Beyond Maternal Mortality: A Systematic Review of Evidences on Mistreatment and Disrespect During Childbirth in Health Facilities in India

Does mistreatment during institutional childbirth increase the likelihood of experiencing postpartum depressive symptoms? A prospective cohort study in Nepal

BACKGROUND

Postpartum depression is associated with low socioeconomic status, adverse birthing processes, and life stress. Increasing evidence of mistreatment during childbirth, negative birth experiences, and poor quality of maternal care is of global concern.

OBJECTIVE

To assess the risk of experiencing depressive symptoms among postpartum women exposed to mistreatment during institutional birthing in Nepal.

METHOD

We conducted a prospective cohort study from 29 March to 19 August 2022. Of 1629 women who gave birth in a hospital in Nepal, 1222 were assessed for mistreatment during childbirth and depressive symptoms using the Edinburgh Postnatal Depression Scale. We used binomial generalized linear mixed model to examine the risk ratio of postpartum depressive symptoms in women exposed to mistreatment during childbirth.

RESULTS

The prevalence of postpartum depressive symptoms was 4.4%. Women exposed to mistreatment during childbirth were almost fifty percent more likely to have postpartum depressive symptoms (cRR 1.47; 95% CI 1.14, 1.89; p = 0.003) compared with the unexposed group. Furthermore, adolescent mothers exposed to mistreatment during childbirth had a seventy percent increased risk of depressive symptoms (aRR 1.72; 95% CI 1.23, 2.41; p = 0.002). Similarly, women who gave birth to female infants were thirty percent more likely to experience postpartum depressive symptoms (aRR 1.32; 95% CI 1.01-1.74; p = 0.039).

CONCLUSION

We observed an association between postpartum depressive symptoms and mistreatment during institutional births in Nepal. The implementation of appropriate respectful maternity care during childbirth and also routine screening for depressive symptoms is critical to improving perinatal mental health and well-being.

The EMERGE framework to measure empowerment for health and development

RATIONALE

Women's empowerment is a UN Sustainable Development Goal and a focus of global health and development but survey measures and data on gender empowerment remain weak. Existing indicators are often disconnected from theory; stronger operationalization is needed.

OBJECTIVE

We present the EMERGE Framework to Measure Empowerment, a framework to strengthen empowerment measures for global health and development.

METHOD

We initiated development of this framework in 2016 as part of EMERGE - an initiative designed to build the science of survey research and availability of high-quality survey measures and data on gender empowerment. The framework is guided by existing theories of empowerment, evidence, and expert input. We apply this framework to understand women's empowerment in family planning (FP) via review of state of the field measures.

RESULTS

Our framework offers concrete measurable constructs to assess critical consciousness and choice, agency and backlash, and goal achievement as the empowerment process, recognizing its operation at multiple levels-from the individual to the collective. Internal attributes, social norms, and external contexts and resources create facilitators or barriers to the empowerment process. Review of best evidence FP measures assessing empowerment constructs, social norms, and key influencers (e.g., partners and providers) show a strong landscape of measures, including those with women, partners, and providers, but they are limited in assessing translation of choice to agency to achievement of women's self-determined fertility or contraceptive goals, instead relying on assumption of contraceptive use as the goal. We see no measures on collective empowerment toward women's reproductive choice and rights.

CONCLUSION

The EMERGE Framework can guide development and analysis of survey measures on empowerment and is needed as the current state of the field shows limited coverage of empowerment constructs even in areas which have received more study, such as family planning.

National policies and programs for perinatal mental health in India: A systematic review

BACKGROUND

India is the most populous country in the world with millions of births annually. Perinatal mental disorders (PMDs) are prevalent worldwide including in India. This study was undertaken to evaluate how mental health is addressed in national maternity and mental health policies and programs in India.

METHODS

We conducted a systematic review of the national policies and programs in India related to maternity care and mental health. The identified policies and programs were analysed using health policy triangle framework.

