Maternity care and Human Rights: what do women think?

Childbirth experiences and satisfaction with birth among women in selected Nigerian healthcare facilities during COVID-19 pandemic: a mixed method

Introduction

childbirth experiences are women´s personal feelings and interpretations of birth processes, which could be difficult to describe and explain. The outbreak of Coronavirus disease (COVID-19) instilled tension and worries in all Nigerian citizens and could also affect the birth experiences and satisfaction of women. Thus, this study explored the experiences of childbirth and satisfaction with birth among women in selected Nigerian healthcare facilities during COVID-19 pandemic.

Methods

the study adopted a concurrent triangulation mixed method design, which utilized an in-depth interview and questionnaire to obtain different but complementary data. Sample sizes of 304 and 15 women were recruited for quantitative and qualitative data, respectively. Analysis was done using descriptive statistics and thematic content analysis.

Results

the majority of the participants perceived childbirth to be labor and delivery (3.66 ± 3.16); participants were mostly satisfied with reception received from staff (2.35 ± 2.29) and respecting their privacy (2.04 ± 1.52). Five (5) themes and 18 subthemes emerged from qualitative data. The themes were: understanding of childbirth, satisfaction with care, hospital experiences, unique experiences during birth, and social support.

Conclusion

women had more positive and less negative but unique childbirth experiences. The majority expressed satisfaction within the care given by qualified and competent health workers, despite the challenges posed by COVID-19 pandemic. The provision of physical and emotional support by intimate partners, midwives´ and family members during delivery had a significant influence on maternal satisfaction with the entire birth experience.

Seeking a connection: Women's lived experience of the woman-midwife relationship in mainstream maternity services in Japan

PROBLEM

In Japan, women continue to suffer from mental health and other postpartum issues despite good clinical outcomes of maternity care.

BACKGROUND

As key care providers, midwives potentially affect women's overall birth experience. Most women in Japan give birth in hospitals or obstetric clinics where different midwives and nurses provide one woman with fragmented care. Women's lived experiences of the woman-midwife in these birth facilities are not well known in Japan.

AIM

To understand women's birth experience and relationship with midwives in the mainstream maternity care system in Japan to improve maternity care and women's birth experience.

METHODS

Face-to-face individual interviews with 14 mothers were conducted. The data were analysed using van Manen's hermeneutic phenomenological approach, which reveals the meaning of human experience in the everyday world.

FINDINGS

Four themes were derived from the hermeneutic phenomenological analysis; 1) Closed hearts and bodies in insecure relationships, 2) Alienation, 3) Hopelessness and helplessness, and 4) Women's vulnerability and desire for positive relationships.

DISCUSSION

In institutionalised and fragmented maternity care settings, it is difficult for women and midwives to develop a relationship. In such a care environment, women's birth experience with midwives is negative or even traumatic; yet, women still need and seek the midwife relationship. Respectful care-necessary for women's positive birth experience-requires positive relationship between women and midwives.

CONCLUSION

Women's negative birth experience may affect their mental health and parenting. Maternity and midwifery care in Japan needs to develop relationship-based care to improve women's birth experience.

Trends in facility-based childbirth and barriers to care at a birth center and community hospital in rural Chiapas, Mexico: A mixed-methods study

OBJECTIVE

To assess trends in childbirth at a hospital-birth center among women living in Compañeros En Salud (CES)-affiliated communities in Chiapas, Mexico and explore barriers to childbirth care. Our hypothesis was that despite interventions to support and incentivize childbirth at the hospital-birth center, the proportion of births at the hospital-birth center among women from Compañeros En Salud-affiliated communities has not significantly changed after two years. We suspected that this may be due to structural factors impacting access to care and/or perceptions of care impacting desire to deliver at the birth center.

DESIGN

This explanatory mixed-methods study included a retrospective Compañeros En Salud maternal health census review followed by quantitative surveys and semi-structured qualitative interviews.

PARTICIPANTS AND SETTING

Participants were women living in municipalities in the mountainous Sierra Madre region of Chiapas, Mexico who received prenatal care in one of 10 community clinics served by Compañeros En Salud. Participants were recruited if they gave birth anywhere other than the primary-level rural hospital and adjacent birth center supported by Compañeros En Salud, either at home or at other facilities.

MEASUREMENTS

We compared rates of birth at the hospital-birth center, other health facilities, and at home from 2017-2018. We conducted surveys and interviews with women who gave birth between January 2017-July 2018 at home or at facilities other than the hospital-birth center to understand perceptions of care and decision-making surrounding childbirth location.

FINDINGS

We found no significant difference in rates of overall number of women birthing at the hospital-birth center from Compañeros En Salud-affiliated communities between 2017 and 2018 (p=0.36). Analysis of 158 surveys revealed distance (30.4%), time (27.8%), and costs (25.9%) as reasons for not birthing at the hospital-birth center. From 27 interviews, negative perceptions and experiences of the hospital included low-quality and disrespectful care, low threshold for medical interventions, and harm and suffering. Partners or family members influenced most decisions about childbirth location.

