Women's status and experiences of mistreatment during childbirth in Uttar Pradesh: a mixed methods study using cultural health capital theory

Barriers in utilization and provisioning of obstetric care services (OCS) in India: a mixed-methods systematic review

BACKGROUND

Despite the reduction in the maternal mortality ratio, barriers in obstetric care services (OCS) remain a significant risk factor for adverse maternal and perinatal outcomes in India. This review covers the 'continuum of care' (ANC, child delivery, and PNC services) and identifies multiple barriers in provisioning as well as utilization of OCS in India. We conducted a systematic review to understand the barriers using a mixed-methods approach.

METHODS

PubMed, Scopus, Web of Science, Google Scholar, and Science Direct databases were searched from 1 January 2000 to 30 June 2022. The methodological quality of the included studies was assessed using appropriate tools. After a full-text review of 164 studies, total of 56 studies (33 quantitative, 18 qualitative, and 5 mixed-methods studies) were finally included in the review. All the barriers were classified into five major themes: (i) individual and interpersonal barriers, (ii) social and cultural barriers, (iii) structural barriers, (iv) logistical barriers, and (v) organizational barriers. A thematic synthesis approach was used to present the findings of the included studies.

RESULTS

Lack of knowledge and awareness and less family support in availing the required OCS were key individual and interpersonal barriers. Negative social and cultural practices, such as belief in traditional herbs/healers, dietary restrictions, and discarding colostrum were frequently reported barriers, especially in rural settings. Poor economic status and high health service costs were the most often cited barriers to low institutional delivery and delayed ANC services. Long distances to health facilities and poor road conditions were the most frequently reported logistical barriers. On the provisioning side, poor quality of treatment, shortage of drugs and equipment, and non-cooperative attitude of health professionals were the most significant barriers.

CONCLUSION

This review identified several important barriers ranging from individual and cultural to structural, logistical, and organizational, which are prevalent in India. To mitigate the barriers, the governments need to develop strategies at the individual and organizational levels. Innovative interventions and program implementation at the community and village levels could also be contributory steps towards improving OCS utilization in India.

Can a quality improvement intervention improve person-centred maternity care in Kenya?

Few evidence-based interventions exist to improve person-centred maternity care in low-resource settings. This study aimed to understand whether a quality improvement (QI) intervention could improve person-centred maternity care (PCMC) experiences for women delivering in public health facilities in Kenya. A pre-post design was used to examine changes in PCMC scores across three intervention and matched control facilities at baseline (n = 491) and endline (n = 677). A QI intervention, using the Model for Improvement, was implemented in three public health facilities in Nairobi and Kiambu Counties in Kenya. Difference-in-difference analyses using models that included main effects of both treatment group and survey round was conducted to understand the impact of the intervention on PCMC scores. Findings suggest that intervention facilities' average total PCMC score decreased by 5.3 points post-intervention compared to baseline (95% CI: -8.8, -1.9) and relative to control facilities, holding socio-demographic and facility variables constant. Additionally, the intervention was significantly associated with a 1.8-point decrease in clinical quality index pre-post-intervention (95% CI: -2.9, -0.7), decreased odds of provider visits, and less likelihood to plan to use postpartum family planning. While improving the quality of women's experiences during childbirth is a critical component to ensure comprehensive, high-quality maternity care experiences and outcomes, further research is required to understand which intervention methods may be most appropriate to improve PCMC in resource-constrained settings.

Maternity Care at the Intersections of Language, Ethnicity, and Immigration Status: A Qualitative Study

INTRODUCTION

Women of color and immigrant women are more likely than US-born White women to report mistreatment and poor quality of care during their reproductive health care. Surprisingly little research exists on how language access may impact immigrant women's experiences of maternity care, particularly by race and ethnicity.

METHODS

We conducted qualitative in-depth, one-on-one semi-structured interviews from August 2018 to August 2019 with 10 Mexican and eight Chinese/Taiwanese women (n = 18) living in Los Angeles or Orange County who gave birth within the past 2 years. Interviews were transcribed and translated, and data were initially coded based on the interview guide questions. We identified patterns and themes using thematic analysis methods.

RESULTS

Participants described how a lack of translators and language- and cultural-concordant health care providers and staff impeded their access to maternity care services; in particular, they described barriers to communication with receptionists, providers, and ultrasound technicians. Despite Mexican immigrants' ability to access Spanish-language health care, both Mexican and Chinese immigrant women described how lack of understanding medical concepts and terminology resulted in poor quality of care, lack of informed consent for reproductive procedures, and subsequent psychological and emotional distress. Undocumented women were less likely to report using strategies that leveraged social resources to improve language access and quality care.

CONCLUSIONS

Reproductive autonomy cannot be achieved without access to culturally and linguistically appropriate health care. Health care systems should ensure that comprehensive information is given to women, in a language and manner they can understand, with particular attention toward providing in-language services across multiple ethnicities. Multilingual staff and health care providers are critical in providing care that is responsive to immigrant women.

Labouring women perspectives on mistreatment during childbirth: a qualitative study

BACKGROUND

Respectful care during labour and childbirth, which has recently received a great deal of attention around the world, is vital for providing high-quality maternity care. However, this area has been underexplored in developing countries including Iran.

RESEARCH AIM

This study aimed to assess postpartum women's views regarding disrespect and abuse during labour and childbirth in Iran.

METHODS

A qualitative study that involved a purposive sample of 21 postpartum women was conducted in Tehran, Iran, between 2019 and 2020. Following the semi-structured individual interviews, a conventional content analysis was performed.

ETHICAL CONSIDERATIONS

This research approved by Shahid Beheshti University of Medical Sciences in Tehran, Iran, with the ethical approval number 1396.810. Following explanation of the study's objectives, eligible women consented to participate in the study. The confidentiality of the participants' information and the anonymity of the analysis were maintained at all stage of the study. All data was stored on the password protected file in the researcher computer The findings were only disseminated in summary form, with no identifying of individual participants.

RESULTS

Analysis of the data resulted in two main themes: 'inappropriate interaction' and 'inadequate quality care'. The 'inappropriate interaction' theme includes 'lack of empathy' and 'verbal abuse'. The second theme includes five sub-themes 'lack of participation in decision-making', 'lack of privacy', 'ignorance of women's pain and medical needs', 'rushed labour and painful procedures', and "unsatisfying facilities'.

CONCLUSION

Providing supportive care, respectful communication, adequate participation in decision-making, maintaining privacy, attending to women's labour pain and medical needs, and improving the quality of the physical birth environment are all examples of what labouring women consider to be respectful maternity care. To minimise disrespect and maltreatment of women during childbirth, an all-inclusive strategy engaging women, communities, healthcare professionals, managers, and educators is required.

Provider implicit and explicit bias in person-centered maternity care: a cross-sectional study with maternity providers in Northern Ghana

BACKGROUND

Person-centered maternity care (PCMC) has become a priority in the global health discourse on quality of care due to the high prevalence of disrespectful and lack of responsive care during facility-based childbirth. Although PCMC is generally sub-optimal, there are significant disparities. On average, women of low socioeconomic status (SES) tend to receive poorer PCMC than women of higher SES. Yet few studies have explored factors underlying these inequities. In this study, we examined provider implicit and explicit biases that could lead to inequitable PCMC based on SES.

METHODS

Data are from a cross-sectional survey with 150 providers recruited from 19 health facilities in the Upper East region of Ghana from October 2020 to January 2021. Explicit SES bias was assessed using situationally-specific vignettes (low SES and high SES characteristics) on providers' perceptions of women's expectations, attitudes, and behaviors. Implicit SES bias was assessed using an Implicit Association Test (IAT) that measures associations between women's SES characteristics and providers' perceptions of women as 'difficult' or 'good'. Analysis included descriptive statistics, mixed-model ANOVA, and bivariate and multivariate linear regression.

RESULTS

The average explicit bias score was 18.1 out of 28 (SD = 3.60) for the low SES woman vignette and 16.9 out of 28 (SD = 3.15) for the high SES woman vignette (p < 0.001), suggesting stronger negative explicit bias towards the lower SES woman. These biases manifested in higher agreement to statements such as the low SES woman in the vignette is not likely to expect providers to introduce themselves and is not likely to understand explanations. The average IAT score was 0.71 (SD = 0.43), indicating a significant bias in associating positive characteristics with high SES women and negative characteristics with low SES women. Providers with higher education had significantly lower explicit bias scores on the low SES vignette than those with less education. Providers in private facilities had higher IAT scores than those in government hospitals.

CONCLUSIONS

The findings provide evidence of both implicit and explicit SES bias among maternity providers. These biases need to be addressed in interventions to achieve equity in PCMC and to improve PCMC for all women.