RESULTS

Our search yielded 11 relevant documents and no peer reviewed publications. No specific national policy or program on maternal mental health could be identified. Universal access to health and mental health including for women and children was clearly articulated in both national mental health and maternity policies, which emphasised that access to mental health care and treatment is a fundamental right. There were few details about how the programs and policies were developed and no accounts of consultations with community members or service providers in their formation.

CONCLUSION

National maternity and mental health policies and programs in India appear not to consider perinatal mental health. There are promising state-based initiatives, but, given the disease burden of PMDs in India, the absence of a national policy leads to unrecognized and unmet needs of women in the states without these measures. These inequalities can be effectively minimized by well implemented national policies for perinatal mental health, accompanied by evidence-based locally tailored programs and interventions across the country.

Intrapartum violence during facility-based childbirth and its determinants: A cross-sectional study among postnatal women in Tanzania

BACKGROUND

Violence during childbirth indirectly contributes to maternal and neonatal morbidity and mortality. It also causes intrapartum health consequences such as prolonged labor, postpartum hemorrhage, and postpartum psychological problems, including postpartum depression, post-traumatic stress disorder, and other negative feelings that lead to a decreased desire for facility delivery and increase the events of home deliveries which reduce the quality of life. In Tanzania, several efforts have been made to promote respectful maternity care. However, violence during childbirth continues to create a critical barrier for facility-based delivery and is in need of considerable attention throughout the health system.

OBJECTIVES

This study aimed to assess types of intrapartum violence and its determinants among postnatal women in the Dodoma Region, Tanzania.

DESIGN

A cross-sectional study using a questionnaire to interview postnatal women at the exit point after being discharged from the health facility to assess intrapartum violence and its determinants.

METHODS

This study was conducted in Dodoma Region involving 307 postnatal women from April to June 2022. A simple random method was used to select respondents. The Chi-square and Fisher's exact tests were used to assess the association between the categorical variables. The predictors of intrapartum violence were determined using binary logistic regression analysis. Statistical analysis was performed using Statistical Package for Social Science version 25.0. P < 0.05 was considered to be significant.

RESULTS

Overall, 307 postnatal women participated in the study. Among them, 158 (51.5%) postnatal women experienced at least one form of intrapartum violence. The most common forms of intrapartum violence included breach of confidentiality 205 (66.8%), undignified care/verbal abuse 178 (58%), physical abuse 139 (45.3%), and denial or neglected care by midwives 113 (36.8%). Husband employment, urban residence, and being referred from primary hospitals were significant determinants associated with intrapartum violence (adjusted odds ratio = 0.233, 95% confidence interval = 0.057-0.952, p = 0.043, adjusted odds ratio = 2.67, 95% confidence interval = 1.13-10.93, p = 0.026 and adjusted odds ratio = 3.673, 95% confidence interval = 1.131-11.934, p = 0.030, respectively).

CONCLUSION

Violence during childbirth was highly prevalent in this study. Understanding the prevalence and types of intrapartum violence is important in order to promote changes in all levels of the health system. This study reveals the need for key interventions to effect change at many levels; including an interventional study to educate women and birth partners on client rights, and strengthening the health system to meet the needs of women during labor and childbirth. Policies and systems that support respectful maternity care are urgently needed in this setting, including universal training of health professionals in respectful maternity care.

Measurement of self-reported, facility-based labour and birth experiences: The Perinatal Experience Assessment Tool (PEAT)

Background

Women and their families make decisions on accessing perinatal care based on their experiences in the health care system and on the experience of others around them. Receiving supportive maternity care which demonstrates respect is an essential part of quality care. Globally, and in low- and middle-income countries in particular, women report receiving mistreatment and a lack of respect during labour, childbirth and the early postnatal period. These experiences, if negative, may influence choices around place of birth, thus hindering the scale-up of facility-based births.