KEY CONCLUSIONS

Interventions to minimize logistical barriers may not be sufficient to overcome distance and perceptions of low-quality, disrespectful care.

IMPLICATIONS FOR PRACTICE

Better understanding of complex decision-making around childbirth will guide Compañeros En Salud in developing interventions to further meet the needs and preferences of birthing women in rural Chiapas.

Organisational and individual readiness for change to respectful maternity care practice and associated factors in Ibadan, Nigeria: a cross-sectional survey

OBJECTIVES

This study assessed health providers' organisational and individual readiness for change to respectful maternity care (RMC) practice and their associated factors in Ibadan Metropolis, Nigeria.

DESIGN

A cross-sectional survey using standardised structured instruments adapted from the literature.

SETTING

Nine public health facilities in Ibadan Metropolis, Nigeria, 1 December 2019-31 May 2020.

PARTICIPANTS

212 health providers selected via a two-stage cluster sampling.

OUTCOMES

Organisational readiness for change to RMC (ORCRMC) and individual readiness for change to RMC (IRCRMC) scales had a maximum score of 5. Multiple linear regression was used to identify factors influencing IRCRMC and ORCRMC. We evaluated previously identified predictors of readiness for change (change valence, informational assessments on resource adequacy, core self-evaluation and job satisfaction) and proposed others (workplace characteristics, awareness of mistreatment during childbirth, perceptions of women's rights and resource availability to implement RMC). Data were adjusted for clustering and analysed using Stata V.15.

RESULTS

The providers' mean age was 44.0±9.9 years with 15.4±9.9 years of work experience. They scored high on awareness of women's mistreatment (3.9±0.5) and women's perceived rights during childbirth (3.9±0.5). They had high ORCRMC (4.1±0.9) and IRCRMC (4.2±0.6), both weakly but positively correlated (r=0.407, 95% CI: 0.288 to 0.514, p<0.001). Providers also had high change valence (4.5±0.8) but lower perceptions of resource availability (2.7±0.7) and adequacy for implementation (3.3±0.7). Higher provider change valence and informational assessments were associated with significantly increased IRCRMC (β=0.40, 95% CI: 0.11 to 0.70, p=0.015 and β=0.07, 95% CI: 0.01 to 0.13, p=0.032, respectively), and also with significantly increased ORCRMC (β=0.47, 95% CI: 0.21 to 0.74, p=0.004 and β=0.43, 95% CI: 0.22 to 0.63, p=0.002, respectively). Longer years of work experience (β=0.08, 95% CI: 0.01 to 0.2, p=0.024), providers' monthly income (β=0.08, 95% CI: 0.02 to 0.15, p=0.021) and the health facility of practice were associated with significantly increased ORCRMC.

CONCLUSION

The health providers studied valued a change to RMC and believed that both they and their facilities were ready for the change to RMC practice.

Determinants of gestational syphilis among women attending prenatal care programs in the Brazilian Amazon

Background

There was a high proportion of pregnant women who were attending prenatal care who were not tested for syphilis or tested but not treated, among priority countries. The coverage for prenatal care visits, syphilis screening, and treatment are priority indicators for monitoring of the elimination of syphilis. The aim was to determine the factors associated with gestational syphilis among postpartum women who were in a prenatal care program in the Brazilian Amazon.

Methods

An unmatched case-control study was conducted at the hospital in Brazil. Data collection was carried out from November 2020 to July 2021 during hospitalization using a pretested structured questionnaire. The criteria for selection of cases and control followed the guidelines established by the Ministry of Health of Brazil; postpartum women with a laboratory diagnosis based on treponemal and/or nontreponemal tests, symptoms of syphilis or asymptomatic, treatment or not treated, and in a prenatal care program. Gestational syphilis cases were identified as women who tested positive for syphilis, and those who tested negative were controls, at minimally one prenatal care visit, childbirth, and/or the puerperium. The sample size encompassed 59 cases and 118 controls (1: 2 ratio of cases to controls). Data were analyzed using Minitab 20^® and BioEstat 5.3^® software. The odds ratio was calculated by multiple logistic regression.

Results

One hundred and seventy-seven postpartum women were included in the study, 59 cases and 118 controls. Among all participants, 95.5% (169) were tested for syphilis in any trimester during pregnancy and at the delivery and 4.5% (8) were tested in the maternity only, at the time childbirth and/or puerperium. The final multiple logistic regression model evidenced that cases had higher odds compared to controls if they had past history of sexually transmitted infections (AOR: 55.4; p: 0.00), difficulty talking about condom use with their sexual partner (AOR: 4.92; p: 0.01), one to six prenatal care visits (AOR: 4.93; p: 0.01), had not received a sexually transmitted infections test result in the maternity hospital (AOR: 4.09; p: 0.04), lower monthly income (AOR: 4.32; p: 0.04), or one to three miscarriages (AOR: 4.34; p: 0.01).

Conclusion

The sociodemographic, programmatic, obstetric, and sexual factors are associated with gestational syphilis among postpartum women.