Translation and validation of the Hindi-Indian version of the Birth Satisfaction Scale-Revised

AIM

Critical to maternal outcome and development of a healthy and relationship between mother and baby, is the woman's perception of her birth experience. The Birth Satisfaction Scale-Revised (BSS-R) has been demonstrated to be psychometrically robust, easily administered, and scored self-report measure of birth experience. Aim of the study was to translate the UK-BSS-R into Hindi, collect data, and psychometrically validate an Indian (Hindi)-BSS-R.

METHODS

Psychometric assessment of the Indian (Hindi)-BSS-R was undertaken following translation using a cross-sectional design. Evaluation of known-groups validity was undertaken using an embedded between-subjects component. Data were collected from (n = 312) postnatal Hindi speaking women in India. Measurement characteristics were assessed using confirmatory factor analysis, divergent validity and internal consistency analysis.

RESULTS

The measurement properties of the Indian (Hindi)-BSS-R were observed to be equivocal, with the established tri-dimensional measurement model not achieving best fit to data. Instead, an alternative two-factor model offered an excellent fit to data. Significant differences were observed between Indian (Hindi)-BSS-R scores and family type and gestation term status, which highlights the relevance of these contextual aspects to the Indian birth experience. Internal consistency was observed to be low on some sub-scales, indicating the potential need for future revision.

CONCLUSIONS

The Indian (Hindi)-BSS-R is a measure of birth experience, which accepting some measurement caveats, is acceptable for use with Hindi speaking women in India. Further research is required to determine if modification of some of the items is required to improve internal consistency.

Prevalence of violent communication within Indian organisations- A systematic review and meta-analysis

Background

Considering the normalisation of moderate aggression within organisations and the concern of violent occurrences being under-reported in India, violence reflected through coercive language appears to be more frequent than explicit acts of organisational violence.

Aim

To bring-forth consolidated evidence on the prevalence of violent communication within Indian organisations.

Method

1433 articles obtained from four major databases (PubMed, Scopus, Science Direct, Web of Science and Google scholar), complemented by 4 records identified through manual searching, were screened according to the PRISMA guidelines. Thirty-four finalised cross-sectional studies (published since 2000) reporting significant findings on the prevalence of violent communication within Indian organisations, underwent a systematic review (by narrative synthesis) and meta-analysis (using the random-effects model in STATA version 17).

Results

The pooled prevalence of any type of violent communication was 41%. The prevalence of violent communication was higher among males than females (44% vs 28%). Verbal violence was more prevalent than non-verbal violence (36% vs 20%). Subgroup analysis proved prevalence estimate to remain consistent irrespective of the organisational sector, type of organisation, sample size and publication year. However, meta-regression analysis confirmed the sampling method and type of violent communication as potential variables influencing the prevalence rates reported across the studies. All the identified factors influencing the occurrence of violent communication and the corresponding detrimental consequences faced by victims within each organisational sector, endeavour scope for the development of more context-specific prevention strategies.

Conclusion

As evident from the results, the prevalence of any type of violent communication within Indian organisations is quite high. The present review informs Indian entrepreneurs about the necessity for advocating practices to protect their human resources from the experience of violent communication. Practical implications have been presented for healthcare and educational organisations.

Evaluation of community-based participatory governance interventions to improve access to health-related public entitlements in India

Purpose

As the investment in social and health protection remained poor in India, the most vulnerable citizens lack access to existing health related government initiatives with transformational benefits due mostly to the lack of “accurate information”. The purpose of this paper is to explore and demonstrate the impact of participation of the community through a structured intervention that promotes awareness, enables the community to ensure entitlements, and enhances the utilization of government initiatives.

Design/methodology/approach

Through a baseline–endline study using a quasi-experimental design, this research provides empirical evidence of such intervention on awareness and utilization of health, nutrition and developmental initiatives. It involved survey of 400 households from the four study locations before and after the interventions. The pre-post estimation in the “proportion of respondents who were fully aware” was analyzed to measure changes in knowledge. Mc-Nemar test was applied to measure the statistical significance of these changes.

Findings

The results indicate that the intervention of “empowerment centers” has increased knowledge and utilization of the various government schemes, services and facilities that are routine and offer benefits all household members, in general, and women as well as children, in particular. The intervention was found to be successful in improving the local governance systems; empowering communities, linking communities and local level government systems across all sectors, as well as bringing in inter-sectoral linkages across governments systems.

Research limitations/implications

Although there have been many interventions of community participation for reducing inequities across the globe, there is a dearth of documentation and evidence generation. More efforts are required to evaluate such interventions, identify which interventions work and how they can be adapted to different contexts. This also requires exploration of the social processes and contextual realities underlying these interventions.

Originality/value

To the best knowledge of the authors, this research is one-of-its-kind that assessed an intervention targeting cross-cutting schemes and services, beyond just health interventions. The evidence points to the success of grassroots level inter-sectoral community actions, in the form of empowerment centers, to improve awareness and utilization of government interventions through participatory governance, and points to the expanding scope of learning and adapting such interventions to different contexts and scopes.

Respectful Maternity Care in South Asia: What Does the Evidence Say? Experiences of Care and Neglect, Associated Vulnerabilities and Social Complexities

Background

Respectful maternity care encompasses the right to continuity of care and dignified support for women during the reproductive period, enabling informed choice. However, the evidence is limited in the context of South Asia region where maternal, perinatal and newborn mortality is still a critical challenge to health systems. Evidence is required to better understand the context of respectful maternity care to inform directions for appropriate policy and practice.

Objective

The objective of this scoping review was to explore facilitators and barriers of respectful maternity care practice in South Asia.

Design

CINAHL, EMBASE, PubMed, Medline, SCOPUS and Cochrane databases were used to identify related studies. Data were systematically synthesized and analysed thematically.

Findings

There was considerable heterogeneity in the 61 included studies from seven South Asian countries, with most of the research conducted in Nepal and India. While the experience of abuse and neglect was common, 10 critical themes emerged related to neglected choices and compromised quality of care (particularly where there were health inequities) in the context of institutional care experiences; and the imperative for improved investment in training and significant policy and legislative change to enforce equitable and respectful maternity care practice.

Conclusions and Implications for Practice

Evidence about respectful maternity care in South Asia indicates that women accessing professional and facility-based services experienced high levels of disrespect, abuse and maltreatment. Women from vulnerable, socially disadvantaged and economically poor backgrounds were more likely to experience higher level abuse and receive poor quality of care. There is an urgent need for a well-resourced, sustained commitment to mandate and support the provision of respectful and equitable maternity care practice in South Asia.

Breaking the silence about obstetric violence: Body mapping women’s narratives of respect, disrespect and abuse during childbirth in Bihar, India

Background

Evidence on obstetric violence is reported globally. In India, research shows that almost every woman goes through some level of disrespect and abuse during childbirth, more so in states such as Bihar where over 70% of women give birth in hospitals.

Objective

1) To understand how women experience and attach meaning to respect, disrespect and abuse during childbirth; and 2) document women’s expectations of respectful care.

Methods

‘Body mapping’, an arts-based participatory method, was applied. The analysis is based on in-depth interviews with eight women who participated in the body mapping exercise at their homes in urban slums and rural villages. Analysis was guided by feminist relational discourse analysis.

Findings

Women reported their experiences of birthing at home, public facilities, and private hospitals in simple terms of what they felt ‘good’ and ‘bad’. Good experiences included being spoken to nicely, respecting privacy, companion of choice, a bed to rest, timely care, lesser interventions, obtaining consent for vaginal examination and cesarean section, and better communication. Bad experiences included unconsented interventions including multiple vaginal examinations by different care providers, unanesthetized episiotomy, repairs and uterine exploration, verbal, physical, sexual abuse, extortion, detention and lack of privacy.

Discussion

The body maps capturing birth experiences, created through a participatory method, accurately portray women’s respectful and disrespectful births and are useful to understand women’s experience of a sensitive issue in a patriarchal culture. An in-depth understanding of women’s choices, experiences and expectations can inform changes practices in and policies and help to develop a culture of sharing birth experiences.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04503-7.

The Economic Toll of COVID ‐19: A Cohort Study of Prevalence and Economic Factors Associated with postpartum depression in Kenya

Objective

The aim of the study is to examine the risk of postpartum depression (PPD) among women who delivered during the COVID‐19 pandemic compared to women who delivered before the COVID‐19 pandemic and how economic challenges are associated with PPD.

Methods

Data were collected from 2332 women. This includes 1197 women from healthcare facilities in 2019 who were followed up at 2–4 and 10 weeks postpartum. Additionally, we recruited 1135 women who delivered from March 16, 2020 onward when COVID‐19 restrictions were mandated in Kenya in the same catchment areas as the original sample to compare PPD rates.

