Discordance in self-report and observation data on mistreatment of women by providers during childbirth in Uttar Pradesh, India

Respectful maternity care during childbirth: Experiences and observation among mothers in a tertiary-care institute in Manipur

Background

Respectful maternity care (RMC) refers to the humane and dignified treatment of a childbearing woman throughout her pregnancy, childbirth and immediate postpartum period. Disrespect and abuse of women during labour, childbirth and immediate postpartum period in health facilities is one of the reasons which deter them from further utilizing maternal healthcare services. The present study was thus undertaken to determine to what extent RMC practices are being followed in a health facility in Manipur.

Materials and Methods

A cross-sectional study was conducted from May 2022 to August 2022 in a Health facility among women coming for institutional delivery along with direct observations of the labour room. The study tool comprises a semistructured questionnaire related to respectful maternity care which was adapted from the Person-Centered Maternity Care Scale, a validated instrument. The direct observation method was carried out using a checklist adapted from a standardized tool developed by the United States Agency for International Development (USAID). Descriptive statistics were generated and approval of the study was obtained from the Institutional Ethics Committee.

Results

A total of 336 (99.1%) women reported at least one form of disrespect or abuse during childbirth. Maximum abuse (91.4%) was reported in the facility and environment domain. Direct observation done on 22 deliveries in the labour room found that 72.7% of the women experienced at least one form of disrespect and abuse. Two (9.1%) women were observed to face physical force or abusive behaviour.

Conclusion

Almost all the women reported at least one form of disrespect or abuse during childbirth. There is a need to improve the health facilities and women need to be treated with dignity and respect as it is being violated according to the findings in many studies as with ours.

Experiences, prevalence and drivers of disrespect and abuse of adolescents during facility-based childbirth in sub-Saharan Africa: a scoping review protocol

INTRODUCTION

Adolescents are more likely to experience disrespect and abuse (D&A) by skilled health personnel during facility-based childbirth. However, research evidence on the experiences, prevalence and drivers of D&A of adolescents in childbirth is limited. We aim to establish research evidence on the experiences, prevalence and drivers of D&A of adolescents during facility-based childbirth in sub-Saharan Africa and identify gaps in the literature to inform future research.

METHODS AND ANALYSIS

The protocol is designed using Arksey and O'Malley's methodological framework and will be reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. We will systematically search to retrieve peer-reviewed articles published in English from 2011 to date in PubMed/Medline, EBSCOhost (Africa Wide Information, CINAHL, PsycINFO and SocINDEX), Web of Science (SciELO Citation Index and Web of Science Core Collection) and Scopus. Two independent reviewers will screen the references by titles, abstracts and full texts. Discrepancies in screening results will be resolved through discussions. Key elements of included studies will be charted using a predetermined tool. We will perform numerical analysis and synthesis of narrative accounts of the extent, nature and distribution of review studies.

ETHICS AND DISSEMINATION

No ethical approval is required since the scoping review will use openly available public data and information. Review findings will be disseminated at conferences and published in peer-reviewed journals. No protocol registration is required.

A critical review: developing a birth integrity framework for epidemiological studies through meta-ethnography

Over the past decade, there has been growing evidence that women worldwide experience sub-standard care during facility-based childbirth. With this critical review, we synthesize concepts and measurement approaches used to assess maternity care conditions and provision, birth experiences and perceptions in epidemiological, quantitative research studies (e.g., obstetric violence, maternal satisfaction, disrespect or mistreatment during childbirth, person-centered care), aiming to propose an umbrella concept and framework under which the existing and future research strands can be situated. On the 82 studies included, we conduct a meta-ethnography (ME) using reciprocal translation, in-line argumentation, and higher-level synthesis to propose the birth integrity multilevel framework. We perform ME steps for the conceptual level and the measurement level. At the conceptual level, we organize the studies according to the similarity of approaches into clusters and derive key concepts (definitions). Then, we 'translate' the clusters into one another by elaborating each approach's specific angle and pointing out the affinities and differences between the clusters. Finally, we present an in-line argumentation that prepares ground for the synthesis. At the measurement level, we identify themes from items through content analysis, then organize themes into 14 categories and subthemes. Finally, we synthesize our result to the six-field, macro-to-micro level birth integrity framework that helps to analytically distinguish between the interwoven contributing factors that influence the birth situation as such and the integrity of those giving birth. The framework can guide survey development, interviews, or interventional studies.

Comparing observed occurrence of mistreatment during childbirth with women's self-report: a validation study in Ghana, Guinea and Nigeria

BACKGROUND

There has been substantial progress in developing approaches to measure mistreatment of women during childbirth. However, less is known about the differences in measurement approaches. In this study, we compare measures of mistreatment obtained from the same women using labour observations and community-based surveys in Ghana, Guinea and Nigeria.

METHODS

Experiences of mistreatment during childbirth are person-centred quality measures. As such, we assessed individual-level and population-level accuracy of labour observation relative to women's self-report for different types of mistreatment. We calculated sensitivity, specificity, percent agreement and population-level inflation factor (IF), assessing prevalence of mistreatment in labour observation divided by 'true' prevalence in women's self-report. We report the IF degree of bias as: low (0.75

RESULTS

1536 women across Ghana (n=779), Guinea (n=425) and Nigeria (n=332) were included. Most mistreatment items demonstrated better specificity than sensitivity: observation of any physical abuse (44% sensitive, 89% specific), any verbal abuse (61% sensitive, 73% specific) and presence of a labour companion (19% sensitive, 93% specific). Items for stigma (IF 0.16), pain relief requested (IF 0.38), companion present (IF 0.32) and lack of easy access to fluids (IF 0.46) showed high risk of bias, meaning labour observations would substantially underestimate true prevalence. Other items showed low or moderate bias.

CONCLUSION

Using self-report as the reference standard, labour observations demonstrated moderate-to-high specificity (accurately identifying lack of mistreatment) but low-to-moderate sensitivity (accurately identifying presence of mistreatment) among women. For overall prevalence, either women's self-report or observations can be used with low-moderate bias for most mistreatment items. However, given the dynamicity, complexity, and limitations in 'objectivity', some experiences of mistreatment (stigma, pain relief, labour companionship, easy access to fluids) require measurement via women's self-report. More work is needed to understand how subjectivity influences how well a measure represents individual's experiences.