Domains of competence in midwifery students: a basis for developing a competence assessment tool for iranian undergraduate midwifery students

BACKGROUND

Current study was conducted with the aim of explaining domains of clinical competence in undergraduate midwifery students so that it addresses the challenges in midwifery curriculum and improving clinical assessment methods in Iranian undergraduate midwifery students.

METHODS

Qualitative approach and conventional content analysis were used in the design of the present study. The research setting included midwifery and nursing schools and hospitals and health centers affiliated to Tehran and Guilan universities of medical sciences in Iran. The target population consisted of undergraduate midwifery students in the fourth to eighth semesters of school, midwives working in hospitals and health centers, midwifery faculty members, and obstetricians. The participants were selected through purposive maximum variation sampling, which continued until data saturation. After in-depth semi-structured interviews, the content of the interviews was analyzed according to the steps proposed by Zhang & Wildemuth.

RESULTS

Twenty-four people participated in this study, including seven midwifery students, seven midwives, nine midwifery and reproductive and sexual health faculty members, and one obstetrician. The participants were aged 20-56 years and their mean age was 39.75 years. Their level of education varied from midwifery student to PhD. The mean work experience of the participants was 13.62 years and the mean duration of the interviews was 48 min. The analysis of the data obtained from the experiences of the participants led to the formation of the four categories of ethical and professional function in midwifery, holistic midwifery care, effective interaction, and personal and professional development, along with ten subcategories.

CONCLUSION

The findings of the present study showed that clinical competence in midwifery students involves different domains that correspond well overall to the general definitions of clinical competence in different sources. These findings can be used as a basis for the design and psychometric assessment of a clinical competence assessment tool for undergraduate midwifery students.

Challenges to the right to health in sub-Saharan Africa: reflections on inequities in access to dialysis for patients with end-stage kidney failure

Realization of the individual’s right to health in settings such as sub-Saharan Africa, where health care adequate resources are lacking, is challenging. This paper demonstrates this challenge by illustrating the example of dialysis, which is an expensive but life-saving treatment for people with kidney failure. Dialysis resources, if available in sub-Saharan Africa, are generally limited but in high demand, and clinicians at the bedside are faced with deciding who lives and who dies. When resource limitations exist, transparent and objective priority setting regarding access to such expensive care is required to improve equity across all health needs in a population. This process however, which weighs individual and population health needs, denies some the right to health by limiting access to health care.

This paper unpacks what it means to recognize the right to health in sub-Saharan Africa, acknowledging the current resource availability and scarcity, and the larger socio-economic context. We argue, the first order of the right to health, which should always be realized, includes protection of health, i.e. prevention of disease through public health and health-in-all policy approaches. The second order right to health care would include provision of universal health coverage to all, such that risk factors and diseases can be effectively and equitably detected and treated early, to prevent disease progression or development of complications, and ultimately reduce the demand for expensive care. The third order right to health care would include equitable access to expensive care. In this paper, we argue that recognition of the inequities in realization of the right to health between individuals with “expensive” needs versus those with more affordable needs, countries must determine if, how, and when they will begin to provide such expensive care, so as to minimize these inequities as rapidly as possible. Such a process requires good governance, multi-stakeholder engagement, transparency, communication and a commitment to progress. We conclude the paper by emphasizing that striving towards the progressive realization of the right to health for all people living in SSA is key to achieving equity in access to quality health care and equitable opportunities for each individual to maximize their own state of health.

The un-silencing of Japanese women's voices in maternity care: A hermeneutic phenomenological study of the woman-midwife relationship

OBJECTIVE

The purpose of this article is to understand the meaning of the woman-midwife relationship, with the overall aim to improve maternity care and women's birth experiences in Japan. To better understand the meaning of the woman-midwife relationship, this article presents women's and midwives' experiences of having or not having a voice in maternity care.

RESEARCH DESIGN

Hermeneutic phenomenology, as described by Max van Manen, helped to uncover the meaning of the phenomenon-the woman-midwife relationship-through participants' lived experience. Individual interviews were conducted with 14 women and 10 midwives living in Japan. The interview data were interpreted and thematically analysed to reveal the meaning of the woman-midwife relationship.

FINDINGS

'Having a voice' emerged as a central theme underpinning the meaning of the woman-midwife relationship; aspects of which included, 1) being unheard, 2) losing a voice, 3) having a voice, and 4) midwives speaking for women. Although having a voice should be a legitimate right for women in maternity care, some women's voices were unheard or lost in the experience with midwives. Conversely, some women gained a voice, especially when they positively and continuously developed their relationship with their midwife. How the woman and the midwife related to each other clearly affected their experience of having a voice in maternity care.

KEY CONCLUSION

Having a voice, which portrays dimensions of choice, control, and autonomy, in their own maternity care is vital for women's positive birth experience. The woman-midwife relationship is critical in enabling women to have a voice and midwives to speak for women. Women and midwives need to develop their relationship. Moreover, the maternity care system needs to allow sufficient time and space, for instance, by ensuring midwife continuity of care to develop a positive woman-midwife relationship.