Results

Adjusting for covariates, women who delivered during COVID‐19 had 2.5 times higher odds of screening positive for PPD than women who delivered before COVID‐19 (95% confidence interval [CI] 1.92–3.15). Women who reported household food insecurity, required to pay a fee to cover the cost of PPE during labor and delivery and/or postnatal visit(s), and those who reported COVID‐19 employment‐related impacts had a higher likelihood of screening for PPD compared to those who did not report these experiences.

Conclusion

The COVID‐19 pandemic has greatly increased the economic vulnerability of women, resulting in increases in PPD.

The COVID‐19 pandemic has greatly increased the economic vulnerability of women and has increased PPD.

Rate and Types of Childbirth Mistreatment and Abuse and Its Association with Satisfaction with Birth Care: A Cross-Sectional Study of 1196 Kurdish Women

BACKGROUND AND OBJECTIVES

Concern about mistreatment and abuse during childbirth care is growing, and evidence suggests that many women worldwide experience mistreatment during childbirth. The study aimed to assess the prevalence of abused women during labor, types of abuse, rate of satisfaction with birth care among abused women, and associated sociodemographic and obstetric factors with mistreatment and abuse in the delivery room.

METHODS

A cross-sectional study was conducted with data from 1196 women who experienced a vaginal delivery at least once within the past year in a public health setting in Erbil city, Kurdistan Region, Iraq. The author developed a questionnaire after a comprehensive review of the literature. Data were collected through direct interviews with the sample. Frequency, percentage, and chi-square tests were used for data analysis.

RESULTS

About half of the study sample (49.9%) mentioned that they experienced mistreatment and/or abuse during labor and delivery. The most experienced type of mistreatment and abuse were as follows: lack of privacy (84.6%), patient-blaming (58.5), purposeful neglect (51.6%), abandonment of care, and detention in facilities (43.9%), Non-consented care (42.9%). The rate of physical and verbal abuse was 24.3% and 29.8%, respectively. There was a highly significant association between parity and general satisfaction with birth care with experiencing abuse (P = 0.006, P ≤ 0.001).

CONCLUSIONS

Mistreatment and abuse of women during childbirth are present among Kurdish women, leading to generally non-satisfaction with birth care, and exploring the reasons behind why health care providers mistreatment and abuse women during childbirth is critical.

Strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings: A mixed-methods systematic review

Stigma and discrimination are fundamental causes of health inequities, and reflect privilege, power, and disadvantage within society. Experiences and impacts of stigma and discrimination are well-documented, but a critical gap remains on effective strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings. We aimed to address this gap by conducting a mixed-methods systematic review and narrative synthesis to describe strategy types and characteristics, assess effectiveness, and synthesize key stakeholder experiences. We searched MEDLINE, CINAHL, Global Health, and grey literature. We included quantitative and qualitative studies evaluating strategies to reduce stigma and discrimination in sexual and reproductive healthcare settings. We used an implementation-focused narrative synthesis approach, with four steps: 1) preliminary descriptive synthesis, 2) exploration of relationships between and across studies, 3) thematic analysis of qualitative evidence, and 4) model creation to map strategy aims and outcomes. Of 8,262 articles screened, we included 12 articles from 10 studies. Nine articles contributed quantitative data, and all measured health worker-reported outcomes, typically about awareness of stigma or if they acted in a stigmatizing way. Six articles contributed qualitative data, five were health worker perspectives post-implementation and showed favorable experiences of strategies and beliefs that strategies encouraged introspection and cultural humility. We mapped studies to levels where stigma can exist and be confronted and identified critical differences between levels of stigma strategies aimed to intervene on and evaluation approaches used. Important foundational work has described stigma and discrimination in sexual and reproductive healthcare settings, but limited interventional work has been conducted. Healthcare and policy interventions aiming to improve equity should consider intervening on and measuring stigma and discrimination-related outcomes. Efforts to address mistreatment will not be effective when stigma and discrimination persist. Our analysis and recommendations can inform future intervention design and implementation research to promote respectful, person-centered care for all.

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.

The nature of obstetric violence and the organisational context of its manifestation in India: a systematic review

Over the last decades, the Indian government has adopted several strategies and programmes to encourage institutional childbirth and reduce maternal mortality. However, ensuring institutional delivery does not of itself ensure safe and dignified delivery and there are frequently episodes of violence during childbirth. Obstetric violence has long-term adverse effects on the health and well-being of women. The present study attempts to understand the nature of obstetric violence and the organisational contexts in which patterns of violent behaviours and actions emerge and are reproduced, contributing to obstetric violence. A database search for literature was conducted on PubMed and studies on women's experience during childbirth in health facilities in India were selected, based on the inclusion criteria. The present review's findings show that the most prevalent form of obstetric violence is verbal abuse followed by physical abuse and other dehumanising behaviour. Women from lower castes, Muslim communities, and low-income families were shown to be more likely to encounter dehumanising and neglectful behaviour from care providers in public health facilities. Obstetric violence during childbirth arises from encounters between care providers and women at an individual level, health system failures, and an abusive institutional atmosphere and culture. The abusive environment in health facilities fosters fear about facility care among women, contributes to worsened health outcomes, and deters women from further utilisation of health care services. Therefore, along with expanding institutional births and access to emergency obstetric care, measures should be taken to ensure dignified and caring treatment of women during childbirth.

Examining person-centered maternity care in a peri-urban setting in Embakasi, Nairobi, Kenya

INTRODUCTION

Peri-urban settings have high maternal mortality and the quality of care received in different types of health facilities is varied. Yet few studies have explored the construct of person-centered maternity care (PCMC) within peri-urban settings. Understanding women's experience of maternity care in peri-urban settings will allow health facility managers and policy makers to improve services in these settings. This study examines factors associated with PCMC in a peri-urban setting in Kenya.

METHODS AND MATERIALS

We analyzed data from a cross-sectional study with 307 women aged 18-49 years who had delivered a baby within the preceding six weeks. Women were recruited from public (n = 118), private (n = 76), and faith based (n = 113) health facilities. We measured PCMC using the 30-item validated PCMC scale which evaluates women's experiences of dignified and respectful care, supportive care, and communication and autonomy. Factors associated with PCMC were evaluated using multilevel models, with women nested within facilities.

RESULTS

The average PCMC score was 58.2 (SD = 13.66) out of 90. Controlling for other factors, literate women had, on average, about 6-point higher PCMC scores than women who were not literate (β = 5.758, p = 0.006). Women whose first antenatal care (ANC) visit was in the second (β = -5.030, p = 0.006) and third trimester (β = -7.288, p = 0.003) had lower PCMC scores than those whose first ANC were in the first trimester. Women who were assisted by an unskilled attendant or an auxiliary nurse/midwife at birth had lower PCMC than those assisted by a nurse, midwife or clinical officer (β = -8.962, p = 0.016). Women who were interviewed by phone (β = -7.535, p = 0.006) had lower PCMC scores than those interviewed in person.

CONCLUSIONS

Factors associated with PCMC include literacy, ANC timing and duration, and delivery provider. There is a need to improve PCMC in these settings as part of broader quality improvement activities to improve maternal and neonatal health.

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

The aim of this systematic review is to examine current evidence on the nature and extent of disrespect and abuse (D&A), mistreatment and practices of respectful maternity care of women during childbirth in India. Electronic databases were searched for published studies relevant to the topic. The search was conducted from May to September 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to conduct the review. A results synthesis was done using the Bowser and Hill landscape analytical framework for D&A of women during childbirth. Eleven studies are included in this review of which six were cross-sectional, four were qualitative, and one used a mixed-method approach. The type of abuse most frequently reported was the lack of respect and dignity (nondignified care) experienced by the women, usually in the form of negative and unfriendly attitudes of the providers. The least frequent form of mistreatment was physical abuse and detention in the facilities. The frequency of reported D&A was high, ranging from 10% to 77.3%. These behaviors were influenced by lack of education and empowerment of the women, their low socioeconomic status, poor training of providers and supervision, and a lack of accountability. Overall, disrespectful and abusive behavior had adverse impact on the utilization of health facilities for childbirth. It created a psychological distance between women and health providers. To our knowledge, this is the first systematic literature review to be conducted on respectful maternity care in India.

Examining obstetric interventions and respectful maternity care in Hungary: Do informal payments for continuity of care link to quality?

BACKGROUND

In Hungary, 60% of women pay informally to secure continuity with a "chosen" provider for prenatal care and birth. It is unclear if paying informally influences quality of maternity care. This study examined associations between incentivized continuity care models and obstetric procedures and respectful care.