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Key Words

• cross-sectional survey
• maternal health
• public health

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MESH Headings

• Female
• Humans
• Pregnancy
• Self Report
• Ghana
• Guinea/epidemiology
• Nigeria
• Parturition
• Pain

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Grants

• 001 World Health Organization
• UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training
• United States Agency for International Development (USAID)

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Affiliation(s)

Hedieh Mehrtash Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland Department of Global Health, University of Washington School of Public Health, Seattle, Washington, USA
Meghan A Bohren Gender and Women's Health Unit, Nossal Institute for Global Health, University of Melbourne, Melbourne, Victoria, Australia
Kwame Adu-Bonsaffoh Department of Obstetrics and Gynecology, University of Ghana Medical School, Accra, Ghana
Theresa Azonima Irinyenikan Department of Obstetrics and Gynaecology, University of Medical Sciences Teaching Hospital, Akure, Nigeria
Blair O Berger Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
Ernest Maya Department of Population Health, School of Public Health, University of Ghana, Accra, Ghana
Mamadou Dioulde Balde Cellulle de Recherche en Sante de la Reproduction en Guinee (CERREGUI), Conakry, Guinea
Thae Maung Maung Department of Medical Research, Ministry of Health and Sports, Yangon, Myanmar
Adeniyi Kolade Aderoba National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK Department of Obstetrics and Gynaecology, Mother and Child Hospital Akure, Akure, Nigeria
Özge Tuncalp Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
Hannah H Leslie Division of Prevention Science, University of California San Francisco, San Francisco, California, USA

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Disrespect and abuse during childbirth and postpartum depression: a scoping review

This study aims to map, within the scientific literature, the relationship between disrespect and abuse during childbirth and the occurrence of postpartum depression. This is a scoping review designed in accordance with the recommendations of the Joanna Briggs Institute. The search was performed in Embase, LILACS, MEDLINE, PsycINFO, Web of Science, and in the CAPES Portal of Theses and Dissertations. We included studies that investigated the relationship between disrespect and abuse during childbirth with postpartum depression, considering cases diagnosed by physicians and by self-reports via validated scales, without restrictions regarding the year of publication and language. A total of 3,399 publications were identified and, after removing the duplicates and reading the title, abstracts, and the full-texts, seven articles were selected to integrate this review. Studies were published from 2017 onward, in four countries. Women who had experienced disrespect and abuse during childbirth were more likely to experience symptoms of postpartum depression. A standard terminology is necessary for disrespectful and abusive care during childbirth, as well as the elaboration of a measurement instrument that is universally accepted.

Postnatal women's perception on person-centered maternity care in twin cities of Rawalpindi and Islamabad: a descriptive study

BACKGROUND

Person-Centered Maternity Care (PCMC) is known as one of the most important components of maternal care. Every woman has the ultimate right of respectful health care. Previous research documents that lack of supportive care and respectful behavior experienced by pregnant women can act as a barrier to the utilization of health care services. Few studies have used PCMC tool to document this phenomenon. The objective of this descriptive study was to assess the women's perception of PCMC in Pakistan.

METHODS

Three hundred and seventy-seven (377) postnatal women of ages 18-49 years participated in the research. The study sites were secondary and tertiary care hospitals located in the twin cities of Rawalpindi and Islamabad. The PCMC tool used in this study is a validated scale with three sub-domains of i) communication and autonomy, ii) supportive care, and iii) dignity and respect. Data was analyzed using SPSS version 16, and descriptive and bivariate analysis was undertaken.

RESULTS

The PCMC mean score was 54 ± [10.7] out of 90. About half (55%) of women had good perception of PCMC. Sub-domain of supportive care scored the lowest as compared to the other two domains. Overall, 36% women reported physical abuse while 22% reported verbal abuse at the hands of the healthcare providers. Most of the women (88%) said that health providers did not introduce themselves. About 30% women claimed that health care providers never asked for permission before doing any medical procedures and 20% of women claimed that doctors did not describe the purpose of examination while 178 (47%) of women said that health provider explained the purpose of medications all the time, additionally, about 14% were never given the choice to ask questions.

CONCLUSION

The study concluded that the majority of postnatal women perceived that they were not getting optimum Person-Centered Maternity Care. Some core aspects in supportive care domain were missing. In order to improve the quality of hospital-based childbirths, efforts are needed to improve the quality of care.

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

Background

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

Methods

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

Results

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

Conclusions

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

The prevalence of respectful maternity care during childbirth and its determinants in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Respectful maternity care is the provision of woman-centered health care during childbirth that is friendly, abuse-free, timely, and discrimination-free. Although several epidemiological studies on the magnitude and determinants of Respectful maternity care in Ethiopia have been conducted, the results have been inconsistent and varied. This makes drawing equivocal conclusions and evidence at the national level harder. Hence, this systematic review and meta-analysis aimed at estimating the pooled prevalence of respectful maternity care and its determinants in Ethiopia.

METHODS

Studies conducted from 2013 to June 30, 2022, were searched by using PubMed, Google Scholar, Science Direct, Scopus, ProQuest, Web of Science, Cochrane Library, and Direct of Open Access Journals. Searching was carried out from May 15- June 30, 2022. In total, sixteen studies were considered in the final analysis. The data were extracted using Microsoft Excel and analyzed using STATA 16 software. The methodological quality of included studies was assessed by using Joanna Briggs Institute's critical appraisal checklist for prevalence studies. To estimate the pooled national prevalence of respectful maternity care, a random effect model with a DerSimonian Laird method was used. To assess the heterogeneity of the included studies, the Cochrane Q test statistics and I2 tests were used. To detect the presence of publication bias, a funnel plot and Begg's and Egger's tests were used.

RESULTS

Sixteen studies were eligible for this systematic review and meta-analysis with a total of 6354 study participants. The overall pooled prevalence of respectful maternity care in Ethiopia was 48.44% (95% CI: 39.02-57.87). Receiving service by CRC-trained health care providers [AOR: 4.09, 95% CI: 1.73, 6.44], having ANC visits [AOR: 2.34, 95% CI: 1.62, 3.06], planning status of the pregnancy [AOR = 4.43, 95% CI: 2.74, 6.12], giving birth during the daytime [AOR: 2.61, 95% CI: 1.92, 3.31], and experiencing an obstetric complication[AOR: 0.46, 95% CI: 0.30, 0.61] were identified as determinants of RMC.

CONCLUSION

As per this meta-analysis, the prevalence of respectful maternity care in Ethiopia was low. Managers in the health sector should give due emphasis to the provision of Compassionate, Respectful, and Care(CRC) training for healthcare providers, who work at maternity service delivery points. Stakeholders need to work to increase the uptake of prenatal care to improve client-provider relationships across a continuum of care. Human resource managers should assign an adequate number of health care providers to the night-shift duties to reduce the workload on obstetric providers.

