A critical interpretive synthesis of power and mistreatment of women in maternity care

Women's experiences of facility-based abortion care: A WHO qualitative evidence synthesis

The World Health Organization's Abortion Care Guideline requires abortion care to be not only safe but also effective, efficient, accessible, equitable, acceptable, and person centered. We synthesized qualitative evidence from 111 papers from 42 countries selected from a systematic search of literature published between January 1996 and September 2023. We developed a typology of experiences experienced by abortion seekers engaging with facility-based abortion care services at any stage of the abortion care pathway; factors that modify the experience as well as the consequences of these experiences for the abortion seeker. The resulting typology characterized positive experiences as offering emotional support and protection against harm; mixed experiences of care i.e. care of variable quality but not considered negative; and negative experiences, such as intentionally obstructing women as decision makers; behavior intended to judge, shame, or punish, care lacking in dignity, delay or denial of care and care leading to harm unrelated to the clinical condition. The abortion context, or the woman's personal characteristics exacerbated negative experiences which were often accepted as unactionable or led to seeking alternative types of care. On the other hand, emotionally supportive care decreased internalized stigma, increased confidence, and substituted for lack of social support. The typology provides a basis for determining whether the quality of abortion care aligns with WHO recommendations and provide a basis for bridging the policy -program gap, to improve quality of abortion care and to inform monitoring efforts.

Birthing parent perspectives on measuring the quality of perinatal care: metrics, timing, and process

Objective

Centering birthing parents is critical for improving reproductive health policies and practices. This study investigates patient perspectives on measuring the quality of perinatal care.

Methods

A cross-sectional qualitative research study was conducted at an academic medical center in the Southeastern United States. Individuals who had recently given birth participated in audio-recorded interviews between May 2020 and September 2020. This analysis addresses the research question, "If we were providing quality healthcare for families, how would we know?" Transcribed and translated responses were inductively coded to develop categories and identify themes.

Results

Forty birthing parents participated in the study. Metrics, timing, and process were identified as important components of meaningfully measuring the quality of perinatal care. Recommended metrics included asking patients whether their health priorities were addressed. Additional metrics of importance were whether coping strategies were provided, the clarity of information provided, patient comprehension of health information, the extent to which care planning was collaborative among patients and their healthcare team members, whether clinicians alleviated patient doubts, patient feelings of being taken care of, healthcare team mannerisms, clinician demonstrations of respect for patient autonomy, and postpartum visit attendance. With regard to timing, patients desired that their healthcare team members "check-in" with them as part of an ongoing, direct dialog. Birthing parents also wanted opportunities to provide feedback soon after encounters. As part of a robust measurement process, they wanted to share their insights with someone who was not a part of their healthcare team, for maintaining confidentiality. The patients desired a "serious platform" with accessible methods for all birthing parents to be able to convey nuanced accounts of their care. They also wanted to hear from the healthcare institutions about their feedback. Birthing parents sought assurances for their perinatal care feedback to be de-identified to protect them from potential retaliation. The participants recognized that they might need to utilize healthcare services from the same institution and individuals in the future.

Conclusion

Birthing parents expressed desire for their perinatal healthcare experiences to be understood. Meaningful quality measurement may be promoted through transparent and multimethod opportunities for patients to securely share insights. In addition to healthcare systems communicating assurances of patient confidentiality, institutional feedback in response to patient-reported experiences is recommended.

Global inequities in adverse pregnancy outcomes: what can we do?

The Health Equity Leadership & Exchange Network states that "health equity exists when all people, regardless of race, sex, sexual orientation, disability, socioeconomic status, geographic location, or other societal constructs, have fair and just access, opportunity, and resources to achieve their highest potential for health." It is clear from the wide discrepancies in maternal and infant mortalities, by race, ethnicity, location, and social and economic status, that health equity has not been achieved in pregnancy care. Although the most obvious evidence of inequities is in low-resource settings, inequities also exist in high-resource settings. In this presentation, based on the Global Pregnancy Collaboration Workshop, which addressed this issue, the bases for the differences in outcomes were explored. Several different settings in which inequities exist in high- and low-resource settings were reviewed. Apparent causes include social drivers of health, such as low income, inadequate housing, suboptimal access to clean water, structural racism, and growing maternal healthcare deserts globally. In addition, a question is asked whether maternal health inequities will extend to and be partially due to current research practices. Our overview of inequities provides approaches to resolve these inequities, which are relevant to low- and high-resource settings. Based on the evidence, recommendations have been provided to increase health equity in pregnancy care. Unfortunately, some of these inequities are more amenable to resolution than others. Therefore, continued attention to these inequities and innovative thinking and research to seek solutions to these inequities are encouraged.

