majority of studies had weak designs and failed to exclude possible biases. Current evidence for the effectiveness of interventions to change health professionals' behaviour in developing countries is either scanty or flawed due to poorly designed research. Given the recent drive to improve quality of care, this should be a priority area for researchers and international agencies supporting health systems development in developing countries. This review provides an insight into some of the methodological issues that interested researchers