Measurement of respectful maternity care in exit interviews following facility childbirth: a criterion validity assessment in Nigeria

Background

Valid methods for assessing women’s experiences of maternity care are essential to the global efforts toward providing positive childbirth environments for all women in all health facilities.

Methods

This criterion validity study used observation of childbirth as the reference standard compared to exit interviews with women upon discharge with a live baby, usually within 24 hours of childbirth. We investigated eight positive and sixteen negative maternity care experience indicators. Data were collected from ten primary healthcare facilities in Gombe State, northeast Nigeria, in August 2018 and August 2019. Data analysis involved tabulation of demographic characteristics of women and childbirth context, computation of individual level validity metrics including the area under the receiver operating curve (AUC) and estimating population level validity using the inflation factor (IF).

Results

A total of 724 women were observed and interviewed at the time of discharge (exit) following facility childbirth, 15% of whom were adolescents, 99% were married, 43% had no formal education, and a skilled birth attendant had attended only 12%. The prevalence of positive maternity care experience indicators ranged between 25% and 96% in childbirth observations. For these positive indicators, the agreement between childbirth observations and exit interviews ranged from 55% to 97%. Six of the eight positive maternity care experience indicators had high overall validity, meaning AUC≥0.70 and 0.75<IF<1.25, with high sensitivity (89% to 99%) and moderate to high specificity (44% to 84%). The prevalence of the 16 negative maternity care experience indicators ranged between 0.1% and 18% in childbirth observations. For these negative indicators, agreement ranged from 87% to 99%. Just six of the 16 negative maternity care experience indicators met the criteria for validation analysis; and these showed low to moderate sensitivity (32% to 74%), high specificity (97% to 100%) and moderate (0.60<AUC<0.70) to high (AUC≥0.70) individual-level validity.

Conclusions

In this high mortality setting with relatively low coverage of skilled attendance at birth, exit interviews with women following facility-based childbirth care provided responses consistent with the observation of childbirth for eight positive and six negative maternity care experience indicators.

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.

Implementing Professional Midwife-Led Maternity Care in India for Healthy Pregnant Women: A Community Case Study

More women and neonates die each year in India than in almost every other country of the world. Since 1947, India has in principle provided free medical maternal health care to all pregnant and childbearing women. Although rates of maternal and neonatal deaths have fallen since the 1990s, major inequalities remain. Some Indian States have very high rates of interventions, (e.g., cesarean section), while others have intervention and care rates that are too low. Disrespectful treatment of women in labor and lack of evidence-based practice have also been reported. The World Health Organization and others have strongly recommended that professional midwives (trained in a woman-centered philosophy and to international standards) have a key role for reducing mortality and morbidity, minimizing unnecessary interventions in pregnancy and labor, and improving maternal care quality in low- and medium-income countries. This paper provides a community case-report of the first professional midwifery programme in India designed to international standards, implemented in 2011 in Hyderabad. We describe the design and implementation in the programme's first eleven years, as a basis for further scale-up and testing in India, and in other low- or medium-income countries. The ultimate aim is to improve maternal care quality, choice and outcomes in India and in similar socio-economic and cultural settings.

Respectful delivery care and associated factors among mothers delivered in public health facilities of Dessie city, Northeast Ethiopia: a cross-sectional study

Background

The government of Ethiopia has been implementing compassionate, respectful, and caring strategies to increase institutional delivery and decrease maternal mortality in recent years. There is limited evidence on respectful delivery care and associated factors in low-income countries like Ethiopia. Therefore, this study aimed to assess the proportion of respectful delivery care and associated factors among mothers delivered in the health facilities of Dessie city, Northeast Ethiopia.

Methods

A health facility-based cross-sectional study was conducted among a total of 390 mothers from April 16 to May 30, 2018. A pretested structured interviewer-administered questionnaire was used to collect the data. The data were entered into Epidata and analyzed using Stata/SE 14. Binary logistic regression analysis was used to identify associated factors. Variables having P-value less than 0.2 in the bivariable regression were selected as a candidate for multi-variable regression. Adjusted odds ratio (AOR) with 95% confidence interval (CI) was estimated to measure the strength and direction of the association respectively.

Results

The proportion of respectful delivery care among mothers delivered in public health facilities of Dessie city was 43.4%, 95% CI (39.1%, 47.6%). It was found to be 34.9% in hospital and 74.1 in health center. Respectful delivery care was associated with day time delivery [AOR = 2.23, 95% CI (1.30, 3.82)], any maternal and/or fetal complications [AOR = 0.50, 95% CI (0.27, 0.94)], gave birth in health center [AOR = 3.22, 95% CI (1.61, 6.46)] and educated mothers [AOR = 2.87, 95% CI (1.18, 7.01)].

Conclusions

The proportion of respectful delivery care in the study area was low as compared to the government emphasis and other works of literature. This study indicated that any maternal and/or newborn complications, daytime delivery, giving birth in a health center, and maternal education were associated with respectful delivery care. Women empowerment through education could be a recalled intervention for respectful care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01713-1.

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.

To call or not to call: exploring the validity of telephone interviews to derive maternal self-reports of experiences with facility childbirth care in northern Nigeria

Background

To institutionalise respectful maternity care, frequent data on the experience of childbirth care is needed by health facility staff and managers. Telephone interviews have been proposed as a low-cost alternative to derive timely and actionable maternal self-reports of experience of care. However, evidence on the validity of telephone interviews for this purpose is limited.

Methods

Eight indicators of positive maternity care experience and 18 indicators of negative maternity care experience were investigated. We compared the responses from exit interviews with women about their childbirth care experience (reference standard) to follow-up telephone interviews with the same women 14 months after childbirth. We calculated individual-level validity metrics including, agreement, sensitivity, specificity, area under the receiver operating characteristic curve (AUC). We compared the characteristics of women included in the telephone follow-up interviews to those from the exit interviews.

Results

Demographic characteristics were similar between the original exit interview group (n=388) and those subsequently reached for telephone interview (n=294). Seven of the eight positive maternity care experience indicators had reported prevalence higher than 50% at both exit and telephone interviews. For these indicators, agreement between the exit and the telephone interviews ranged between 50% and 92%; seven positive indicators met the criteria for validation analysis, but all had an AUC below 0.6. Reported prevalence for 15 of the 18 negative maternity care experience indicators was lower than 5% at exit and telephone interviews. For these 15 indicators, agreement between exit and telephone interview was high at over 80%. Just three negative indicators met the criteria for validation analysis, and all had an AUC below 0.6.