"I have to listen to them or they might harm me" and other narratives of why women endure obstetric violence in Bihar, India

BACKGROUND

Evidence suggests that obstetric violence has been prevalent globally and is finally getting some attention through research. This human rights violation takes several forms and is best understood through the narratives of embodied experiences of disrespect and abuse from women and other people who give birth, which is of utmost importance to make efforts in implementing respectful maternity care for a positive birthing experience. This study focused on the drivers of obstetric violence during labor and birth in Bihar, India.

METHODS

Participatory qualitative visual arts-based method of data collection-body mapping-assisted interviews (adapted as birth mapping)-was conducted to understand women's perception of why they are denied respectful maternity care and what makes them vulnerable to obstetric violence during labor and childbirth. This study is embedded in feminist and critical theories that ensure women's narratives are at the center, which was further ensured by the feminist relational discourse analysis. Eight women participated from urban slums and rural villages in Bihar, for 2-4 interactions each, within a week. The data included transcripts, audio files, body maps, birthing stories, and body key, which were analyzed with the help of NVivo 12.

FINDINGS

Women's narratives suggested drivers that determine how they will be treated during labor and birth, or any form of sexual, reproductive, and maternal healthcare seeking presented through the four themes: (1) "I am admitted under your care, so, I will have to do what you say"-Influence of power on care during childbirth; (2) "I was blindfolded … because there were men"-Influence of gender on care during childbirth; (3) "The more money we give the more convenience we get"-Influence of structure on care during childbirth; and (4) "How could I ask him, how it will come out?"-Influence of culture on care during childbirth. How women will be treated in the society and in the obstetric environment is determined by their identity at the intersections of age, class, caste, marital status, religion, education, and many other sociodemographic factors. The issues related to each of these are intertwined and cross-cutting, which made it difficult to draw clear categorizations because the four themes influenced and overlapped with each other. Son preference, for example, is a gender-based issue that is part of certain cultures in a patriarchal structure as a result of power-based imbalance, which makes the women vulnerable to disrespect and abuse when their baby is assigned female at birth.

DISCUSSION

Sensitive unique feminist methods are important to explore and understand women's embodied experiences of trauma and are essential to understand their perspectives of what drives obstetric violence during childbirth. Sensitive methods of research are crucial for the health systems to learn from and embed women's wants, to address this structural challenge with urgency, and to ensure a positive experience of care.

When addressing resources is not enough: lessons learned from a respectful maternal and neonatal care provider training intervention evaluation in Kenya and Tanzania

BACKGROUND

Respectful Maternal and Neonatal Care (RMNC) maintains and respects a pregnant person's dignity, privacy, informed choice, and confidentiality free from harm and mistreatment. It strives for a positive pregnancy and post-pregnancy care experiences for pregnant people and their families, avoiding any form of obstetric violence. Though RMNC is now widely accepted as a priority in obstetric care, there is a gap in resources and support tools for healthcare wproviders to clearly understand the issue and change long-established practices such as non-humanized caesarean sections. MSI Reproductive Choices (MSI) manages 31 maternities across 7 countries with a zero-tolerance approach towards disrespectful maternity care and obstetric violence. MSI developed and implemented a hybrid training package, which includes an online module and 1-day in-person workshop that allows healthcare providers to explore their beliefs and attitudes towards RMNC. It leverages methodologies used in Values-Clarification-Attitudes-Transformation (VCAT) workshops and behaviour change approaches.

METHODS

The impact of this training intervention was measured from the healthcare providers' and patients' perspectives. Patient experience of (dis)respectful care was collected from a cross-sectional survey of antenatal and postnatal patients attending MSI maternities in Kenya and Tanzania before and following the RMNC training intervention. Healthcare providers completed pre- and post-workshop surveys at day 1, 90 and 180 to measure any changes in their knowledge, attitudes and perception of intended behaviours regarding RMNC.