METHODS

This is a cross-sectional survey of a representative sample of Hungarian women (N = 589) in 2014. We calculated descriptive statistics comparing experiences among women who paid informally for continuity with a chosen provider with those who received care in the public health system. After adjusting for social and clinical covariates, we used logistic regression to estimate the odds of obstetric procedures and disrespectful care and linear regression to estimate the level of autonomy (MADM scale).

RESULTS

Of women in our sample, 317 (53%) saw a chosen doctor, 68 (11%) a chosen midwife, and 204 (33%) had care in the public system. Women who paid an obstetrician informally had the highest rates of cesarean (49.5%), induction of labor (31.2%), and epidural (15%), and reported lower rates of disrespectful care (41%) compared to public care (64%). Paying for continuity with an obstetrician significantly predicted cesarean (aOR 1.61 [95%CI 1.00-2.58]), episiotomy (2.64, [1.39-5.03]), and epidural (3.15 [1.07-9.34]), but not induction of labor (1.59 [0.99-2.57]). Informal payment continuity models predicted increased autonomy scores (doctor: 3.97, 95% CI 2.39-5.55; midwife: 7.37, 95% CI 5.36-9.34) and reduced odds of disrespectful care. There were no differences in the prevalence of scheduled cesareans or inductions performed without a medical indication.

CONCLUSIONS

Continuity models secured with informal payments significantly increased both women's experience of respectful care and rates of obstetric procedures. Intervention rates exceed global standards, and women do not choose elective procedures to preserve continuity.

Capturing women's voices: lived experiences of incivility during childbirth in the United States

Increasing research has improved global awareness of mistreatment during childbirth. However, research primarily focuses on "higher-intensity" mistreatment during childbirth, and largely focuses on women outside the United States (U.S.). We address these gaps by exploring the phenomenology of incivility, a "lower-intensity" mistreatment, experienced by women during childbirth in the U.S. We used a combination of interpretative phenomenological analysis (IPA) and thematic analysis to analyze the qualitative responses (N = 200) of experiences of incivility during childbirth. We identified nine primary themes of incivility: lack of empathy, denial/minimization, ignoring, pressure, privacy issues, breastfeeding/formula issues, identity-based, uncomfortable physical interactions, and silencing. Results demonstrate incivility is critical to consider as a form of mistreatment in childbirth because it violates respect. The results help nuance the understanding of how mistreatment is experienced in childbirth. Results also demonstrate unique manifestations of incivility were shaped by the sociopolitical context of the U.S. Implications for policy development and health outcomes are discussed.

Respectful maternity care in public health care facilities in Gujarat: A direct observation study

Introduction:

Respectful maternity care (RMC) is not only the marker of quality maternity care but also ensures the protection of basic human rights of every child-bearing woman. This paper discusses the assessment of RMC services during the intrapartum period at public health care facilities in Gujarat state.

Material and Methods:

A cross-sectional research design was used for the study. The data were collected from three different levels of public health facilities such as primary health center (PHC), community health center (CHC), and district hospital (DH) in one of the districts in Gujarat. A standardized tool developed by the United States Agency for International Development based on the RMC charter was used for data collection. A total of 41 pregnant women across three public health facilities were observed during intrapartum care.

Findings:

Most women experienced disrespectful intrapartum care provided at the public health care facilities; however, at-least two performance standards of the RMC charter were met during intrapartum care at each public health care facility. Comparatively, the PHC demonstrated higher RMC performance compliance than DH and the CHC. Most often violations of RMC standards included beneficiaries were not greeted, privacy not maintained, they were not encouraged to ask questions, and support not provided during labor.

Conclusion:

Respectful maternity care is evidently not practiced in public health care facilities. Designing comprehensive behavioral training on RMC, especially for primary, secondary, and tertiary care physicians and nursing staff can improve the adaption of RMC standards in respective public health care facilities. Positive experiences of intrapartum care can potentially improve the uptake of maternal care facilities. Further research is needed to understand local contextual factors, social norms, and patient-provider interactions.

Can changes to improve person-centred maternity care be spread across public health facilities in Uttar Pradesh, India?

Poor quality person-centred maternity care (PCMC) leads to delays in care and adverse maternal and newborn outcomes. This study describes the impact of spreading a Change Package, or interventions that other health facilities had previously piloted and identified as successful, to improve PCMC in public health facilities in Uttar Pradesh, India. A quasi-experimental design was used including matched control-intervention facilities and pre-post data collection. This study took place in Uttar Pradesh, India in 2018-2019. Six large public health facilities participated in the evaluation of the spread study, including three intervention and three control facilities. Intervention facilities were introduced to a quality improvement (QI) Change Package to improve PCMC. In total, 1200 women participated in the study, including 600 women at baseline and 600 women at endline. Difference-in-difference estimators are used to examine the impact of spreading a QI Change Package across spread sites vs. control sites and at baseline and endline using a validated PCMC scale. Out of a 100-point scale, a 24.93 point improvement was observed in overall PCMC scores among spread facilities compared to control facilities from baseline to endline (95% CI: 22.29, 27.56). For the eight PCMC indicators that the Change Package targeted, spread facilities increased 33.86 points (95% CI: 30.91, 36.81) relative to control facilities across survey rounds. Findings suggest that spread of a PCMC Change Package results in improved experiences of care for women as well as secondary outcomes, including clinical quality, nurse and doctor visits, and decreases in delivery problems.Trial registration: ClinicalTrials.gov identifier: NCT04208841..

Relationship of post-traumatic stress disorder with disrespect and abuse during childbirth in a group of Iranian postpartum women: a prospective study

BACKGROUND

Disrespect and abuse (D&A) violate the fundamental principles of ethics, human rights, and basic obligations to protect and relieve patients. This study aimed to identify the status of D&A and its relationship with the post-traumatic stress disorder (PTSD) among Iranian women.

METHODS

This prospective study was conducted on 288 mothers admitted to the maternity wards of three public and three private hospitals in Tabriz. The data collection tools were socio-demographic and obstetric questionnaires as well as D&A (6-18 h postpartum) and PTSD (one month postpartum) scales, which were completed by participants in interviews. Multivariate logistic regression was employed to determine the relationship between PTSD and D&A in adjusting the socio-demographic and obstetric variables.

RESULTS

In this study, 74.7% of mothers reported one or multiple types of D&A. According to the diagnostic criteria for PTSD, 16.3% of the participants experienced postpartum PTSD. The mean (± standard deviation) of the PTSD score was reported 7.32 (± 2.0) in the women experiencing D&A, whereas it was 1.0 (± 0.0) in the women having no experiences of D&A. According to the Mann-Whitney U test results, there was a significant relationship between the total and all subscales of PTSD score and D&A (p < 0.001). The multivariate logistic regression results indicated that the likelihood of PTSD was significantly lower in the participants without any D&A experiences than in those with D&A experiences (aOR: 0.06; 95% CI 0.01 to 0.58; p = 0.015).

CONCLUSION

Given the PTSD-D&A relationship, it is recommended to improve maternal care in maternity facilities to prevent any unintended PTSD complications.

Results of a person-centered maternal health quality improvement intervention in Uttar Pradesh, India

Background

Poor patient experiences during delivery in Uttar Pradesh, India is a common problem. It delays presentation at facilities after the onset of labor and contributes to poor maternal health outcomes. Patient-centered maternity care (PCMC) is recognized by the World Health Organization as critical to overall quality. Changing PCMC requires changing the process of care, and is therefore especially challenging.

Methods

We used a matched case-control design to evaluate a quality improvement process directed at PCMC and based on widely established team-based methods used in many OECD countries. The intervention was introduced into three government facilities and teams supported to brainstorm and test improvements over 12 months. Progress was measured through pre-post interviews with new mothers, scored using a validated PCMC scale. Analysis included chi-squared and difference-in-difference tests.

Findings

On a scale to 100, the PCMC score of the intervention group increased 22.9 points compared to controls. Deliveries attended by midwives, dais, ASHAs or non-skilled providers resulted in significantly higher PCMC scores than those attended to by nurses or doctors. The intervention was associated with one additional visit from a doctor and over two additional visits from nurses per day, compared to the control group.

Interpretation

This study has demonstrated the effectiveness of a team-based quality improvement intervention to ameliorate women’s childbirth experiences. These improvements were locally designed and led, and offer a model for potential replication.

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

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.

A comparison of intensive vs. light-touch quality improvement interventions for maternal health in Uttar Pradesh, India

Background

Poor patient experiences during delivery leads to delayed presentation at facilities and contributes to poor maternal health outcomes. Person-centered maternity care (PCMC) is a key component of quality. Improving PCMC requires changing the process of care which can be complex and necessitate significant external input, making replication and scale difficult. This study compares the effectiveness two Quality Improvement (QI) intervention phases, one Intensive, one Light-Touch.