Conclusions

The telephone interviews conducted 14 months after childbirth did not yield results that were consistent with exit interviews conducted at the time of facility discharge. Women’s reports of experience of childbirth care may be influenced by the location of reporting or changes in the recall of experiences of care over time.

Respectful maternity care among laboring women in public hospitals of Benishangul Gumuz Region, Ethiopia: A mixed cross-sectional study with direct observations

Objectives:

Promoting respectful maternity care is a fundamental strategy for enhancing facility birth, which significantly reduces maternal and newborn mortality and morbidity. Despite these effects, disrespect and abusive childbirth care remain a challenge in Ethiopia. Therefore, this study aimed to determine the prevalence of respectful maternity care and its associated factors among laboring women in public hospitals of Benishangul Gumuz region, Ethiopia.

Methods:

A facility-based cross-sectional study design was employed, and trained external assessors observed the care provided to 404 laboring women in public hospitals using structured observation checklists. A focus group discussion and two key informant interviews were also conducted. A structured pre-tested questionnaire and a semi-structured guide were used to generate quantitative and qualitative data, respectively. Seven verification criteria were employed, and the mean value and above for each criterion were used to measure respectful maternity care.

Results:

Of the 404 client–provider interaction observations during childbirth, only 12.6% ( n = 51) participants received respectful maternity care. Being from an urban area (adjusted odds ratio = 3.34, 95% confidence interval: 1.39, 8.08), giving childbirth at daytime (adjusted odds ratio = 2.59, 95% confidence interval: 1.26, 5.33), receiving the service from compassionate and respectful care trained provider (adjusted odds ratio = 4.54, 95% confidence interval: 1.63, 12.66), giving childbirth at general hospital (adjusted odds ratio = 3.03, 95% confidence interval: 1.39, 6.65) were positively associated with respectful maternity care. Staff workload, shortage of supply and equipment, partiality in providing timely care, yelling and insulting at clients and birth companions were also barriers to respectful maternity care.

Conclusion:

The observed respectful maternity care practices were low in the study area. Therefore, the findings of this study suggest that addressing respectful maternity care would require increased compassionate and respectful care trained providers, and sustained efforts to improve access to basic equipment and supply for maternity care with an emphasis on primary hospitals. Tailored interventions aimed at improving respectful maternity care should also target rural residents and nighttime parturients.

Potential of Standard Perinatal Data for Measuring Violation of Birth Integrity

Background: Measuring the phenomenon of violation of birth integrity (vBI) (e.g., obstetric violence) relies in part on the availability and content of maternity care providers' data. The population coverage and linkage possibilities that these data provide make for a yet untapped potential. Although vBI is a complex phenomenon best measured with dedicated instruments, we argue that maternity care providers' data could contribute to enhance our knowledge of the manifestations and frequency of vBI, and allow for analyses across different sub-groups of the population. Looking into the German standardized perinatal data, we investigate which variables are relevant to vBI-related research, and how complete their reporting is.

Methods: First, we analyse state-of-the-art frameworks and recommendations, and, for each vBI-related domain, we search for and list corresponding variables in the perinatal data which could contribute to a better understanding of vBI issues. Second, we use an example and analyse the content of perinatal data obtained between 2013 and 2016 in the context of the BaBi birth cohort study set in Bielefeld, Germany. We use descriptive statistics to assess the completeness of the data.

Results: The vBI-related variables can be classified in three main categories: discrimination based on specific patient socio-demographic attributes (e.g., height and weight to calculate BMI before pregnancy, foreign origin), indication for medical interventions (i.e., medicalization-related variables: indication for cesarean sections and induction), and supportive care, in particular the mobilization dimension (e.g., continuous fetal heartbeat monitoring). The data analyses included 876 births, of which 601 were vaginal birth. We found poor reporting on demographic variables in terms of completeness. Medicalization and mobilization variables are better documented, although limited in scope.

Conclusions: Putting more emphasis on the completeness of standardized data could increase their potential for vBI-related research. Perinatal data alone are insufficient to assess vBI, but a broader, theory-informed discussion of indicators to be included in standardized datasets would contribute to capturing the different aspects of integrity violation in a more systematic way and expand the evidence-base on different types of vBI.

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.

Presence of birth companion-a deterrent to disrespectful behaviours towards women during delivery: an exploratory mixed-method study in 18 public hospitals of India

Birthing women require support, particularly emotional support, during the process of labour and delivery. Traditionally, across cultures, this support was made available by the continuous presence of a companion during labour, childbirth and the immediate post-partum period. However, this practice is not universal, especially in health facilities in low- and middle-income countries. This cross-sectional study was conducted in 18 tertiary health care facilities of India using a mixed-method approach. The quantitative data were collected to document the number of birthing women, birth companions and healthcare providers in the labour rooms, and the typology of disrespect and abuse (D&A) faced by women. This was followed by in-depth interviews with 55 providers to understand their perspective on the various dimensions of D&A and the challenges they face to provide respectful care. This article explores the status of birth companionship in India and its plausible associations with D&A faced by birthing women in public facilities. Our study reveals that birth companionship is still not a common practice in Indian public hospitals. Birth companions were present during less than half of the observational period, also less than half of the birthing women were accompanied by a birth companion. Lack of hospital policy, space constraints, overcrowding and privacy concerns for other patients were cited as reasons for not allowing birth companions in the labour rooms, whose supportive roles, both for women and providers, were otherwise widely acknowledged during the qualitative interviews. Also, the presence of birth companions was found to be critically negatively associated with occurrences of D&A of birthing women. We contend that owing to the high pressure on the public hospitals in India, birth companions can be a low-cost intervention model for promoting respectful maternity care. However, adequate infrastructure is a critical aspect to be taken care of.

Women's report of mistreatment during facility-based childbirth: validity and reliability of community survey measures

Background

Accountability for mistreatment during facility-based childbirth requires valid tools to measure and compare birth experiences. We analyse the WHO ‘How women are treated during facility-based childbirth’ community survey to test whether items mapping the typology of mistreatment function as scales and to create brief item sets to capture mistreatment by domain.