Methods

We conducted a focussed review of the literature between 2010 and 2019 to identify recent research addressing the assessment of women's experiences during childbirth in low- and middle-income country facilities. The World Health Organization (WHO) and White Ribbon Alliance themes and concepts of respectful maternity care served as a guide. Themes included disrespectful or abusive experiences such as verbal abuse or rudeness, abandonment, corruption, lack of privacy, failure to respect traditional practices, discrimination, and physical or sexual abuse. Experienced midwives in two low-resource countries contributed to the identification of appropriate indicators of respectful, non-abusive care, and eventual agreement as to which to include in an assessment tool monitoring women's experiences.

Results

Our review of the literature identified 18 publications meeting pre-established criteria. This resulted in the eventual selection of 33 indicators of respectful care sub-grouped under 9 domains: 1) communication/verbal interaction, 2) supportive care, 3) physical abuse, 4) non-consented care, 5) non-confidential care/lack of privacy, 6) stigma and discrimination, 7) abandonment/neglect, 8) detention/inability to pay, and 9) health facility conditions. We converted these indicators into questions to be asked by an interviewer during a short interview following discharge to assess the childbirth experience.

Conclusions

The Perinatal Experience Assessment Tool (PEAT) may be used to monitor or evaluate the experiences that women report after facility-based childbirth. It can be administered by trained, independent interviewers in the facility following discharge. The PEAT enables maternity leaders to assess the extent to which maternity services are conducted in a respectful, non-abusive manner and modify practices and procedures as feasible and appropriate.

Etiology of Pregnancy-related Acute Kidney Injury among Obstetric Patients in India: A Systematic Review

Background

Pregnancy-related acute kidney injury (PRAKI) is an important cause of fetomaternal mortality and morbidity in developing countries. We undertook a systematic review to identify the causes of PRAKI among obstetric patients in India.

Materials and methods

We systematically searched PubMed, MEDLINE, Embase, and Google Scholar using appropriate search terminology between 1 January 2010 to 31 December 2021. Studies reporting the etiology of PRAKI among obstetric patients (pregnant and within 42 days postpartum) in India were included for evaluation. Studies done in any other geographical location besides India were excluded. We also excluded studies done in any one trimester or any specific subgroup of patients [e.g., postpartum acute kidney injury (AKI), postabortal AKI]. A five-point questionnaire was used to assess the risk of bias in included studies. The results were synthesized as per preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.

Results

A total number of 7 studies with 477 participants were included for analysis. All were single-center descriptive observational studies either done in tertiary care public or private hospitals. Sepsis (mean, 41.9%; median, 49.4%; and range, 6-56.1%) was the most common cause of PRAKI followed by hemorrhage (mean, 22.1%; median, 23.5%; and range, 8.3-38.5%) and pregnancy-induced hypertension (mean, 20.9%; median, 20.7; and range, 11.5-39%). Among these seven studies, five were of moderate quality, one was of high quality, and another one was of low quality. Our study is limited due to the lack of consensus definition of PRAKI in literature and heterogeneity in reporting methods. Our study highlights the need for a structured reporting format for PRAKI to understand the true disease burden and take control measures.

Conclusion

There is a moderate quality of evidence to suggest that sepsis followed by hemorrhage and pregnancy-induced hypertension are the commonest causes of PRAKI in India.

How to cite this article

Gautam M, Saxena S, Saran S, Ahmed A, Pandey A, Mishra P, et al. Etiology of Pregnancy-related Acute Kidney Injury among Obstetric Patients in India: A Systematic Review. Indian J Crit Care Med 2022;26(10):1141-1151.