Effects of prenatal group program in rural Tanzania: A quasi-experimental study

AIM

This study conducted in rural Tanzania examined the effects of a midwife-led prenatal group program on: (1) improvement of knowledge of the physiological symptoms of pregnancy; (2) promotion of pregnancy-related empowerment; (3) enhancement of intention to self-care behaviors for safer childbirth; and (4) gaining satisfaction with antenatal care visits.

METHODS

This work was a quasi-experimental study with a control group using a pre-post study design conducted in two district hospitals in Tanzania. Data were collected from 108 analyzed pregnant women from the prenatal group program (n = 54) and control program (n = 54) using questionnaires before (baseline) and after (endline) the program. The program consisted of lecture, sharing, and review sessions. The control program consisted of the same lectures. The contents of both programs included physiological symptoms of pregnancy and self-care behaviors. The primary outcome was knowledge of common symptoms of pregnancy. The secondary outcomes were Pregnancy-Related Empowerment Scale score, intention to self-care behaviors, and satisfaction.

RESULTS

The primary outcome of knowledge of common symptoms of pregnancy was significantly increased in the intervention group compared with the control group (t = 2.677, p = .009). The secondary outcome of one of the Pregnancy-Related Empowerment Scale statements about midwife's respectful attitude toward women's decision was significantly increased in the intervention group compared with the control group (U = 2.076, p = .038).

CONCLUSIONS

The interventional prenatal group program during pregnancy was effective in increasing knowledge of common symptoms of pregnancy and in identifying favorable midwife connectedness.

Universal healthcare coverage, patients' rights, and nurse-patient communication: a critical review of the evidence

The Sustainable Development Goals adopted by world leaders on September 25, 2015, aimed to end poverty and hunger, promote gender equity, empower women and girls, and ensure human dignity and equality by all human beings in a healthy environment. These development goals were premised on international human rights norms and institutions, thereby acknowledging the relevance of human rights in achieving each goal. Particularly, sustainable development goal 3, whose objective is to achieve universal health coverage, enhance healthy lives, and promote well-being for all, implicitly recognizes the right to health as crucial. Our focus in this paper is to discuss how promoting patients’ rights and enhancing effective nurse-patient communication in the healthcare setting is a significant and necessary way to achieve universal health coverage. Through a critical review of the empirical research evidence, we demonstrated that enhancing patients’ rights and effect nurse-patient communication will promote people-centered care, improve patients’ satisfaction of care outcomes, increase utilization of care services, and empower individuals and families to self-advocate for their health. These steps directly impact primary healthcare strategies and the social determinants of health as core components to achieving universal health coverage. We argue that without paying attention to the human rights dimensions or employing human rights strategies, implementing the other efforts will be inadequate and unsustainable in protecting the poorest and most vulnerable populations in the achievement of goal 3.

Systems on the Edge: Developing Organizational Theory for the Persistence of Mistreatment in Childbirth

Mistreatment in childbirth is institutionalized in many healthcare settings globally, causing widespread harm. Rising concern has elicited research on its prevalence and characteristics, with limited attention to developing explanatory theory. Mistreatment, a complex systemic and behavioral phenomenon, requires social science theory to explain its persistence despite official norms that promote respectful care. Diane Vaughan's normalization of organizational deviance theory from organizational sociology, emerged from studies of how things go wrong in organizations. Its multi-level framework provided an opportunity for analogical cross-case comparison to elaborate theory on mistreatment as normalized organizational deviance. To elaborate the theory, the Tanzanian public health system in the period of 2010-2015 was selected as a case. A broad Scopus search identified 4,068 articles published on the health system and maternal health in Tanzania of which 122 were selected. Data was extracted using a framework based on the theory and reviews of mistreatment in healthcare. Relationships and patterns emerged through comparative analysis across concepts and system levels and then were compared with Vaughan's theory and additional organizational theories. Analysis revealed that normalized scarcity at the macro-level combined with production pressures for biomedical care and imbalanced power-dependence altered values, structures, and processes in the health system. Meso-level actors struggled to achieve production goals with limited autonomy and resources, resulting in workarounds and informal rationing. Biomedical care was prioritized, and emotion work was rationed in provider interactions with women, which many women experienced as disrespect. Analogical comparison with another case of organizational deviance based on literature enabled a novel approach to elaborate theory. The emergent theory sheds light on opportunities to transform systems and routinize respectful care. Theory application in additional settings and exploration of other social theories is needed for further understanding of this complex problem.

Operationalizing respectful maternity care at the healthcare provider level: a systematic scoping review

BACKGROUND

Ensuring the right to respectful care for maternal and newborn health, a critical dimension of quality and acceptability, requires meeting standards for Respectful Maternity Care (RMC). Absence of mistreatment does not constitute RMC. Evidence generation to inform definitional standards for RMC is in an early stage. The aim of this systematic review is clear provider-level operationalization of key RMC principles, to facilitate their consistent implementation.

METHODS

Two rights-based frameworks define the underlying principles of RMC. A qualitative synthesis of both frameworks resulted in seven fundamental rights during childbirth that form the foundation of RMC. To codify operational definitions for these key elements of RMC at the healthcare provider level, we systematically reviewed peer-reviewed literature, grey literature, white papers, and seminal documents on RMC. We focused on literature describing RMC in the affirmative rather than mistreatment experienced by women during childbirth, and operationalized RMC by describing objective provider-level behaviors.