Methods

We use a matched case-control design to compare two phases of a QI Intervention targeting PCMC, with three facilities in each. The Intensive phase was introduced into three government facilities where teams were supported to identify, design, and test potential improvements over 12 months. The Light-Touch phase was subsequently introduced in three other government facilities and changes were tracked over six months. We compared the two groups using multivariate linear regression and difference-in-difference models to assess changes in PCMC outcome

Results

Both Intensive and Light-Touch arms demonstrated large improvements in PCMC. On a scale from 0 to 100, Intensive facilities increased in PCMC scores from 85.02 to 97.13, while Light-Touch facilities increased from 63.42 to 87.47. For both there was a ‘halo’ effect, with a similar improvement recorded for the specific improvement activities focused on, as w ell as aspects of PCMC not directly addressed.

Conclusions

This study demonstrates that a short, inexpensive, light-touch and directive intervention can change staff practices and significantly improve the experiences of women during childbirth. It also shows that improvements in a few areas of provider-patient interaction have a ‘halo’ effect, changing many other aspects of patient-provider interaction at the same time.

Trial registration

QI Phase 1 - NCT04208867. Retrospectively registered. December 19th, 2019.

QI Phase 2 –NCT04208841. Retrospectively registered. December 23, 2019.

Respectful maternity care and its relationship with childbirth experience in Iranian women: a prospective cohort study

Background

Intrapartum respectful maternity care is defined as a fundamental human right that can affect the mother’s experiences. This study aimed to determine the status of respectful maternity care and its relationship with childbirth experience among Iranian women.

Methods

This prospective cohort study recruited 334 postpartum women in postpartum wards of two public and four private hospitals in Tabriz, Iran. Quota sampling was used based on the number of births in each hospital. Data were collected through interviews with the use of the following tools: sociodemographic and obstetrics characteristics questionnaire, respectful maternity care scale (6 to 18 h postpartum), and childbirth experience questionnaire (30 to 45 days postpartum). The General Linear Model was used to determine the relationship between respectful maternity care and childbirth experience.

Results

The mean respectful maternity care score was 62.58 with a range of 15 to 75, and the total childbirth experience score was 3.29 with a range of 1 to 4. After adjusting for sociodemographic and obstetrics characteristics, a statistically significant direct correlation was found between respectful maternity care and a positive childbirth experience (P < 0.001).

Conclusions

The findings reveals a direct relationship between respectful maternity care and positive childbirth experience. Therefore, it is recommended that mangers and policy makers in childbirth facilities reinforce facilitating a respectful maternity care to improve women’s child birth experience and prevent potential adverse effects of negative childbirth experiences.

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

Background

Disrespectful maternity care is a key impediment to achieving a good quality care. Identifying predicting factors can be used in mitigating any potential risk in for disrespect and abuse in maternity care. The present study was conducted to determine prevalence and predictors of perceived disrespectful maternity care among Iranian women.

Methods

A cross-sectional study was conducted in three public and three private hospitals in the city of Tabriz involving 334 postpartum women. Tools included socio-demographic, pregnancy, labour and birth characteristics questionnaires, and disrespect and abuse scales. Data were collected in 6 to 18 h after birth. Multivariate logistic regression was used to determine predictors of disrespectful maternity care.

Results

A majority of the women (253; 75.7%) reported one or several types of perceived disrespectful maternity care. The most frequent types related to not allowing women to choose labour positions (142; 44.3%) and not allowing them to move during labour (148; 42.5%). Nighttime childbirth (aOR 3.07; 95% CI 1.61 to 5.88) increased the likelihood of perceived disrespectful maternity care. However, presence of spouses to accompany their wives in waiting rooms (aOR 0.32; 95% CI 0.11 to 0.88), the attendance of private physicians (aOR 0.05; 95% CI 0.02 to 0.12), and midwives (aOR 0.22; 95% CI 0.11 to 0.45) decreased the likelihood of perceived disrespectful maternity care.

Conclusion

The results showed high levels of perceived disrespectful maternity care in postpartum women. Therefore, appropriate interventions, such as encouraging spouses’ presence, increasing the number of night shift staff, and training obstetric residents and midwives by holding ethics classes, with particular emphasis on empathy with patients.

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

BACKGROUND

Respectful maternity care is a rightful expectation of women. However, disrespectful maternity care is prevalent in various settings. Therefore, a systematic review and meta-analysis were conducted to identify various forms of ill-treatment, determinants, and pooled prevalence of disrespectful maternity care in India.

METHODS

A systematic review was performed in various databases. After quality assessment, seven studies were included. Pooled prevalence was estimated using the inverse variance method and the random-effects model using Review Manager Software.

RESULTS

Individual study prevalence ranged from 20.9% to 100%. The overall pooled prevalence of disrespectful maternity care was 71.31% (95% CI 39.84-102.78). Pooled prevalence in community-based studies was 77.32% (95% CI 56.71-97.93), which was higher as compared to studies conducted in health facilities, this being 65.38% (95% CI 15.76-115.01). The highest reported form of ill-treatment was non-consent (49.84%), verbal abuse (25.75%) followed by threats (23.25%), physical abuse (16.96%), and discrimination (14.79%). Besides, other factors identified included lack of dignity, delivery by unqualified personnel, lack of privacy, demand for informal payments, and lack of basic infrastructure, hygiene, and sanitation. The determinants identified for disrespect and abuse were sociocultural factors including age, socioeconomic status, caste, parity, women autonomy, empowerment, comorbidities, and environmental factors including infrastructural issues, overcrowding, ill-equipped health facilities, supply constraints, and healthcare access.

CONCLUSION

The high prevalence of disrespectful maternity care indicates an urgent need to improve maternity care in India by making it more respectful, dignified, and women-centered. Interventions, policies, and programs should be implemented that will protect the fundamental rights of women.

Do you need to pay for quality care? Associations between bribes and out-of-pocket expenditures on quality of care during childbirth in India

While it is mandated that reproductive and child health services be provided for free at public facilities in India, qualitative evidence suggests it is common for facilities to request bribes and other informal payments for medicines, medical tests or equipment. This article examines the prevalence of bribe requests, total out-of-pocket expenditures (OOPEs) and associations between bribe requests and total OOPEs on the experience of quality of care and maternal complications during childbirth. Women who delivered in public facilities in Uttar Pradesh, India were administered a survey on sociodemographic characteristics, bribe requests, total OOPEs, types of health checks received and experience of maternal complications. Data were analysed using descriptive, bivariate and multivariate statistics. Among the 2018 women who completed the survey, 43% were asked to pay a bribe and 73% incurred OOPEs. Bribe requests were associated with lower odds of receiving all health checks upon arrival to the facility (aOR = 0.49; 95% CI: 0.24-0.98) and during labour and delivery (aOR = 0.44; 95% CI: 0.25-0.76), lower odds of receiving most or all health checks after delivery (aOR = 0.44; 95% CI: 0.31-0.62) and higher odds of experiencing maternal complications (aOR = 1.45; 95% CI: 1.13-1.87). Although it is mandated that maternity care be provided for free in public facilities in India, these findings suggest that OOPEs are high, and bribes/tips contribute significantly. Interventions centred on improving person-centred care (particularly guidelines around bribes), health system conditions and women's expectations of care are needed.

Respectful maternity care and associated factors among women who delivered at Harar hospitals, eastern Ethiopia: a cross-sectional study

Background

In Ethiopia, approximately three-fourths of mothers do not deliver in health facilities. Disrespect and abuse during childbirth fallouts in underutilization of institutional delivery that upshots maternal morbidity and mortality. Thus, the ambition of this study was to assess respectful maternity care and associated factors in Harar hospitals, Eastern Ethiopia.

Methods

A facility-based cross-sectional study was conducted from April 01 to July 01, 2017. A total of 425 women, delivered at Harar town hospitals, were nominated using a systematic random sampling technique. A pretested and organized questionnaire was used to collect the data. After checking for completeness, the data were entered into EpiData version 3.1 and exported to SPSS version 22.0 for cleaning and analyses. Both bivariate and multivariable logistic regression was computed to identify factors associated with respectful maternity care. Statistical significance was declared at a P-value of < 0.05.

Results

Data were collected on 425 women. Overall, only 38.4% (95% CI: 33.7, 42.0%) of women received respectful maternity care. Delivering at private hospitals [AOR: 2.3, 95% CI: 1.25, 4.07], having ANC follow-up [AOR: 1.8, 95% CI: 1.10, 3.20], planned pregnancy [AOR: 3.0, 95% CI: 1.24, 7.34], labor attended by male provider [AOR: 1.8, 95% CI: 1.14, 2.77] and normal maternal outcome [AOR: 2.3, 95% CI: 1.13, 4.83] were significantly associated with respectful maternity care.