Obstetric Violence Is Prevalent in Routine Maternity Care: A Cross-Sectional Study of Obstetric Violence and Its Associated Factors among Pregnant Women in Sri Lanka's Colombo District

The phenomenon of obstetric violence has been documented widely in maternity care settings worldwide, with scholars arguing that it is a persistent, common, but preventable impediment to attaining dignified health care. However, gaps remain in understanding local expressions of the phenomenon, associations with other types of violence against women, and implications for women's trust and confidence in health providers and services. We focused on these issues in this cross-sectional study of 1314 women in Sri Lanka's Colombo district. Specifically, in this study, we used Sinhalese and Tamil translations of the NorVold Abuse Questionnaire and the Abuse Assessment Screen to measure prevalence of women's experiences with obstetric violence in maternity care and lifetime and pregnancy-specific domestic violence. Then, the results were interpreted by considering the women's sociodemographic characteristics, such as age, ethnicity, and family income, to reveal previously undocumented associations between obstetric and domestic violence during pregnancy, as well as other factors associated with experiencing obstetric violence. We argue that obstetric violence is prevalent in government-sector (public) maternity care facilities in the Colombo district and is associated with young age, lower family income, non-majority ethnicity, and rural residency. Significantly, this study sheds light on a serious concern that has been underexamined, wherein women who report experiencing obstetric violence are also less likely to be asked by a health care provider about domestic violence experiences. Further research at the clinical level needs to focus on appropriate training and interventions to ensure women's safety and cultivate relationships between patients and health care providers characterized by trust, confidence, and respect.

Quality of perinatal care for women with high-risk pregnancies during the COVID-19 pandemic in Iran

Background

COVID-19 has had a catastrophic effect on the healthcare system. Healthcare quality assessment measures the difference between expected and actual performances to identify gaps in the healthcare system. This study aimed to evaluate the quality of perinatal care for women with high-risk pregnancies (HPR) during the COVID-19 pandemic.

Materials and Methods

This cross-sectional study enrolled 450 women with HPR from health centers in Ahvaz, Iran, from December 2020 to May 2021, using a multi-stage sampling method. Quality of care was assessed using an observational checklist adapted from Ministry of Health guidelines. Data were analyzed using descriptive and statistical methods.

Results

The quality of the assessed aspect in comprehensive health centers and in peripartum, perinatal, and postpartum wards was moderate. The overall score for peripartum care was significantly positively correlated with the length of the retraining period, and the quality of perinatal care was significantly related to the proportion of elective cesarean sections and preterm delivery.

Conclusion

The development of care practices in health centers in Iran should focus on education and counseling. Practices in peripartum wards should emphasize the use of partographs, physical/mental support, and privacy for mothers, while perinatal wards should focus on timely counseling.

Mistreatment during childbirth and postnatal period reported by women in Nepal —a multicentric prevalence study

Introduction

Trust of women and families toward health institutions has led to increased use of their services for childbirth. Whilst unpleasant experience of care during childbirth will halt this achievement and have adverse consequences. We examined the experience of women regarding the care received during childbirth in health institutions in Nepal.

Method

A prospective cohort study conducted in 11 hospitals in Nepal for a period of 18 months. Using a semi-structured questionnaire based on the typology of mistreatment during childbirth, information on childbirth experience was gathered from women (n = 62,926) at the time of discharge. Using those variables, principal component analysis was conducted to create a single mistreatment index. Bivariate and multivariate linear regression analyses were conducted to assess the association of the mistreatment index with sociodemographic, obstetric and newborn characteristics.

Result

A total of 62,926 women were consented and enrolled in the study. Of those women, 84.3% had no opportunity to discuss any concerns, 80.4% were not adequately informed before providing care, and 1.5% of them were refused for care due to inability to pay. According to multivariate regression analysis, women 35 years or older (β, − 0.3587; p-value, 0.000) or 30–34 years old (β,− 0.38013; p-value, 0.000) were less likely to be mistreated compared to women aged 18 years or younger. Women from a relatively disadvantaged (Dalit) ethnic group were more likely to be mistreated (β, 0.29596; p-value, 0.000) compared to a relatively advantaged (Chettri) ethnic group. Newborns who were born preterm (β, − 0.05988; p-value, 0.000) were less likely to be mistreated than those born at term.