RESULTS

Through a systematic review, 514 records (peer-reviewed articles, reports, and guidelines) were assessed to identify operational definitions of RMC grounded in those rights. After screening and review, 54 records were included in the qualitative synthesis and mapped to the seven RMC rights. The majority of articles provided guidance on operationalization of rights to freedom from harm and ill treatment; dignity and respect; information and informed consent; privacy and confidentiality; and timely healthcare. Only a quarter of articles mentioned concrete or affirmative actions to operationalize the right to non-discrimination, equality and equitable care; less than 15%, the right to liberty and freedom from coercion. Provider behaviors mentioned in the literature aligned overall with seven RMC principles; yet the smaller number of available research studies that included operationalized definitions for some key elements of RMC illustrates the nascent stage of evidence-generation in this area.

CONCLUSIONS

Lack of systematic codification, grounded in empirical evidence, of operational definitions for RMC at the provider level has limited the study, design, implementation, and comparative assessment of respectful care. This qualitative systematic review provides a foundation for maternity healthcare professional policy, training, programming, research, and program evaluation aimed at studying and improving RMC at the provider level.

"I Would Have Stayed Home if I Could Manage It Alone": A Case Study of Ethiopian Mother Abandoned by Care Providers During Facility-Based Childbirth

Background

Every woman is entitled to respectful care during pregnancy and childbirth as a basic human right. However, not all women are being treated equally well.

Case Presentation

This case study highlights some of the common disrespectful practices that women face. This is a testimony of a 28-year-old mother of two, narrated in her own words. The data were collected during an in-depth interview in November 2019. The interview was conducted in her house and her name has been changed to protect her identity. The interview was audio-taped using a digital voice recorder, later transcribed, and translated verbatim from the local language – Amharic, to English.

Conclusion

This woman’s story highlights the unfortunate reality for some women. Five themes emerged from her narrative: denial of care: the provider left her unattended at a critical moment and denied her the care that she came for; non-consented care: she did not consent to the episiotomy; non-dignified care: she was carried by her arms and legs to the delivery couch, and left naked and bleeding on the couch after birth; taking a sick baby home without medical assistance: she was forced to leave the hospital even though her child had breathing difficulties and was not able to suck or breastfeed; and loss of trust in care providers: for her second birth this woman went to a facility where a relative works, as she no longer trusted these providers.

The role of evaluation in iterative learning and implementation of quality of care interventions

Background: The Lancet Global Health Commission (LGHC) has argued that quality of care (QoC) is an emergent property that requires an iterative process to learn and implement. Such iterations are required given that health systems are complex adaptive systems.Objective: This paper explores the multiple roles that evaluations need to play in order to help with iterative learning and implementation. We argue evaluation needs to shift from a summative focus toward an approach that promotes learning in complex systems. A framework is presented to help guide the iterative learning, and includes the dimensions of clinical care, person-centered care, continuum of care, and 'more than medicine. Multiple roles of evaluation corresponding to each of the dimensions are discussed.Methods: This paper is informed by reviews of the literature on QoC and the roles of evaluation in complex systems. The proposed framework synthesizes the multiple views of QoC. The recommendations of the roles of evaluation are informed both by review and experience in evaluating multiple QoC initiatives.Results: The specific roles of different evaluation approaches, including summative, realist, developmental, and participatory, are identified in relationship to the dimensions in our proposed framework. In order to achieve the potential of LGHC, there is a need to discuss how different evaluation approaches can be combined in a coherent way to promote iterative learning and implementation of QoC initiatives.Conclusion: One of the implications of the QoC framework discussed in the paper is that time needs to be spent upfront in recognizing areas in which knowledge of a specific intervention is not complete at the outset. This, of course, implies taking stock of areas of incompleteness in knowledge of context, theory of change, support structures needed in order for the program to succeed in specific settings. The role of evaluation should not be limited to only providing an external assessment, but an important goal in building evaluation capacity should be to promote adaptive management among planners and practitioners. Such iterative learning and adaptive management are needed to achieve the goals of sustainable development goals.

The influence of quality and respectful care on the uptake of skilled birth attendance in Tanzania

BACKGROUND

An increase in the uptake of skilled birth attendance is expected to reduce maternal mortality in low- and middle-income countries. In Tanzania, the proportion of deliveries assisted by a skilled birth attendant is only 64% and the maternal mortality ratio is still 398/100.000 live births. This article explores different aspects of quality of care and respectful care in relation to maternal healthcare. It then examines the influence of these aspects of care on the uptake of skilled birth attendance in Tanzania in order to offer recommendations on how to increase the skilled birth attendance rate.

METHODS

This narrative review employed the "person-centered care framework for reproductive health equity" as outlined by Sudhinaraset (2017). Academic databases, search engines and websites were consulted, and snowball sampling was used. Full-text English articles from the last 10 years were included.