Methods

The cross-sectional community survey was conducted at up to 8 weeks post partum among women giving birth at hospitals in Ghana, Guinea, Myanmar and Nigeria. The survey contained items assessing physical abuse, verbal abuse, stigma, failure to meet professional standards, poor rapport with healthcare workers, and health system conditions and constraints. For all domains except stigma, we applied item-response theory to assess item fit and correlation within domain. We tested shortened sets of survey items for sensitivity in detecting mistreatment by domain. Where items show concordance and scale reliability ≥0.60, we assessed convergent validity with dissatisfaction with care and agreement of scale scores between brief and full versions.

Results

2672 women answered over 70 items on mistreatment during childbirth. Reliability exceeded 0.60 in all countries for items on poor rapport with healthcare workers and in three countries for items on failure to meet professional standards; brief scales generally showed high agreement with longer versions and correlation with dissatisfaction. Brief item sets were ≥85% sensitive in detecting mistreatment in each country, over 90% for domains of physical abuse and health system conditions and constraints.

Conclusion

Brief scales to measure two domains of mistreatment are largely comparable with longer versions and can be informative for these four distinct settings. Brief item sets efficiently captured prevalence of mistreatment in the five domains analysed; stigma items can be used and adapted in full. Item sets are suitable for confirmation by context and implementation to increase accountability and inform efforts to eliminate mistreatment during childbirth.

Development of measures for assessing mistreatment of women during facility-based childbirth based on labour observations

INTRODUCTION

Mistreatment of women during childbirth is increasingly recognised as a significant issue globally. Research and programmatic efforts targeting this phenomenon have been limited by a lack of validated measurement tools. This study aimed to develop a set of concise, valid and reliable multidimensional measures for mistreatment using labour observations applicable across multiple settings.

METHODS

Data from continuous labour observations of 1974 women in Nigeria (n=407), Ghana (n=912) and Guinea (n=655) were used from the cross-sectional WHO's multicountry study 'How women are treated during facility-based childbirth' (2016-2018). Exploratory factor analysis was conducted to develop a scale measuring interpersonal abuse. Two indexes were developed through a modified Organisation for Economic Co-operation and Development approach for generating composite indexes. Measures were evaluated for performance, validity and internal reliability.

RESULTS

Three mistreatment measures were developed: a 7-item Interpersonal Abuse Scale, a 3-item Exams & Procedures Index and a 12-item Unsupportive Birth Environment Index. Factor analysis results showed a consistent unidimensional factor structure for the Interpersonal Abuse Scale in all three countries based on factor loadings and interitem correlations, indicating good structural construct validity. The scale had a reliability coefficient of 0.71 in Nigeria and approached 0.60 in Ghana and Guinea. Low correlations (Spearman correlation range: -0.06-0.19; p≥0.05) between mistreatment measures supported our decision to develop three separate measures. Predictive criterion validation yielded mixed results across countries. Both items within measures and measure scores were internally consistent across countries; each item co-occurred with other items in a measure, and scores consistently distinguished between 'high' and 'low' mistreatment levels.

CONCLUSION

The set of concise, comprehensive multidimensional measures of mistreatment can be used in future research and quality improvement initiatives targeting mistreatment to quantify burden, identify risk factors and determine its impact on health and well-being outcomes. Further validation and reliability testing of the measures in other contexts is needed.

The prevalence of uterine fundal pressure during the second stage of labour for women giving birth in health facilities: a systematic review and meta-analysis

BACKGROUND

Uterine fundal pressure involves a birth attendant pushing on the woman's uterine fundus to assist vaginal birth. It is used in some clinical settings, though guidelines recommend against it. This systematic review aimed to determine the prevalence of uterine fundal pressure during the second stage of labour for women giving birth vaginally at health facilities.

METHODS

The population of interest were women who experienced labour in a health facility and in whom vaginal birth was anticipated. The primary outcome was the use of fundal pressure during second stage of labour. MEDLINE, EMBASE, CINAHL and Global Index Medicus databases were searched for eligible studies published from 1 January 2000 onwards. Meta-analysis was conducted to determine a pooled prevalence, with subgroup analyses to explore heterogeneity.

RESULTS

Eighty data sets from 76 studies (n = 898,544 women) were included, reporting data from 22 countries. The prevalence of fundal pressure ranged from 0.6% to 69.2% between studies, with a pooled prevalence of 23.2% (95% CI 19.4-27.0, I2 = 99.97%). There were significant differences in prevalence between country income level (p < 0.001, prevalence highest in lower-middle income countries) and method of measuring use of fundal pressure (p = 0.001, prevalence highest in studies that measured fundal pressure based on women's self-report).

CONCLUSIONS

The use of uterine fundal pressure on women during vaginal birth in health facilities is widespread. Efforts to prevent this potentially unnecessary and harmful practice are needed.

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..

Person-centered maternity care and postnatal health: associations with maternal and newborn health outcomes

BACKGROUND

Limited evidence exists on how women's experiences of care, specifically person-centered maternity care during childbirth, influence maternal and newborn health outcomes.

OBJECTIVE

This study aimed to examine the associations between person-centered maternity care and maternal and newborn health outcomes.

STUDY DESIGN

Longitudinal data were collected with 1014 women who completed baseline at a health facility and followed up at 2 weeks and 10 weeks after birth. A validated 30-item person-centered maternity care scale was administered to postpartum women within 48 hours after childbirth. The person-centered maternity care scale has 3 subscales: dignity and respect, communication and autonomy, and supportive care. Bivariate and multivariable log Poisson regressions were used to examine the relationship between person-centered maternity care and reported maternal complications, newborn complications, postpartum depression, postpartum family planning uptake, exclusive breastfeeding, and newborn immunizations.

RESULTS

Controlling for demographic characteristics, women with high total person-centered maternity care score at baseline had significantly lower risk of reporting maternal complications (adjusted relative risk, 0.63; 95% confidence interval, 0.42–0.95), screening positive for depression (adjusted relative risk, 0.55; 95% confidence interval, 0.38–0.81), and reporting newborn complications (adjusted relative risk, 0.74; 95% confidence interval, 0.56–0.97), respectively, than women with low total person-centered maternity care scores. Women with high scores on the supportive care subscale had significantly lower risk of reporting maternal and newborn complications than women with low scores on these subscales (adjusted relative risk, 0.52 [95% confidence interval, 0.42–0.65] and 0.74 [95% confidence interval, 0.60–0.91], respectively). Significant associations were found between all 3 subscale scores and screening positive for depression. Women with high total person-centered maternity care scores were also more likely to adopt a family planning method than those with low scores (adjusted relative risk, 1.25; 95% confidence interval, 1.02–1.52). In particular, women with high scores on the communication and autonomy subscale had significantly higher odds of adopting a family planning method than women with low scores (risk ratio, 1.15; 95% confidence interval, 1.08–1.23).