Conclusion

The study reports high rate of some categories of mistreatment of women during childbirth. Women from disadvantaged ethnic group, young women, and term newborns are at higher risk of mistreatment. Strengthening health system and improving health workers’ readiness and response will be key in experience respectful care during childbirth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04639-6.

Women's experiences throughout the birthing process in health facilities in Arab countries: a systematic review

BACKGROUND

Mistreatment of women during facility-based childbirth has become a significant public health issue globally and is gaining worldwide attention. This systematic review of quantitative studies aimed to estimate the prevalence of mistreatment women may experience throughout the birthing process in health facilities in Arab countries. The review also aimed to identify the types of mistreatment, terminology, tools, and methods used to address this topic.

METHODOLOGY

The search was conducted using three electronic databases: "PubMed," "Embase," and "CINAHL" in May 2020. Studies meeting the inclusion criteria were included and assessed for risk of bias. The analysis was conducted based on the evidence-based typology developed by Bohren et al. as a guide to try to estimate the prevalence of mistreatment.

RESULTS

Eleven studies out of 174 were included. The included studies belonged to only seven Arab countries out of 22 Arab countries. The mistreatment of women during childbirth is still new in the region. Searching within the included studies yielded diverse and indirect terms that were a proxy for the word mistreatment. These terms were not comprehensive to cover different aspects of the topic. The tools that were used to measure the terms widely varied.. Moreover, it was not possible to estimate the prevalence of mistreatment of women due to high heterogeneity among the 11 studies.

CONCLUSION

The topic of mistreatment of women in Arab countries was not adequately addressed in the studies included in this review. More research on this topic is recommended due to its importance in improving maternal health in the region. However, a standardized and comprehensive terminology for mistreatment of women, a standardized tool, and a standardized methodology are recommended to enable comparability between results and allow pooling to estimate the prevalence.

Desrespeitos e abusos, maus tratos e violência obstétrica: um desafio para a epidemiologia e a saúde pública no Brasil

Resumo Estudos sobre desrespeitos e abusos/maus tratos/violência obstétrica durante gestação, parto e puerpério têm aumentado nas últimas décadas. Entretanto, os pesquisadores interessados na temática se deparam com muitas dificuldades teóricas e metodológicas. Nesse sentido, o objetivo do presente estudo consiste em discutir e refletir sobre como questões relacionadas a definição e terminologia, mensuração e políticas públicas no Brasil têm dificultado a pesquisa da temática, assim como a mitigação desses atos. O primeiro problema abordado foi a falta de consenso em relação a terminologia e definição desse construto. Essa situação provoca um efeito em cascata, com a utilização de instrumentos de aferição não validados que implicam falta de precisão e comparabilidade entre os estudos. Outra questão mencionada é a falta de estudos explorando as consequências desses atos na saúde da mulher e do recém-nascido, configurando uma das principais lacunas sobre o tema atualmente. A ausência de estudos causais impacta a tomada de decisão em saúde, prejudicando a elaboração de políticas públicas específicas.

Is respectful care provided by community health workers associated with infant feeding practices? A cross sectional analysis from India

Objectives

Breastfeeding and complementary feeding practices in India do not meet recommendations. Community health care workers (CHWs) are often the primary source of information for pregnant and postpartum women about Infant and Young Child Feeding (IYCF) practices. While existing research has evaluated the effectiveness of content and delivery of information through CHWs, little is known about the quality of the interpersonal communication (respectful care). We analyzed the effect of respectful interactions on recommended IYCF practices.

Methods

We use data from evaluation of an at-scale mHealth intervention in India that serves as a job aid to the CHWs (n = 3266 mothers of children < 12 m from 841 villages in 2 Indian states). The binary indicator variable for respectful care is constructed using a set of 7 questions related to trust, respect, friendliness during these interactions. The binary outcomes variables are exclusive breastfeeding, timely introduction of complimentary feeding, and minimum diet diversity for infants. We also explore if most of the pathway from respectful care to improved behaviors is through better recall of messages (mediation analysis). All models controlled for socio-economic-demographic characteristics and number of interactions with the CHW.