RESULTS

The results demonstrate that healthcare provider knowledge, attitudes and perceived RMNC practices can be improved with this training interventions. Patients also reported a more positive experience of their maternity care following the training.

CONCLUSION

RMNC is a patient-centred care priority in all MSI maternities. The training bridges the gap in resources currently available to support changes in healthcare wproviders' attitudes and behaviours towards provision of RMNC. Ensuring health system infrastructure supports compassionate obstetric care represents only the first step towards ensuring RMNC. The results from the evaluation of this RMNC provider training intervention demonstrates how healthcare provider knowledge and attitudes may represent a bottleneck to ensuring RMNC that can be overcome using VCAT and behaviour change approaches.

Adoption of policies to improve respectful maternity care in Timor-Leste

INTRODUCTION

There are now well-established global standards for supporting improvement in women's experience of maternity services, including frameworks for the prevention of mistreatment during childbirth. To support initiatives to improve the quality of care in maternal health services in Timor-Leste, we examine the adoption of global respectful maternity care standards in the national intrapartum care policy and in three urban birth facilities in Dili.

METHODS

From May to July 2022, we conducted a desk review of the Timor-Leste National Intrapartum Care Standards and Clinical Protocols for Referral Facilities and Community Health Centres. This was followed by a health-facility audit of policies, guidelines and procedures in three main maternity facilities in the capital, Dili to examine the extent to which the WHO (2016) standards for women's experiences of care have been adopted.

RESULTS

Despite the availability of global guidelines, key standards to improve women's experience of care have not been included in the National Intrapartum Care guidelines in Timor-Leste. There was no mention of avoiding mistreatment of women, needing informed consent for procedures, or strengthening women's own capability and confidence. In the policy wording, women tended to be distanced from the care 'procedures' and the protocols could be improved by taking a more woman-centred approach. The results of the health facility assessment showed extremely low use of standards that improve women's experiences of care. Health Facility 1 and 2 met two of the 21 quality measures, while Health Facility 3 met none of them.

CONCLUSION

The discourse communicated through policy fundamentally affects how health care issues are framed and how policies are enacted. Given the findings of this study, combined with previously documented issues around quality of care and low satisfaction with maternal health services, there is a need for a fundamental shift in the culture of care for women. This will require an immediate focus on leadership, training and policy-frameworks to increase respectful care for women in health facilities. It will also require longer-term effort to address the power imbalances that drive mistreatment of women within and across social systems, and to support models of care that inherently foster understanding and compassion.

Strategies to improve interpersonal communication along the continuum of maternal and newborn care: A scoping review and narrative synthesis

Effective interpersonal communication is essential to provide respectful and quality maternal and newborn care (MNC). This scoping review mapped, categorized, and analysed strategies implemented to improve interpersonal communication within MNC up to 42 days after birth. Twelve bibliographic databases were searched for quantitative and qualitative studies that evaluated interventions to improve interpersonal communication between health workers and women, their partners or newborns' families. Eligible studies were published in English between January 1st 2000 and July 1st 2020. In addition, communication studies in reproduction related domains in sexual and reproductive health and rights were included. Data extracted included study design, study population, and details of the communication intervention. Communication strategies were analysed and categorized based on existing conceptualizations of communication goals and interpersonal communication processes. A total of 138 articles were included. These reported on 128 strategies to improve interpersonal communication and were conducted in Europe and North America (n = 85), Sub-Saharan Africa (n = 12), Australia and New Zealand (n = 10), Central and Southern Asia (n = 9), Latin America and the Caribbean (n = 6), Northern Africa and Western Asia (n = 4) and Eastern and South-Eastern Asia (n = 2). Strategies addressed three communication goals: facilitating exchange of information (n = 97), creating a good interpersonal relationship (n = 57), and/or enabling the inclusion of women and partners in the decision making (n = 41). Two main approaches to strengthen interpersonal communication were identified: training health workers (n = 74) and using tools (n = 63). Narrative analysis of these interventions led to an update of an existing communication framework. The categorization of different forms of interpersonal communication strategy can inform the design, implementation and evaluation of communication improvement strategies. While most interventions focused on information provision, incorporating other communication goals (building a relationship, inclusion of women and partners in decision making) could further improve the experience of care for women, their partners and the families of newborns.