Conclusions

Only four out of ten women received respectful care during labor and delivery. Providing women-friendly, abusive free, timely and discriminative free care are the bases to improve the uptake of institutional delivery. Execution of respectful care advancement must be the business of all healthcare providers. Furthermore, to come up with a substantial reduction in maternal mortality, great emphasis should be given to make the service woman-centered.

Evidence of 'obstetric violence' in India: an integrative review

The term 'obstetric violence' has been used to describe the mistreatment, disrespect and abuse or dehumanized care of women during childbirth by health care providers. This is a review of the existing literature in India on violence against women during childbirth. The review used the typology of Bohren et al. (2015). An internet search of PubMed, Google Scholar and JSTOR was conducted using the terms 'obstetric violence', 'mistreatment', 'disrespect and abuse' and 'dehumanized care'. Studies based on empirical research on women's experiences during childbirth in health facilities in India were included in the review. The search yielded sixteen studies: one case study, two ethnographic studies, two mixed-methods studies, three cross-sectional qualitative studies, seven cross-sectional quantitative studies and one longitudinal quantitative study. The studies were analysed using the seven categories of mistreatment outlined by Bohren et al. (2015): 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. An additional category of 'harmful traditional practices and beliefs' emerged from the Indian literature, which was also included in the review. Although geographically limited, the selected research highlighted varying prevalences of the different forms of 'obstetric violence' in both public and private birth facilities in India. 'Obstetric violence' in India was found to be associated with socio-demographic factors, with women of lower social standing experiencing greater levels of mistreatment. In response to this normalized public health issue, a multi-pronged, rights-based framework is proposed that addresses the social, political and structural contexts of 'obstetric violence' in India.

Can an integrated obstetric emergency simulation training improve respectful maternity care? Results from a pilot study in Ghana

BACKGROUND

Few evidence-based interventions exist on how to improve respectful maternity care (RMC) in low-resource settings. We sought to evaluate the effect of an integrated simulation-based training on provision of RMC.

METHODS

The pilot project was in East Mamprusi District in northern Ghana. We integrated specific components of RMC, emphasizing dignity and respect, communication and autonomy, and supportive care, into a simulation training to improve identification and management of obstetric and neonatal emergencies. Forty-three providers were trained. For evaluation, we conducted surveys at baseline (N = 215) and endline (N = 318) 6 months later, with recently delivered women to assess their experiences of care using the person-centered maternity care scale. Higher scores on the scale represent more respectful care.

RESULTS

Compared to the baseline, women in the endline reported more respectful care. The average person-centered maternity care score increased from 50 at baseline to 72 at endline, a relative increase of 43%. Scores on the subscales also increased between baseline and endline: 15% increase for dignity and respect, 87% increase for communication and autonomy, and 55% increase for supportive care. These differences remained significant in multivariate analysis controlling for several potential confounders.

CONCLUSIONS

The findings suggest that integrated provider trainings that give providers the opportunity to learn, practice, and reflect on their provision of RMC in the context of stressful emergency obstetric simulations have the potential to improve women's childbirth experiences in low-resource settings. Incorporating such trainings into preservice and in-service training of providers will help advance global efforts to promote RMC.

"Our fear is finished," but nothing changes: efforts of marginalized women to foment state accountability for maternal health care in a context of low state capacity

Background

Women in India are often asked to make informal payments for maternal health care services that the government has mandated to be free. This paper is a descriptive case study of a social accountability project undertaken by SAHAYOG, a nongovernmental organization in Uttar Pradesh, India. SAHAYOG worked with community-based organizations and a grassroots forum comprised of low caste, Muslim, and tribal women to decrease the prevalence of health provider demands that women and their families make informal payments.

Methods

The study entailed document review; interviews and focus group discussions with program implementers, governmental stakeholders, and community activists; and participant observation in health facilities.

Results

The study found that SAHAYOG adapted their strategy over time to engender greater empowerment and satisfaction among program participants, as well as greater impact on the health system. Participants gained knowledge resources and agency; they learned about their entitlements, had access to mechanisms for complaints, and, despite risk of retaliation, many felt capable of demanding their rights in a variety of fora. However, only program participants seemed successfully able to avoid making informal payments to the health sector; health providers still demanded that other women make payments. Several features of the micro and macro context shaped the trajectory of SAHAYOG’s efforts, including deeply rooted caste dynamics, low provider commitment to ending informal payments, the embeddedness of informal payments, human resources scarcity, and the overlapping private interests of pharmaceutical companies and providers.

Conclusion

Though changes were manifest in certain fora, providers have not necessarily embraced the notion of low caste, tribal, or Muslim women as citizens with entitlements, especially in the context of free government services for childbirth. Grassroots advocates, CBOs, and SAHAYOG assumed a supremely difficult task. Project strategy changes may have made the task somewhat less difficult, but given the population making the rights claims and the rights they were claiming, widespread changes in demands for informal payments may require a much larger and stronger coalition.

Providers and women's perspectives on person-centered maternity care: a mixed methods study in Kenya

Background

Globally, there has been increasing attention to women’s experiences of care and calls for a person-centered care approach. At the heart of this approach is the patient-provider relationship. It is necessary to examine the extent to which providers and women agree on the care that is provided and received. Studies have found that incongruence between women’s and providers’ perceptions may negatively impact women’s compliance, satisfaction, and future use of health facilities. However, there are no studies that examine patient and provider perspectives on person-centered care.

Methods

To fill this gap in the literature, we use cross-sectional data of 531 women and 33 providers in seven government health facilities in Kenya to assess concordance and discordance in person-centered care measures. Additionally, we analyze 41 in-depth interviews with providers from three of these facilities to examine why differences in reporting may occur. Descriptive statistical methods were used to measure the magnitude of differences between reports of women and reports of providers. Thematic analyses were conducted for provider surveys.

Results

Our findings suggest high discordance between women and providers’ perspectives in regard to person-centered care experiences. On average, women reported lower levels of person-centered care compared to providers, including low respectful and dignified care, communication and autonomy, and supportive care. Providers were more likely to report higher rates of poor health facility environment such as having sufficient staff. We summarize the overarching reasons for the divergence in women and provider reports as: 1) different understanding or interpretation of person-centered care behaviors, and 2) different expectations, norms or values of provider behaviors. Providers rationalized abuse towards women, did not allow a companion of choice, and blamed women for poor patient-provider communication. Women lacked assurance in privacy and confidentiality, and faced challenges related to the health facility environment. Providers attributed poor person-centered care to both individual and facility/systemic factors.

Conclusions

Implications of this study suggests that providers should be trained on person-centered care approaches and women should be counseled on understanding patient rights and how to communicate with health professionals.

Do women's perspectives of quality of care during childbirth match with those of providers? A qualitative study in Uttar Pradesh, India

Background: Persistently high maternal mortality levels are a concern in developing countries. In India, monetary incentive schemes have increased institutional delivery rates appreciably, but have not been equally successful in reducing maternal mortality. Maternal outcomes are affected by quality of obstetric care and socio-cultural norms. In this light there is need to examine the quality of care provided to women delivering in institutions.

Objective: This study aimed to examine pregnant women’s expectations of high-quality care in public health facilities in Uttar Pradesh, India, and to contrast this with provider’s perceptions of the same, as well as the barriers that limit their ability to provide high-quality care.

Methods: A qualitative descriptive analysis was conducted on data from two studies – focus group discussions with rural women in their last trimester of pregnancy (conducted in 2014) to understand women’s experience and satisfaction with maternal care services, and in-depth interviews with care providers (conducted in 2016–17) to understand provision of person-centred care. Provider perspectives were matched with themes of women’s perspectives on quality of childbirth care in facilities.

Results: Major themes of care prioritised by women included availability of doctors at the facility; availability of medicines; food; ambulance services; maintenance of cleanliness and hygiene; privacy; good and safe delivery with no complications; client-provider interaction; financial cost of care. Many women also voiced no expectation of care, indicating disillusionment from the existing system. Providers concurred with women on all themes of care except availability of doctors, as they felt that trained nurses were proficient in conducting deliveries.

Conclusions: This study shows that women have clear expectations of quality care from facilities where they go to deliver. Understanding their expectations and matching them with providers’ perspectives of care is critical for efforts to improve the quality of care and thereby impact maternal outcomes.

An investigation into mistreatment of women during labour and childbirth in maternity care facilities in Uttar Pradesh, India: a mixed methods study

OBJECTIVES

To investigate the nature and context of mistreatment during labour and childbirth at public and private sector maternity facilities in Uttar Pradesh, India.