Results

About half of women reported positive, respectful interactions with CHWs. Interactions that are more respectful were associated with better recall of appropriate health messages. Interactions that are more respectful were associated with a greater likelihood of adopting all child-feeding behaviors except timely initiation of breastfeeding. After including recall in the model, the effect of respectful interactions alone reduced.

Conclusions

Respectful care from CHWs appears to be significantly associated with some behaviors around infant feeding, with the primary pathway being through better recall of messages. Focusing on improving social and soft skills of CHWs that can translate into better CHW-beneficiary interactions can pay rich dividends.

Funding

This study is funded by Grant No. OPP1158231 from Bill and Melinda Gates Foundation. Trial registration number: 10.1186/ISRCTN83902145

Determinants of respectful maternity care in India: A cross-sectional study

Background

Respectful maternity care (RMC) is a basic right of all pregnant women. The study identifies the sociodemographic and economic factors influencing disrespect and abuse (D&A) faced by women during pregnancy, childbirth, and immediate postpartum period in India.

Methodology

A cross-sectional study was conducted across six health facilities in three states of India from June 2019 to June 2020 among 401 women aged 18 years or more who had a live birth within the past 2 months of data collection. A validated structured interview schedule was used to capture data on sociodemographic and economic characteristics; antenatal, intranatal, and postnatal history; and incidences of D&A based on Bowser's seven domains of RMC. Ordered logistic regression was done to identify the determinant of high D&A.

Results

The composite score of D&A ranged from 0 to 48 with a median interquartile range of 13 (9-17). All women faced one or the other kind of D&A. Women with the lowest food security (odds ratio [OR] = 3.3; 95% confidence interval: 1.6-6.7), who did not avail any antenatal care from the facility (OR = 1.9 [1.1-3.2]), and in the lowest wealth index (OR = 2.2 [1.3-3.7]) faced more D&A than those with high food security, more than two ANC services from same health facility, and in the high wealth index, respectively. Women who had low mobility score experienced lower D&A (OR = 0.5 [0.3-0.8]) as compared to the women with a high mobility score. Nonconsented care, nonconfidential care, and physical discomfort were the most common types of D&A.

Conclusions

RMC is directly associated with socioeconomic status of women. Policy and program interventions are needed to address the inequity in health service care provision and expanding the social security net for women.

Does disrespect and abuse during childbirth differ between public and private hospitals in Southeast Nigeria

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.

Understanding quality of contraceptive services from women's perspectives in Gujarat, India: a focus group study

OBJECTIVES

Understanding quality of contraceptive care from clients' perspectives is critical to ensuring acceptable and non-harmful services, yet little qualitative research has been dedicated to this topic. India's history of using incentives to promote contraceptive use, combined with reports of unsafe conditions in sterilisation camps, make a focus on quality important. The study objective was to understand women's experiences with and preferences for contraceptive counselling and care in the public sector in India.

DESIGN

Qualitative study using eight focus group discussions (FGDs). FGDs were thematically analysed using a framework approach.

SETTING

Rural and urban areas in one district in Gujarat.

PARTICIPANTS

31 sterilisation and 42 reversible contraceptive users who were married and represented different backgrounds. Inclusion criteria were: (1) female, (2) at least 18 years and (3) receipt of contraception services in the last 6 months from public health services.

RESULTS

Providers motivate married women to use contraception and guide women to specific methods based on how many children they have. Participants found this common practice acceptable. Participants also discussed the lack of counselling about reversible and permanent options and expressed a need for more information on side effects of reversible methods. There were mixed opinions about whether compensation received for accepting long-term methods affects contraceptive decision making. While many women were satisfied with their experiences, we identified minor themes related to provider coercion towards provider-controlled methods and disrespectful and abusive treatment during sterilisation care, both of which require concerted efforts to address systemic factors enabling such experiences.