CONCLUSION

Improving person-centered maternity care may improve maternal and newborn health outcomes. Specifically, improving supportive care may decrease the risk of maternal and newborn complications, whereas improving communication and autonomy may increase postpartum family planning uptake.

Providers' perceptions of disrespect and abuse during childbirth: a mixed-methods study in Kenya

Disrespect and abuse during childbirth are violations of women's human rights and an indicator of poor-quality care. Disrespect and abuse during childbirth are widespread, yet data on providers' perspectives on the topic are limited. We examined providers' perspectives on the frequency and drivers of disrespect and abuse during facility-based childbirth in a rural county in Kenya. We used data from a mixed-methods study in a rural county in Western Kenya with 49 maternity providers (32 clinical and 17 non-clinical) in 2016. Providers were asked structured questions on disrespect and abuse, followed by open-ended questions on why certain behaviours were exhibited (or not). Most providers reported that women were often treated with dignity and respect. However, 53% of providers reported ever observing other providers verbally abuse women and 45% reported doing so themselves. Observation of physical abuse was reported by 37% of providers while 35% reported doing so themselves. Drivers of disrespect and abuse included perceptions of women being difficult, stress and burnout, facility culture and lack of accountability, poor facility infrastructure and lack of medicines and supplies, and provider attitudes. Provider bias, training and women's empowerment influenced how different women were treated. We conclude that disrespect and abuse are driven by difficult situations in a health system coupled with a facilitating sociocultural environment. Providers resorted to disrespect and abuse as a means of gaining compliance when they were stressed and feeling helpless. Interventions to address disrespect and abuse need to tackle the multiplicity of contributing factors. These should include empowering providers to deal with difficult situations, develop positive coping mechanisms for stress and address their biases. We also need to change the culture in facilities and strengthen the health systems to address the system-level stressors.

Client-provider interaction: understanding client experience with family planning service providers through the mystery client approach in India

The benefits of employing a rights-based approach in family planning (FP) programmes have made the client's rights to informed choices and quality care an essential part of any such programme. client-provider interaction is one of the critical components of the quality of care (QoC) framework of FP. While several studies have assessed QoC in FP services in India, very few have focused on the in-depth assessment of the interaction between the client and the provider during service delivery. The present study used the mystery client approach to assess the quality of interactions between clients and FP service providers in two of the most populous states of India: Bihar and Uttar Pradesh (UP). Findings highlighted that the providers spent very little time with the clients, gave them information on only one or two FP methods, and rarely talked about possible side-effects of the methods. Furthermore, the providers seemed hesitant to suggest any FP method other than condoms to newly married women. This study concluded that despite being a government priority, the quality of client-provider interaction in these two states was extremely poor.

Abuse and disrespectful care on women during access to antenatal care services and its implications in Ndola and Kitwe health facilities

BACKGROUND

Antenatal care utilization is fundamental in preventing adverse pregnancy and birth outcomes. This paper assessed abuse and disrespectful care on women during access to antenatal care services and its implications in Ndola and Kitwe districts of Zambia.

METHODS

The assessment used a cross-sectional study design with a sample size of 505 women of child bearing age (15-49). Eighteen (18) high volume health facilities were identified as benchmarks for catchment areas (study sites) and using cluster sampling, households within catchment areas of health facilities were sampled. Chi-square and poison regression analysis was performed to ascertain associations between abuse and disrespect and antenatal care utilization.

RESULTS

One third (33%) of the participants attended less than half of the recommended antenatal visits. Results reveal a statistical significant association between; physical abuse (p value = 0.039); not being allowed to assume position of choice during examination (p value = 0.021); not having privacy during examination (p value = 0.006) and antenatal care service utilization. The difference in the logs of expected count on the number of antenatal care visits is expected to be; 0.066 (CI: -0.115,-0.018) unit lower for women who experienced lack of privacy during examinations; 0.067 (CI: -0.131,-0.004) unit lower for women who were discriminated based on specific attributes and 0.067 (CI: -0.120,-0.014) unit lower for women who were left unattended.

CONCLUSION

Abuse and disrespect during antenatal care service impedes demand for health care and service utilization thereby barricading the element of the package of services aimed at improving maternal and newborn health.

Disrespect and abuse of women during the process of childbirth at health facilities in sub-Saharan Africa: a systematic review and meta-analysis

Background

Disrespectful and abusive treatment of women by health care providers during the process of childbirth at health facility is an international problem. There is a lack of data on disrespect and abuse of women during the process of childbirth at health facilities in Sub-Saharan Africa. The purpose of this study was to determine the prevalence of disrespect and abuse of women during the process of childbirth at health facilities in sub-Saharan Africa.

Methods

The PRISMA guideline protocol was followed to write the systematic review and meta-analysis. Published studies were searched from Medline, PubMed, CINAHL, EMBASE, Maternal and infant care, science direct, and PsycINFO. Articles were accessed by three reviewers (ZY, BT and AA) using the following key terms, “attitude of health personnel” AND “delivery obstetrics*/nursing” OR “maternity care” AND “disrespect” OR “abuse” OR “professional misconduct” AND “parturition” AND “prevalence” AND “professional-patient relations” AND “Sub-Saharan Africa”. Additional articles were retrieved by cross referencing of reference. The heterogeneity of studies were weighed using Cochran’s Q test and I² test statistics. Publication bias was assessed by Egger’s test.

Results

Thirty three studies met the inclusion and included in this systematic review and meta–analysis of disrespect and abuse of women during the process of childbirth at health facilities. The pooled prevalence of disrespect and abuse women during the process of childbirth at health facilities in Sub-Saharan Africa was 44.09% (95% CI: 29.94–58.24).Particularly physical abuse was 15.77% (95% CI: 13.38–18.15), non-confidential care was 16.87% (95% CI: 14.49–19.24), abandonment was 16.86% (95% CI: 13.88–19.84) and detention was 4.81% (95% CI: 3.96–5.67).

Conclusion

In this study disrespect and abuse of women during the process of childbirth at health facilities are high compared with other studies, particularly non-confidential care and abandonment his high compared with other studies. This study points out that the ministry of health, health care providers, maternal health experts shall due attention to women’s right during the process of childbirth at health facilities.

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.