RESULTS

Uptake of skilled birth attendance was influenced by different aspects of technical quality of maternal care as well as person-centred care, and these factors were interrelated. For example, disrespectful care was linked to factors which made the working circumstances of healthcare providers more difficult such as resource shortages, low levels of integrated care, inadequate referral systems, and bad management. These issues disproportionately affected rural facilities. However, disrespectful care could sometimes be attributed to personal attitudes and discrimination on the part of healthcare providers. Dissatisfied patients responded with either quiet acceptance of the circumstances, by delivering at home with a traditional birth attendant, or bypassing to other facilities. Best practices to increase respectful care show that multi-component interventions are needed on birth preparedness, attitude and infrastructure improvement, and birth companionship, with strong management and accountability at all levels.

CONCLUSIONS

To further increase the uptake of skilled birth attendance, respectful care needs to be addressed within strategic plans. Multi-component interventions are required, with multi-stakeholder involvement. Participation of traditional birth attendants in counselling and referral can be considered. Future advances in information and communication technology might support improved quality of care.

Women's Views of and Responses to Maternity Services Rendered during Labor and Childbirth in Maternity Units in a Semi-Rural District in South Africa

Facility-based delivery is an important strategy to prevent poor labor outcomes, and midwives are at the center of maternal care. However, disrespectful and abusive maternal care by midwives is prevalent and leads to poor antenatal care utilization and increased numbers of home deliveries. The objective of the study was to assess the views of women about the care they received during labor and childbirth and describe the interactions between the women and the midwives. This was a qualitative study using in-depth interviews with women who had delivered in midwife obstetric units at a district hospital in Tshwane District, South Africa. Twenty-six women aged 18-41 years, and had delivered within the previous six months were selected, using purposive sampling. A thematic content analysis approach and NVivo11 computer software were used to identify emergent themes. Most women had had negative experiences of the maternity services they had received during labor and childbirth. Shouting and rude remarks by midwives caused tension between the midwives and the women and had created a major barrier for communication. The abuse and disrespect that the women were subjected to had created a hostile and uncaring environment for them. They felt stressed, fearful, and anxious throughout labor and childbirth. In response to the hostile environment, they employed manipulative tactics such as pushing before time in the hope of getting attention. These acts resulted in punitive responses from the midwives who joined forces against them, reprimanded, or ignored them. Good interactions, described as being respectful, approachable, and polite, and the sharing of information yielded positive experiences of maternity care. The state of maternity services rendered during labor and childbirth is counterproductive to the existing plan of increasing early antenatal care bookings and presentation to the facilities for labor and childbirth. There is a need to retrain midwives in the respectful care of women during labor and childbirth to facilitate a change in their attitudes.

From Global Rights to Local Relationships: Exploring Disconnects in Respectful Maternity Care in Malawi

Widespread reports of "disrespect and abuse" in maternity wards in low- and middle-income countries have triggered the development of rights-based respectful maternity care (RMC) standards and initiatives. To explore how international standards translate into local realities, we conducted a team ethnography, involving observations in labor wards in government facilities in central Malawi, and interviews and focus groups with midwives, women, and guardians. We identified a dual disconnect between, first, universal RMC principles and local notions of good care and, second, between midwives and women and guardians. The latter disconnect pertains to fraught relationships, reproduced by and manifested in mechanistic care, mutual responsibilization for trouble, and misunderstandings and distrust. RMC initiatives should be tailored to local contexts and midwife-client relationships. In a hierarchical, resource-strapped context like Malawi, promoting mutual love, understanding, and collaboration may be a more productive way to stimulate "respectful" care than the current emphasis on formal rights and respect.

Women's experiences of midwifery care immediately before and after caesarean section deliveries at a public Hospital in the Western Region of Ghana

Background

Childbirth remains a uniquely multifaceted, mental-cognitive and a major life experience to women. It is composed of a variety of psycho social and emotional aspects and creates memories, sometimes bad experiences and unmet expectations which leaves the mother with lasting scars. Therefore, this study aimed at exploring post-caesarean section delivered mothers experiences of midwifery care in a public hospital in Ghana.

Methods

This descriptive exploratory qualitative research used an interpretative approach to explore mothers’ experiences of midwifery care immediately before and after caesarean section (CS). The study employed a purposive sampling technique in recruiting 22 participants who had knowledge of the phenomenon under study. Data collection was guided by an interview guide, which involved face to face individual interviews and focus group discussion at the postnatal ward and clinic. All interviews were audio-recorded and lasted 30–40 min. Audio recordings were transcribed verbatim and inductive thematic data analysis employed.

Results

Four major themes emerged from the analysis of participants’ transcripts: Support by Midwives (physical and psychological, and attitude towards patients’ pain management); Protection of mothers (provision of privacy, confidentiality and physical environment); Provision of information/communication (before caesarean section, and before a minor task) and midwives’ attitude (attitude towards delivery care).