"They Tarred Me with the Same Brush": Navigating Stigma in the Context of Child Removal

Child removals are increasing in England and Wales. Family court involvement is particularly common among women with multiple disadvantages, and the rates are higher in economically marginalised areas. This article aims to explore women's narratives of child removal within life stories of homelessness and examines how stigma, power and State surveillance manifest in their experiences. Data drawn from qualitative interviews with 14 mothers in the north-east of England who had experienced the removal of their children through the family courts are explored within the wider context of a neoliberal political agenda of "troubled families", and in particular, "deviant mothers". The participants describe how stigma structured their interactions with social services. Despite the known poor outcomes associated with child removal for both mothers and children, professional involvement often tapers off afterwards, with little support for mothers. Drawing on women's accounts, we seek to illuminate their experiences of child removal and enhance our understanding of how stigma plays out in statutory settings, further entrenching social exclusion and ultimately increasing health inequalities.

Women's perspectives on disrespect and abuse during facility-based childbirth in Ethiopia: a qualitative study

BACKGROUND

Disrespect and abuse violates women's basic human rights and autonomy and can traumatize women who are already in a vulnerable position during childbirth and deter them from utilizing skilled care for future childbirth. This study explored women's perspectives on the acceptability of disrespect and abuse during facility-based childbirth in Ethiopia.

METHODS

A qualitative descriptive design using five focus group discussions and fifteen in-depth, semi-structured, interviews was conducted with women between October 2019 to January 2020 in north Showa zone of Oromia region, central Ethiopia. Using purposive sampling, women who had given birth at public health facilities of North Showa zone during the twelve months preceding data collection were recruited, regardless of birth outcome. Inductive thematic analysis using Open Code software was used to explore the perspectives of participants.

RESULTS

While women reject disrespectful and abusive acts during childbirth generally, they may consider some disrespectful acts as acceptable and or necessary under certain circumstances. Four emerging themes were identified. (1) Disrespect and abuse is not acceptable, (2) Disrespectful and abusive actions are acceptable only if intended to save lives, (3) Disrespectful and abusive actions are an accepted part of everyday practice to prevent complications and adverse outcomes, (4) Disrespectful and abusive actions are necessary to discipline disobedient women.

CONCLUSION

Women's perceptions of disrespectful and abusive acts of care providers is deeply rooted within the context of violence in Ethiopia and the societal hierarchies that have systematically disempowered women. Given the pervasiveness of disrespect and abusive actions during childbirth, policymakers, clinical managers and care providers must take these essential contextual and societal norms into account and devise comprehensive clinical interventions that addresses the root causes.

Theories for interventions to reduce physical and verbal abuse: A mixed methods review of the health and social care literature to inform future maternity care

Despite global attention, physical and verbal abuse remains prevalent in maternity and newborn healthcare. We aimed to establish theoretical principles for interventions to reduce such abuse. We undertook a mixed methods systematic review of health and social care literature (MEDLINE, SocINDEX, Global Index Medicus, CINAHL, Cochrane Library, Sept 29th 2020 and March 22nd 2022: no date or language restrictions). Papers that included theory were analysed narratively. Those with suitable outcome measures were meta-analysed. We used convergence results synthesis to integrate findings. In September 2020, 193 papers were retained (17,628 hits). 154 provided theoretical explanations; 38 were controlled studies. The update generated 39 studies (2695 hits), plus five from reference lists (12 controlled studies). A wide range of explicit and implicit theories were proposed. Eleven non-maternity controlled studies could be meta-analysed, but only for physical restraint, showing little intervention effect. Most interventions were multi-component. Synthesis suggests that a combination of systems level and behavioural change models might be effective. The maternity intervention studies could all be mapped to this approach. Two particular adverse contexts emerged; social normalisation of violence across the socio-ecological system, especially for 'othered' groups; and the belief that mistreatment is necessary to minimise clinical harm. The ethos and therefore the expression of mistreatment at each level of the system is moderated by the individuals who enact the system, through what they feel they can control, what is socially normal, and what benefits them in that context. Interventions to reduce verbal and physical abuse in maternity care should be locally tailored, and informed by theories encompassing all socio-ecological levels, and the psychological and emotional responses of individuals working within them. Attention should be paid to social normalisation of violence against 'othered' groups, and to the belief that intrapartum maternal mistreatment can optimise safe outcomes.