Beyond health system contact: measuring and validating quality of childbirth care indicators in primary level facilities of northern Ethiopia

BACKGROUND

Measurement of quality of health care has been largely overlooked and continues to be a major health system bottleneck in monitoring performance and quality to evaluate progress against defined targets for better decision making. Hence, metrics of maternity care are needed to advance from health service contact alone to content of care. We assessed the accuracy of indicators that describe the quality of basic care for childbirth functions both at the individual level as well as at the population level in Northern Ethiopia.

METHODS

A validation study was conducted by comparing women's self-reported coverage of maternal and newborn health interventions during intra-partum and immediate postpartum care received in primary level care facilities of Northern Ethiopia against a gold standard of direct observation by a trained third party (n = 478). Sensitivity, specificity and individual-level reporting accuracy via the area under the receiver operating curve (AUC) and inflation factor (IF) to estimate population-level accuracy for each indicator was applied for validity analysis.

FINDINGS

455(97.5%) of women completed the survey describing health interventions. Thirty-two (43.2%) of the 93-basic quality child birth care indicators that were assessed could be accurately measure at the facility and population level (AUC > 0.60 and 0.75 < IF< 1.25). Few of the valid indicators were: whether women and their companion were greeted respectfully, whether an HIV test was offered, and whether severe bleeding (hemorrhage) was experienced by the woman. An additional 21(28.4%) indicators accurately measure at the facility or individual level, but the indicators under or over estimate at population level. Thirteen other indicators could accurately measure at population level. Eight (8.6%) indicators didn't meet either of the validity criteria.

CONCLUSION

Women were able to accurately report on several indicators of quality for basic child birth care. For those few indicators that required a technical understanding tended to have higher don't know response from the women. Therefore, valid indicators should be included as a potential measurement of quality for the childbirth care process to ensure that essential interventions are delivered.

A Rapid Review of Available Evidence to Inform Indicators for Routine Monitoring and Evaluation of Respectful Maternity Care

BACKGROUND

Some opportunities to routinely capture and improve respectful maternity care (RMC) during facility-based childbirth include quality improvement (QI) initiatives, community-based monitoring efforts through community score cards (CSC), and performance-based financing (PBF) initiatives. But there is limited guidance on which types of RMC indicators are best suited for inclusion in these initiatives. We sought to provide practical evidence-based recommendations on indicators that may be used for routine measurement of RMC in programs.

METHODS

We used a rapid review approach, which included (1) reviewing existing documents and publications to extract RMC indicators and identify which have or can be used in facility-based QI, CSCs, and PBF schemes; (2) surveying RMC and maternal health experts to rank indicators, and (3) analyzing survey data to select the most recommended indicators.

RESULTS

We identified 49 indicators spanning several domains of RMC and mistreatment including dignified/nondignified care, verbal and physical abuse, privacy/confidentiality, autonomy/loss of autonomy, supportive care/lack thereof, communication, stigma, discrimination, trust, facility environment/culture, responsiveness, and nonevidence-based care. Based on the analysis of the survey data, we recommend 33 indicators (between 2 and 6 indicators for each RMC domain) that may be suited for incorporation in both facility-based QI and CSC-related monitoring efforts.

CONCLUSION

Integrating RMC indicators into QI and CSC initiatives, as well as in other maternal and neonatal health programs, could help improve RMC at the facility and community level. More research is needed into whether RMC can be integrated into PBF initiatives. Integration of RMC indicators into programs to improve quality of care and other health system outcomes will facilitate routine monitoring and accountability around experience of care. Measurement and improvement of women's experiences will increase maternal health service utilization and improve quality of care as a means of reducing maternal and neonatal morbidity and mortality.

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.

How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys

BACKGROUND

Women across the world are mistreated during childbirth. We aimed to develop and implement evidence-informed, validated tools to measure mistreatment during childbirth, and report results from a cross-sectional study in four low-income and middle-income countries.

METHODS

We prospectively recruited women aged at least 15 years in twelve health facilities (three per country) in Ghana, Guinea, Myanmar, and Nigeria between Sept 19, 2016, and Jan 18, 2018. Continuous observations of labour and childbirth were done from admission up to 2 h post partum. Surveys were administered by interviewers in the community to women up to 8 weeks post partum. Labour observations were not done in Myanmar. Data were collected on sociodemographics, obstetric history, and experiences of mistreatment.

FINDINGS

2016 labour observations and 2672 surveys were done. 838 (41·6%) of 2016 observed women and 945 (35·4%) of 2672 surveyed women experienced physical or verbal abuse, or stigma or discrimination. Physical and verbal abuse peaked 30 min before birth until 15 min after birth (observation). Many women did not consent for episiotomy (observation: 190 [75·1%] of 253; survey: 295 [56·1%] of 526) or caesarean section (observation: 35 [13·4%] of 261; survey: 52 [10·8%] of 483), despite receiving these procedures. 133 (5·0%) of 2672 women or their babies were detained in the facility because they were unable to pay the bill (survey). Younger age (15-19 years) and lack of education were the primary determinants of mistreatment (survey). For example, younger women with no education (odds ratio [OR] 3·6, 95% CI 1·6-8·0) and younger women with some education (OR 1·6, 1·1-2·3) were more likely to experience verbal abuse, compared with older women (≥30 years), adjusting for marital status and parity.

INTERPRETATION

More than a third of women experienced mistreatment and were particularly vulnerable around the time of birth. Women who were younger and less educated were most at risk, suggesting inequalities in how women are treated during childbirth. Understanding drivers and structural dimensions of mistreatment, including gender and social inequalities, is essential to ensure that interventions adequately account for the broader context.

FUNDING

United States Agency for International Development and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO.

Association between person-centered maternity care and newborn complications in Kenya

OBJECTIVE

Despite the recognized importance of person-centered care, very little information exists on how person-centered maternity care (PCMC) impacts newborn health.

METHODS

Baseline and follow-up data were collected from women who delivered in government health facilities in Nairobi and Kiambu counties in Kenya between August 2016 and February 2017. The final analytic sample included 413 respondents who completed the baseline survey and at least one follow-up survey at 2, 6, 8, and/or 10 weeks. Data were analyzed using descriptive, bivariate, and multivariate statistics. Logistic regression was used to assess the relationship between PCMC scores and outcomes of interest.

RESULTS

In multivariate analyses, women with high PCMC scores were significantly less likely to report newborn complications than women with low PCMC scores (adjusted odds ratio [aOR] 0.39, 95% confidence interval [CI] 0.16-0.98). Women reporting high PCMC scores also had significantly higher odds of reporting a willingness to return to the facility for their next delivery than women with low PCMC score (aOR 12.72, 95% CI 2.26-71.63). The domains of Respect/Dignity and Supportive Care were associated with fewer newborn complications and willingness to return to a facility.