METHODS

This study analyses mixed-methods data obtained through systematic clinical observations and open-ended comments recorded by the observers to describe care provision for 275 mothers and their newborns at 26 hospitals in three districts of Uttar Pradesh from 26 May to 8 July 2015. We conducted a bivariate descriptive analysis of the quantitative data and used a thematic approach to analyse qualitative data.

FINDINGS

All women in the study encountered at least one indicator of mistreatment. There was a high prevalence of not offering birthing position choice (92%) and routine manual exploration of the uterus (80%) in facilities in both sectors. Private sector facilities performed worse than the public sector for not allowing birth companions (p = 0.02) and for perineal shaving (p = < 0.001), whereas the public sector performed worse for not ensuring adequate privacy (p = < 0.001), not informing women prior to a vaginal examination (p = 0.01) and for physical violence (p = 0.04). Prepared comments by observers provide further contextual insights into the quantitative data, and additional themes of mistreatment, such as deficiencies in infection prevention, lack of analgesia for episiotomy, informal payments and poor hygiene standards at maternity facilities were identified.

CONCLUSIONS

Mistreatment of women frequently occurs in both private and public sector facilities. This paper contributes to the literature on mistreatment of women during labour and childbirth at maternity facilities in India by articulating new constructs of overtreatment and under-treatment. There are five key implications of this study. First, a systematic and context-specific effort to measure mistreatment in public and private sector facilities in high burden states in India is required. Second, a training initiative to orient all maternity care personnel to the principles of respectful maternity care would be useful. Third, innovative mechanisms to improve accountability towards respectful maternity care are required. Fourth, participatory community and health system interventions to support respectful maternity care would be useful. Lastly, we note that there needs to be a long-term, sustained investment in health systems so that supportive and enabling work-environments are available to front- line health workers.

Disrespect and abuse during facility-based childbirth and its sociodemographic determinants - A barrier to healthcare utilization in rural population

CONTEXT

The provider-driven disrespect and abuse (DA) of women during childbirth is a marker for quality of maternal care and violation of basic human rights.

AIMS

This study was done to assess prevalence and sociodemographic determinants of DA experienced during facility-based childbirth.

SETTINGS AND DESIGN

This is a cross-sectional, community-based study done in six villages in the district of Aligarh, north India.

SUBJECTS AND METHODS

In all, 305 women who underwent facility-based childbirth were interviewed by pretested and structured questionnaire at home between 4 and 6 weeks postpartum period.

STATISTICAL ANALYSIS USED

Descriptive statistics, Chi-square test, and bivariate regression analysis using SPSS 20.0 were used.

RESULTS

A total of 257 (84.3%) of 305 women reported any form of DA. Nonconsented services (71.1%) and nonconfidential care (62.3%) were the most common types. Abandonment/neglect during childbirth was reported by 10.2% women, nondignified care by 9.2%, physical abuse by 5.9%, detention in the health facility by 3.3%, and discrimination by 3.9%. Women who had undergone vaginal birth [odds ratio (OR) 3.36; confidence interval (CI) 1.7-6.5], at public health facility (OR 2.65; CI 1.4-5.0), given care by providers other than doctors (OR 2.89; CI 1.5-5.5), who belonged to low socioeconomic status (OR 3.68; CI 1.4-9.7), and who did not decide place of delivery themselves (OR 4.49; CI 2.0-12.1) were more at risk of DA. Out of all females unwilling to attend facility in future, 93.8% reported experiencing DA. The association between any DA and decision to attend the facility in future was statistically significant.

CONCLUSION

More than 8 of 10 women experienced any DA during facility-based childbirth. It can be a barrier to utilization of facility for childbirth. Preventing DA is important to improve quality of maternal care and institutional deliveries.

Is quality of care during childbirth consistent from admission to discharge? A qualitative study of delivery care in Uttar Pradesh, India

Background

Improving quality of maternal healthcare services is key to reducing maternal mortality across developing nations, including India. Expanding access to institutionalized care alone has failed to address critical quality barriers to safe, effective, patient-centred, timely and equitable care. Multi-dimensional quality improvement focusing on Person Centred Care(PCC) has an important role in expanding utilization of maternal health services and reducing maternal mortality.

Methods

Nine public health facilities were selected in two rural districts of Uttar Pradesh(UP), India, to understand women’s experiences of childbirth and identify quality gaps in the process of maternity care. 23 direct, non-participant observations of uncomplicated vaginal deliveries were conducted using checklists with special reference to PCC, capturing quality of care provision at five stages—admission; pre-delivery; delivery; post-delivery and discharge. Data was thematically analysed using the framework approach. Case studies, good practices and gaps were noted at each stage of delivery care.

Results

Admission to maternity wards was generally prompt. All deliveries were conducted by skilled providers and at least one staff was available at all times. Study findings were discussed under two broad themes of care ‘structure’ and ‘process’. While infrastructure, supplies and human resource were available across most facilities, gaps were observed in the process of care, particularly during delivery and post-delivery stages. Key areas of concern included compromised patient safety like poor hand hygiene, usage of unsterilized instruments; inadequate clinical care like lack of routine monitoring of labour progression, inadequate postpartum care; partially compromised privacy in the labour room and postnatal ward; and few incidents of abuse and demand for informal payments.

Conclusions

The study findings reflect gaps in the quality of maternity care across public health facilities in the study area and support the argument for strengthening PCC as an important effort towards quality improvement across the continuum of delivery care.

Validation of the person-centered maternity care scale in India

Background

Person-centered care during childbirth is recognized as a critical component of quality of maternity care. But there are few validated tools to measure person-centered maternity care (PCMC). This paper aims to fill this measurement gap. We present the results of the psychometric analysis of the PCMC tool that was previously validated in Kenya using data from India. We aim to assess the validity and reliability of the PCMC scale in India, and to compare the results to those found in the Kenya validation.

Methods

We use data from a cross-sectional survey conducted from August to October 2017 with recently delivered women at 40 government facilities in Uttar Pradesh, India (N = 2018). The PCMC measure used is a previously validated scale with subscales for dignity and respect, communication and autonomy, and supportive care. We performed psychometric analyses, including iterative exploratory and confirmatory factor analysis, to assess construct and criterion validity and reliability.

Results

The results provide support for a 27-item PCMC scale in India with a possible score range from 0 to 81, compared to the 30-item PCMC scale in Kenya with a 0 to 90 possible score range. The overall PCMC scale has good reliability (Cronbach alpha = 0.85). Similar to Kenya, we are able to group the items in to three conceptual domains representing subscales for “Dignity and Respect,” “Communication and Autonomy,” and “Supportive Care.” The sub-scales also have relatively good reliability (Cronbach alphas range from 0.67 to 0.73). In addition, increasing scores on the scale is associated with future intentions to deliver in the same facility, suggesting good criterion validity.

Conclusions

This research extends the PCMC literature by presenting results of validating the PCMC scale in a new context. The psychometric analysis using data from Uttar Pradesh, India corroborates the Kenya analysis showing the scale had good content, construct, and criterion validity, as well as high reliability. The overlap in items suggests that this scale can be used across different contexts to compare women’s experiences of care, and to inform and evaluate quality improvement efforts to promote comprehensive PCMC.

Expanding the agenda for addressing mistreatment in maternity care: a mapping review and gender analysis

BACKGROUND

This paper responds to the global call to action for respectful maternity care (RMC) by examining whether and how gender inequalities and unequal power dynamics in the health system undermine quality of care or obstruct women's capacities to exercise their rights as both users and providers of maternity care.

METHODS

We conducted a mapping review of peer-reviewed and gray literature to examine whether gender inequality is a determinant of mistreatment during childbirth. A search for peer-reviewed articles published between January 1995 and September 2017 in PubMed, Embase, SCOPUS, and Web of Science databases, supplemented by an appeal to experts in the field, yielded 127 unique articles. We reviewed these articles using a gender analysis framework that categorizes gender inequalities into four key domains: access to assets, beliefs and perceptions, practices and participation, and institutions, laws, and policies. A total of 37 articles referred to gender inequalities in the four domains and were included in the analysis.

RESULTS

The mapping indicates that there have been important advances in documenting mistreatment at the health facility, but less attention has been paid to addressing the associated structural gender inequalities. The limited evidence available shows that pregnant and laboring women lack information and financial assets, voice, and agency to exercise their rights to RMC. Women who defy traditional feminine stereotypes of chastity and serenity often experience mistreatment by providers as a result. At the same time, mistreatment of women inside and outside of the health facility is normalized and accepted, including by women themselves. As for health care providers, gender discrimination is manifested through degrading working conditions, lack of respect for their abilities, violence and harassment,, lack of mobility in the community, lack of voice within their work setting, and limited training opportunities and professionalization. All of these inequalities erode their ability to deliver high quality care.