Conclusion

Mothers delivered by caesarean section had varied experiences of midwifery care which were both positive and negative ones. Provision of psychological support and adequate pain management were positive experiences. The challenges experienced were related to provision of information, privacy, and physical support. Participants, who underwent emergency CS in particular, were dissatisfied with the provision of information concerning the surgical procedure. Provision of privacy and physical support were also issues of great concern. We therefore, recommend supportive and sensitive midwifery care particularly for mothers undergoing emergency CS. Documenting women’s diverse experiences of midwifery care before and after CS delivery is important to healthcare providers, hospital managers and policy makers as the feedback garnered can be used to improve maternity services and inform decisions on midwifery care.

Disrespectful and abusive behavior during childbirth and maternity care in Ethiopia: a systematic review and meta-analysis

Objective

Disrespectful and abusive behavior during childbirth and maternity care is violation of fundamental right of women and unborn child. There is scarce of data on disrespectful and abusive behavior during childbirth and maternity care in Ethiopia. The aim of this study was to determine disrespectful and abusive behavior during childbirth and maternity care in Ethiopia.

Results

Seven studies were included in this meta-analysis of disrespectful and abusive behavior during childbirth and maternity care. The pooled prevalence of disrespect and abuse care during childbirth and maternity care was 49.4% (95% CI 30.9–68.1). Whereas physical abuse was 13.6% (95% CI 5.2–31.2), non-confidential care was 14.1% (95% CI 7.3–25.4), abandonment care was 16.4% (95% CI 14.7–18.2), and detention was 3.2% (95% CI 0.9–11.5). This study showed that disrespectful and abusive behavior during child birth and maternity care is high. Whereas, abandonment care is high. This study indicates that health care providers shall not leave women during childbirth and maternity care and listen women, federal minister of health and regional health bureau also identifying root of cause disrespect and abuse and to alleviate mistreatment during childbirth and maternity care.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4118-2) contains supplementary material, which is available to authorized users.

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.

Disrespect and abuse in maternity care: individual consequences of structural violence

Disrespect and abuse of patients, especially birthing women, does occur in the health sector. This is a violation of women's fundamental human rights and can be viewed as a consequence of women's lives not being valued by larger social, economic and political structures. Here we demonstrate how such disrespect and abuse is enacted at an interpersonal level across the continuum of care in Tanzania. We describe how and why women's exposure to disrespect and abuse should be seen as a symptom of structural violence. Detailed narratives were developed based on interviews and observations of 14 rural women's interactions with health providers from their first antenatal visit until after birth. Narratives were based on observation of 25 antenatal visits, 3 births and 92 in-depth interviews with the same women. All women were exposed to non-supportive care during pregnancy and birth including psychological abuse, physical abuse, abandonment and privacy violations. Systemic gender inequality renders women excessively vulnerable to abuse, expressed as a normalisation of abuse in society. Health institutions reflect and reinforce dominant social processes and normalisation of non-supportive care is symptomatic of an institutional culture of care that has become dehumanised. Health providers may act disrespectfully because they are placed in a powerful position, holding authority over their patients. However, they are themselves also victims of continuous health system challenges and poor working conditions. Preventing disrespect and abuse during antenatal care and childbirth requires attention for structural inequalities that foster conditions that make mistreatment of vulnerable women possible.

"I Was Relieved to Know That My Baby Was Safe": Women's Attitudes and Perceptions on Using a New Electronic Fetal Heart Rate Monitor during Labor in Tanzania

To increase labor monitoring and prevent neonatal morbidity and mortality, a new wireless, strap-on electronic fetal heart rate monitor called Moyo was introduced in Tanzania in 2016. As part of the ongoing evaluation of the introduction of the monitor, the aim of this study was to explore the attitudes and perceptions of women who had worn the monitor continuously during their most recent delivery and perceptions about how it affected care. This knowledge is important to identify barriers towards adaptation in order to introduce new technology more effectively. We carried out 20 semi-structured individual interviews post-labor at two hospitals in Tanzania. A thematic content analysis was used to analyze the data. Our results indicated that the use of the monitor positively affected the women's birth experience. It provided much-needed reassurance about the wellbeing of the child. The women considered that wearing Moyo improved care due to an increase in communication and attention from birth attendants. However, the women did not fully understand the purpose and function of the device and overestimated its capabilities. This highlights the need to improve how and when information is conveyed to women in labor.

Antenatal care and opportunities for quality improvement of service provision in resource limited settings: A mixed methods study

Antenatal care is essential to improve maternal and newborn health and wellbeing. The majority of pregnant women in Tanzania attend at least one visit. Since implementation of the focused antenatal care model, quality of care assessments have mostly focused on utilization and coverage of routine interventions for antenatal care. This study aims to assess the quality of antenatal care provision from a holistic perspective in a rural district in Tanzania. Structure, process and outcome components of quality are explored. This paper reports on data collected over several periods from 2012 to 2015 through facility audits of supplies and services, ANC observations and exit interviews with pregnant women. Additional qualitative methods were used such as interviews, focus group observations and participant observations. Findings indicate variable performance of routine ANC services, partly explained by insufficient resources. Poor performance was also observed for appropriate history taking, attention for client's wellbeing, basic physical examination and adequate counseling and education. Achieving quality improvement for ANC requires increased attention for the process of care provision beyond coverage, including attention for response-based services, which should be assessed based on locally determined criteria.

Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis

Background

What constitutes respectful maternity care (RMC) operationally in research and programme implementation is often variable.

Objectives

To develop a conceptualisation of RMC.

Search strategy

Key databases, including PubMed, CINAHL, EMBASE, Global Health Library, grey literature, and reference lists of relevant studies.

Selection criteria

Primary qualitative studies focusing on care occurring during labour, childbirth, and/or immediately postpartum in health facilities, without any restrictions on locations or publication date.

Data collection and analysis

A combined inductive and deductive approach was used to synthesise the data; the GRADE CERQual approach was used to assess the level of confidence in review findings.

Main results

Sixty‐seven studies from 32 countries met our inclusion criteria. Twelve domains of RMC were synthesised: being free from harm and mistreatment; maintaining privacy and confidentiality; preserving women's dignity; prospective provision of information and seeking of informed consent; ensuring continuous access to family and community support; enhancing quality of physical environment and resources; providing equitable maternity care; engaging with effective communication; respecting women's choices that strengthen their capabilities to give birth; availability of competent and motivated human resources; provision of efficient and effective care; and continuity of care. Globally, women's perspectives of what constitutes RMC are quite consistent.

Conclusions

This review presents an evidence‐based typology of RMC in health facilities globally, and demonstrates that the concept is broader than a reduction of disrespectful care or mistreatment of women during childbirth. Innovative approaches should be developed and tested to integrate RMC as a routine component of quality maternal and newborn care programmes.

Tweetable abstract

Understanding respectful maternity care – synthesis of evidence from 67 qualitative studies.

Understanding respectful maternity care – synthesis of evidence from 67 qualitative studies.

It does matter where you come from: mothers' experiences of childbirth in midwife obstetric units, Tshwane, South Africa

Background

Health professionals are striving to improve respectful care for women, but they fall short in the domains of effective communication, respectful and dignified care and emotional support during labour. This study aimed to determine women’s experiences of childbirth with a view to improving respectful clinical care practices in low-risk, midwife-led obstetric units in the Tshwane District Health District, South Africa.

Methods

A survey covering all midwife-led units in the district was conducted among 653 new mothers. An anonymous questionnaire was administered to mothers returning for a three-days-to-six-weeks postnatal follow-up visit. Mothers were asked about their experiences regarding communication, labour, clinical care and respectful care during confinement. An ANCOVA was performed to identify the socio-demographic variables that significantly predicted disrespectful care. Six items representing the different areas of experience were used in the analysis.

Results

Age, language, educational level and length of residence in the district were significantly associated with disrespectful care (p ≤ 0.01). Overall, the following groups of mothers reported more negative care experiences during labour: women between the ages of 17 and 24 years; women with limited formal education; and women from another province or a neighbouring country. Items which attracted fewer positive responses from participants were the following: 46% of mothers had been welcomed by name on arrival; 47% had been asked to give consent to a physical examination; and 39% had been offered food or water during labour. With regard to items related to respectful care, 54% of mothers indicated that all staff members had spoken courteously to them, 48% said they had been treated with a lot of respect, and 55% were completely satisfied with their treatment.

Conclusion

There is a need to improve respectful care through interventions that are integrated into routine care practices in labour wards. To stop the spiral of abusive obstetric care, the care provided should be culturally sensitive and should address equity for the most vulnerable and underserved groups. All levels of the health care system should employ respectful obstetric care practices, matched with support for midwives and improved clinical governance in maternity facilities.

Electronic supplementary material

The online version of this article (dio: 10.1186/s12978-017-0411-5) contains supplementary material, which is available to authorized users.

Assessing emergency obstetric and newborn care: can performance indicators capture health system weaknesses?

Background

Regular monitoring and assessment of performance indicators for emergency obstetric and newborn care can help to identify priorities to improve health services for women and newborns. The aim of this study was to perform a district wide assessment of emergency obstetric and newborn care performance and identify ways for improvement.

Methods

Facility assessment of 13 dispensaries, four health centers and one district hospital in a rural district in Tanzania was performed in two data collection periods in 2014. Assessment included a facility walk-through to observe facility infrastructure and interviews with facility in-charges to assess available services, staff and supplies. In addition facility statistics were collected for the year 2013. Results were discussed with district representatives.

Results

Approximately 65% of expected births took place in health facilities and 22% of women with complications were treated in facilities expected to provide emergency care. None of the facilities was, however, able to perform at the expected level for emergency obstetric and newborn care since not all required signal functions could be provided. Inadequate availability of essential drugs such as uterotonics, antibiotics and anticonvulsants as well as lack of ability to perform vacuum extraction and blood transfusion limited performance.

Conclusions

Performance of emergency obstetric and newborn care in Magu District was not in accordance with expected guidelines and highly influenced by lack of available resources and an insufficiently functioning health care system. Improving assessment approaches, to look beyond the signal functions, can capture weaknesses in the system and will help to understand poor performance and identify locally applicable ways for improvement.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1282-z) contains supplementary material, which is available to authorized users.