CONCLUSION

PCMC could improve not just the experience of the mother during childbirth, but also the health of her newborn and future health-seeking behavior.

Quality of antenatal care and associated factors in a rural county in Kenya: an assessment of service provision and experience dimensions

Background

This study aimed to assess the quality of antenatal care (ANC) women received in Migori county, Kenya—including both service provision and experience dimensions—and to examine factors associated with each dimension.

Methods

We used survey data collected in 2016 in Migori county from 1031 women aged 15–49 who attended ANC at least once in their most recent pregnancy. ANC quality service provision was measured by nine questions on receipt of recommended ANC services, and experience of care by 18 questions on information, communication, dignity, and facility environment. We summed the responses to the individual items to generate ANC service provision and experience of care scores. We used both linear and logistic regression to examine predictors.

Results

The average service provision score was 10.9 (SD = 2.4) out of a total of 16. Most women received some recommended services once, but not at the frequency recommended by the Kenyan Ministry of Health. About 90% had their blood pressure measured, and 78% had a urine test, but only 58 and 14% reported blood pressure monitoring and urine test, respectively, at every visit. Only 16% received an ultrasound at any time during ANC. The average experience score is 27.3 (SD = 8.2) out of a total score of 42, with key gaps demonstrated in communication. About half of women were not educated on pregnancy complications. Also, about one-third did not often understand the purposes of tests and medicines received and did not feel able to ask questions to the health care provider. In multivariate analysis, women who were literate, employed, and who received all their ANC in a health center had higher experiences scores than women who were illiterate (coefficient = 1.52, CI:0.26,2.79), unemployed (coefficient = 2.73, CI:1.46,4.00), and received some ANC from a hospital (coefficient = 1.99, CI: 0.84, 3.14) respectively. The wealthiest women had two times higher odds of receiving an ultrasound than the poorest women (OR = 2.00, CI:1.20,3.33).

Conclusion

Quality of ANC is suboptimal in both service provision and experience domains, with disparities by demographic and socioeconomic factors and facility type. More efforts are needed to improve quality of ANC and to eliminate the disparities.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4476-4) contains supplementary material, which is available to authorized users.

Disrupting gender norms in health systems: making the case for change

Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.

Person-centred maternity care in low-income and middle-income countries: analysis of data from Kenya, Ghana, and India

BACKGROUND

Several qualitative studies have described disrespectful, abusive, and neglectful treatment of women during facility-based childbirth, but few studies document the extent of person-centred maternity care (PCMC)-ie, responsive and respectful maternity care-in low-income and middle-income countries. In this Article, we present descriptive statistics on PCMC in four settings across three low-income and middle-income countries, and we examine key factors associated with PCMC in each setting.

METHODS

We examined data from four cross-sectional surveys with 3625 women aged 15-49 years who had recently given birth in Kenya, Ghana, and India (surveys were done from August, 2016, to October, 2017). The Kenya data were collected from a rural county (n=877) and from seven health facilities in two urban counties (n=530); the Ghana data were from five rural health facilities in the northern region (n=200); and the India data were from 40 health facilities in Uttar Pradesh (n=2018). The PCMC measure used was a previously validated scale with subscales for dignity and respect, communication and autonomy, and supportive care. We analysed the data using descriptive statistics and bivariate and multivariate regressions to examine predictors of PCMC.

FINDINGS

The highest mean PCMC score was found in urban Kenya (60·2 [SD 12·3] out of 90), and the lowest in rural Ghana (46·5 [6·9]). Across sites, the lowest scores were in communication and autonomy (from 8·3 [3.3] out of 27 in Ghana to 15·1 [5·9] in urban Kenya). 3280 (90%) of the total 3625 women across all countries reported that providers never introduced themselves, and 2076 (57%) women (1475 [73%] of 1980 in India) reported providers never asked permission before performing medical procedures. 120 (60%) of 200 women in Ghana and 1393 (69%) of 1980 women in India reported that providers did not explain the purpose of examinations or procedures, and 116 (58%) women in Ghana and 1162 (58%) in India reported they did not receive explanations on medications they were given; additionally, 104 (52%) women in Ghana did not feel able to ask questions. Overall, 576 (16%) women across all countries reported verbal abuse, and 108 (3%) reported physical abuse. PCMC varied by socioeconomic status and type of facility in three settings (ie, rural and urban Kenya, and India).

INTERPRETATION

Regardless of the setting, women are not getting adequate PCMC. Efforts are needed to improve the quality of facility-based maternity care.

FUNDING

Bill & Melinda Gates Foundation, Marc and Lynne Benioff, and USAID Systems for Health.

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.

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.

Silent voices: institutional disrespect and abuse during delivery among women of Varanasi district, northern India

BACKGROUND

A considerable amount of qualitative evidence reporting abusive treatment of women during delivery by health providers is available. However, there is a dearth of information regarding the actual prevalence and nature of such abuse, which this study aimed to explore.

METHODS

We conducted a community based cross-sectional study using a contextually adapted version of the Staha (meaning 'respect' in Swahili) project questionnaire among 410 rural women who delivered between June, 2014 to August 2015 at any health facility of Varanasi district, northern India. We selected the women through multi-stage cluster random sampling from two rural blocks of Varanasi, which recorded the highest number of institutional deliveries in 2014-15.

RESULTS

The frequency of any abusive behavior (excluding inappropriate demands of money due to its high prevalence-90.5%) was 28.8%. The reported abuses were non-dignified care including verbal abuse and derogatory insults related to the woman's sexual behavior (19.3%); physical abuse (13.4%); neglect or abandonment (8.5%); non-confidential care (5.6%); and feeling humiliation due to lack of cleanliness bordering on filth (4.9%). Women were abused during labor or delivery irrespective of their socio-demographic background. Bivariate analysis using Chi-square tests showed statistically significant associations between abuse and provider type, facility type, and presence of complications during delivery. Binary logistic regression indicated that the odds of being abused was four times higher in those women who experienced complications during delivery. Though statistically insignificant, and contrary to expectations, women also seemed to be abused in private institutions; but with a lower frequency and of lesser severity.

CONCLUSIONS

The prevalence of disrespect and abuse during labor or delivery was high among women irrespective of their socio-demographic background or delivery conditions in government as well as private health facilities. If the problem of disrespect and abuse is not addressed, it can be assumed that such harsh practices might promote home deliveries, which despite being more unsafe provide an empathetic environment in lieu of safe facility-based birthing options.