CONCLUSION

While the evidence base is limited, the literature clearly shows that gender inequality-for both clients and providers-contributes to mistreatment and abuse in maternity care. Researchers, advocates, and practitioners need to further investigate and build upon lessons from the broader gender equality, violence prevention, and rights-based health movements to expand the agenda on mistreatment in childbirth and develop effective interventions.

The shifting axes of marginalities: the politics of identities shaping women's experiences during childbirth in Northeast India

Institutional births in India, including the north eastern state of Assam, have increased steeply in the last decade such that 71% of all births now occur in facilities. Most analyses of disrespect and abuse during childbirth have largely framed the problem within a binary that juxtaposes all users of services in one category, subordinate to institutions and institutional actors. This commentary explores whether a different analysis is possible within a relational context where citizenship itself is graded, and not all marginal groups experience either the same form or the same intensity of mistreatment. Employing a historical lens including examining relations between non-elite groups, current discriminatory state policies and practices, and deepening conflicts over scarce resources, this commentary presents a more localised and granular understanding of how disrespect and abuse may manifest in institutional births in Assam. Experiences of disrespect and abuse during childbirth are mediated by axes of marginalities that are dynamic and non-isomorphic, shaped by state policies, the everyday practices of the citizens, the differential and unequal relations between the state and multiple marginal groups of citizens, and between citizens themselves. Reframing marginality in this way may lend itself to identifying sources of inequities that emanate from both within and outside of health systems, allowing for more sophisticated explorations of disrespect and abuse. This may help improve health systems to ensure that experience of childbirth is more humane, safe and respectful, independent of women's social identities and their locations in the larger political economy.

Childbirth experiences related to obstetric violence in public health units in Quito, Ecuador

OBJECTIVE

To explore women's experiences of obstetric violence related to childbirth in Ecuador.

METHODS

The present cross-sectional descriptive study combined qualitative and quantitative elements of women's childbirth experience in Quito, Ecuador, between July 1, 2016, and July 1, 2017. Women who delivered in public health units providing different levels of care completed a survey of 32 questions, divided into six dimensions of obstetric violence.

RESULTS

Overall, 388 women completed the survey, of whom 259 (66.8%) delivered vaginally and 129 (33.2%) delivered by cesarean. Among 120 women who delivered for the first time, 62 (51.7%) had an episiotomy. At the second stage of labor, uterine fundus pressure (Kristeller maneuver) was performed for 49 (19.4%) of 252 women. Overall, 196 (50.5%) women reported that they were not allowed to engage in early attachment, and 135 (34.8%) reported that they did not receive support for the initiation of breastfeeding.

CONCLUSION

Various forms of obstetric violence are occurring in the public health services of Quito, despite World Health Organization recognition of the need for perinatal care at the highest level. Programs designed to prevent and diminish obstetric violence are urgently required.

Development of a Person-Centered Family Planning Scale in India and Kenya

Despite recognition that person-centered care is a critical component to providing high quality family planning services, there lacks consensus on how to operationalize and measure it. This paper describes the development and validation of a person-centered family planning (PCFP) scale in India and Kenya. Cross-sectional data were collected from 522 women in Kenya and 225 women in India who visited a health facility providing family planning services. Psychometric analyses, including exploratory factor analysis, were employed to assess the validity and reliability of the PCFP scale. Separate scales were developed for India and Kenya due to context-specific items. We assessed criterion validity by examining the association between PCFP and global measures of quality and satisfaction with family planning care. The analysis resulted in a multidimensional PCFP scale, including 20 items in Kenya and 22 items in India. Through iterative factor analysis, two subscales were identified for both countries: "autonomy, respectful care, and communication" and "health facility environment." This scale may be used to evaluate quality improvement interventions and experiences of women globally to support women in achieving their reproductive health goals.

The Effect of a Community Health Worker Utilized Mobile Health Application on Maternal Health Knowledge and Behavior: A Quasi-Experimental Study

Background

Mobile technology (mHealth) is increasingly being used to achieve improved access and quality of maternal care, particularly in rural areas of low- and middle-income countries. In 2011, a mobile application—Mobile for Mothers (MfM)—was implemented in Jharkhand, India to support home visits by community health workers. The objective of this study is to assess the impact of the mHealth intervention on maternal health.

Methods

Households from three subdistricts in the Deoghar district of Jharkhand were selected using a multistage cluster sampling approach. Households from the Sarwan subdistrict received the MfM intervention, those from Devipur subdistrict received other interventions asides MfM from the implementing non-governmental organization (NGO), while households from Mohanpur subdistrict received the current standard of care. Women (n = 2,200) between the ages of 18 and 45 who had delivered a baby in the past 1 year were enrolled into the study. The primary outcomes of interest were maternal health knowledge, antenatal care (ANC) attendance, and delivery in a health facility.

Results

Post-intervention, women in the MfM group had higher maternal health knowledge, were more likely to attend four or more ANC visits, and deliver at the health facility when compared with the NGO and standard care group. After controlling for predictors, women in the intervention group significantly performed better than both the NGO and standard care groups on all three-outcome variables (all P > 0.05).

Conclusion

The results indicate that although the MfM mHealth intervention could influence adherence and practice of recommended maternal health behaviors, it could not overcome key sociocultural determinants of maternal health such as caste and educational status, which are specific to the Indian context. mHealth holds continued promise for maternal health but implementers and policy makers must additionally address health system and sociocultural factors that play a significant role in the uptake of recommended maternal health practices.

Outcomes of a Coaching-Based WHO Safe Childbirth Checklist Program in India

BACKGROUND

The prevalence of facility-based childbirth in low-resource settings has increased dramatically during the past two decades, yet gaps in the quality of care persist and mortality remains high. The World Health Organization (WHO) Safe Childbirth Checklist, a quality-improvement tool, promotes systematic adherence to practices that have been associated with improved childbirth outcomes.

METHODS

We conducted a matched-pair, cluster-randomized, controlled trial in 60 pairs of facilities across 24 districts of Uttar Pradesh, India, testing the effect of the BetterBirth program, an 8-month coaching-based implementation of the Safe Childbirth Checklist, on a composite outcome of perinatal death, maternal death, or maternal severe complications within 7 days after delivery. Outcomes - assessed 8 to 42 days after delivery - were compared between the intervention group and the control group with adjustment for clustering and matching. We also compared birth attendants' adherence to 18 essential birth practices in 15 matched pairs of facilities at 2 and 12 months after the initiation of the intervention.

RESULTS

Of 161,107 eligible women, we enrolled 157,689 (97.9%) and determined 7-day outcomes for 157,145 (99.7%) mother-newborn dyads. Among 4888 observed births, birth attendants' mean practice adherence was significantly higher in the intervention group than in the control group (72.8% vs. 41.7% at 2 months; 61.7% vs. 43.9% at 12 months; P<0.001 for both comparisons). However, there was no significant difference between the trial groups either in the composite primary outcome (15.1% in the intervention group and 15.3% in the control group; relative risk, 0.99; 95% confidence interval, 0.83 to 1.18; P=0.90) or in secondary maternal or perinatal adverse outcomes.

CONCLUSIONS

Birth attendants' adherence to essential birth practices was higher in facilities that used the coaching-based WHO Safe Childbirth Checklist program than in those that did not, but maternal and perinatal mortality and maternal morbidity did not differ significantly between the two groups. (Funded by the Bill and Melinda Gates Foundation; Clinical Trials number, NCT02148952 .).

Women's empowerment and experiences of mistreatment during childbirth in facilities in Lucknow, India: results from a cross-sectional study

BACKGROUND

Recent evidence has found widespread reports of women experiencing abuse, neglect, discrimination, and poor interpersonal care during childbirth around the globe. Empowerment may be a protective mechanism for women against facility mistreatment during childbirth. The majority of previous research on mistreatment during childbirth has been qualitative in nature.

METHODS

In this analysis, we use quantitative data from 392 women who recently gave birth in a facility in the slums of Lucknow, India, to explore whether measures of women's empowerment are associated with their experiences of mistreatment at their last childbirth. We use the Gender Equitable Men (GEM) scale to measure women's views of gender equality.

RESULTS

We find that women who had more equitable views about the role of women were less likely to report experiencing mistreatment during childbirth. These findings suggest that dimensions of women's empowerment related to social norms about women's value and role are associated with experiences of mistreatment during childbirth.

CONCLUSIONS

This expands our understanding of empowerment and women's health, and also suggests that the GEM scale can be used to measure certain domains of empowerment from a women's perspective in this setting.