CONCLUSIONS

Findings illuminate opportunities for quality improvement as we identified several gaps between how women experience contraceptive care and their preferences, and with ideals of quality and rights frameworks. Findings informed adaptation of the Quality of Contraceptive Counselling Scale for India, and have implications for centring quality and rights in global efforts.

Respectful maternal and newborn care: measurement in one EN-BIRTH study hospital in Nepal

BACKGROUND

Respectful maternal and newborn care (RMNC) is an important component of high-quality care but progress is impeded by critical measurement gaps for women and newborns. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study was an observational study with mixed methods assessing measurement validity for coverage and quality of maternal and newborn indicators. This paper reports results regarding the measurement of respectful care for women and newborns.

METHODS

At one EN-BIRTH study site in Pokhara, Nepal, we included additional questions during exit-survey interviews with women about their experiences (July 2017-July 2018). The questionnaire was based on seven mistreatment typologies: Physical; Sexual; or Verbal abuse; Stigma/discrimination; Failure to meet professional standards of care; Poor rapport between women and providers; and Health care denied due to inability to pay. We calculated associations between these typologies and potential determinants of health - ethnicity, age, sex, mode of birth - as possible predictors for reporting poor care.

RESULTS

Among 4296 women interviewed, none reported physical, sexual, or verbal abuse. 15.7% of women were dissatisfied with privacy, and 13.0% of women reported their birth experience did not meet their religious and cultural needs. In descriptive analysis, adjusted odds ratios and multivariate analysis showed primiparous women were less likely to report respectful care (β = 0.23, p-value < 0.0001). Women from Madeshi (a disadvantaged ethnic group) were more likely to report poor care (β = - 0.34; p-value 0.037) than women identifying as Chettri/Brahmin. Women who had caesarean section were less likely to report poor care during childbirth (β = - 0.42; p-value < 0.0001) than women with a vaginal birth. However, babies born by caesarean had a 98% decrease in the odds (aOR = 0.02, 95% CI, 0.01-0.05) of receiving skin-to-skin contact than those with vaginal births.

CONCLUSIONS

Measurement of respectful care at exit interview after hospital birth is challenging, and women generally reported 100% respectful care for themselves and their baby. Specific questions, with stratification by mode of birth, women's age and ethnicity, are important to identify those mistreated during care and to prioritise action. More research is needed to develop evidence-based measures to track experience of care, including zero separation for the mother-newborn pair, and to improve monitoring.

Feasibility of Participatory Theater Workshops to Increase Staff Awareness of and Readiness to Respond to Abuse in Health Care: A Qualitative Study of a Pilot Intervention Using Forum Play among Sri Lankan Health Care Providers

Women globally experience mistreatment by health providers during childbirth. Researchers have identified strategies to counteract this type of abuse in health care, but few have been evaluated. We used a theater technique, Forum Play, in a brief training intervention to increase awareness of abuse in health care and promote taking action to reduce or prevent it. The intervention was implemented in four workshops with 50 participating physicians and nurses from three hospitals in Colombo, Sri Lanka. This article reports the views of 23 workshop participants who also took part in four focus group discussions on the acceptability and feasibility of the method. The participants reported that the intervention method stimulated dialogue and critical reflection and increased their awareness of the everyday nature of abuses experienced by patients. Participants appreciated the participatory format of Forum Play, which allowed them to re-enact scenarios they had experienced and rehearse realistic actions to improve patient care in these situations. Structural factors were reported as limitations to the effectiveness of the intervention, including under-developed systems for protecting patient rights and reporting health provider abuses. Nonetheless, the study indicates the acceptability and feasibility of a theater-based training intervention for reducing the mistreatment of patients by health care providers in Sri Lanka.