From Home to Hospital: Mistreatment of Childbearing Women and Barriers to Facility-Based Birth in Nicaragua

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

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

Reinforcing marginality? Maternal health interventions in rural Nicaragua

To achieve Millennium Development Goal 5 on maternal health, many countries have focused on marginalized women who lack access to care. Promoting facility-based deliveries to ensure skilled birth attendance and emergency obstetric care has become a main measure for preventing maternal deaths, so women who opt for home births are often considered 'marginal' and in need of targeted intervention. Drawing upon ethnographic data from Nicaragua, this paper critically examines the concept of marginality in the context of official efforts to increase institutional delivery amongst the rural poor, and discusses lack of access to health services among women living in peripheral areas as a process of marginalization. The promotion of facility birth as the new norm, in turn, generates a process of 're-marginalization', whereby public health officials morally disapprove of women who give birth at home, viewing them as non-compliers and a problem to the system. In rural Nicaragua, there is a discrepancy between the public health norm and women's own preferences and desires for home birth. These women live at the margins also in spatial and societal terms, and must relate to a health system they find incapable of providing good, appropriate care. Strong public pressure for institutional delivery makes them feel distressed and pressured. Paradoxically then, the aim of including marginal groups in maternal health programmes engenders resistance to facility birth.

Abuse and discrimination towards indigenous people in public health care facilities: experiences from rural Guatemala

Background

Health inequalities disproportionally affect indigenous people in Guatemala. Previous studies have noted that the disadvantageous situation of indigenous people is the result of complex and structural elements such as social exclusion, racism and discrimination. These elements need to be addressed in order to tackle the social determinants of health. This research was part of a larger participatory collaboration between Centro de Estudios para la Equidad y Gobernanza en los Servicios de Salud (CEGSS) and community based organizations aiming to implement social accountability in rural indigenous municipalities of Guatemala. Discrimination while seeking health care services in public facilities was ranked among the top three problems by communities and that should be addressed in the social accountability intervention. This study aimed to understand and categorize the episodes of discrimination as reported by indigenous communities.

Methods

A participatory approach was used, involving CEGSS’s researchers and field staff and community leaders. One focus group in one rural village of 13 different municipalities was implemented. Focus groups were aimed at identifying instances of mistreatment in health care services and documenting the account of those who were affected or who witnessed them. All of the 132 obtained episodes were transcribed and scrutinized using a thematic analysis.

Results

Episodes described by participants ranged from indifference to violence (psychological, symbolic, and physical), including coercion, mockery, deception and racism. Different expressions of discrimination and mistreatment associated to poverty, language barriers, gender, ethnicity and social class were narrated by participants.

Conclusions

Addressing mistreatment in public health settings will involve tackling the prevalent forms of discrimination, including racism. This will likely require profound, complex and sustained interventions at the programmatic and policy levels beyond the strict realm of public health services. Future studies should assess the magnitude of the occurrence of episodes of maltreatment and racism within indigenous areas and also explore the providers’ perceptions about the problem.

Female migrants, family members and community socio-demographic characteristics influence facility delivery in Rufiji, Tanzania

BACKGROUND

Health professionals and public health experts in maternal and newborn health encourage women to deliver at health facilities in an effort to reduce maternal and newborn mortality. In the existing literature, there is scant information on how migration, family members and community influence facility delivery. This study addresses this knowledge gap using 10 years of longitudinal surveillance data from a rural district of Tanzania.

METHODS

Multilevel logistic regression was used to quantify the influence of hypothesized migration, family and community-level factors on facility delivery while adjusting for known confounders identified in the literature. We report adjusted odds ratios (AOR).

RESULTS

Overall, there has been an increase of 14% in facility delivery over the ten years, from 63% in 2001 to 77% in 2010 (p < .001). Women residing in households with female migrants from outside their community were more likely to give birth in a facility AOR = 1.2 (95% CI 1.11-1.29). Furthermore, the previous facility delivery of sisters and sisters-in-law has a significant influence on women's facility delivery; AOR = 1.29, 95% CI 1.15-1.45 and AOR = 1.7, 95% CI 1.35-2.13 respectively. Community level characteristics play a role as well; women in communities with higher socioeconomic status and older women of reproductive age had increased odds of facility delivery; AOR = 2.37, 95% CI 1.88-2.98 and AOR = 1.17, 95% CI 1.03-1.32 respectively.

CONCLUSION

Although there has been an increase in facility delivery over the last decade in Rufiji, this study underscores the importance of female migrants, family members and community in influencing women's place of delivery. The findings of this study suggest that future interventions designed to increase facility delivery must integrate person-to-person facility delivery promotion, especially through women of the community and within families. Furthermore, the results suggest that investment in formal education of the community and increased community socio-economic status may increase facility delivery.

Experiences of and responses to disrespectful maternity care and abuse during childbirth; a qualitative study with women and men in Morogoro Region, Tanzania

Background

Interventions to reduce maternal mortality have focused on delivery in facilities, yet in many low-resource settings rates of facility-based birth have remained persistently low. In Tanzania, rates of facility delivery have remained static for more than 20 years. With an aim to advance research and inform policy changes, this paper builds on a growing body of work that explores dimensions of and responses to disrespectful maternity care and abuse during childbirth in facilities across Morogoro Region, Tanzania.

Methods

This research drew on in-depth interviews with 112 respondents including women who delivered in the preceding 14 months, their male partners, public opinion leaders and community health workers to understand experiences with and responses to abuse during childbirth. All interviews were recorded, transcribed, translated and coded using Atlas.ti. Analysis drew on the principles of Grounded Theory.

Results

When initially describing birth experiences, women portrayed encounters with providers in a neutral or satisfactory light. Upon probing, women recounted events or circumstances that are described as abusive in maternal health literature: feeling ignored or neglected; monetary demands or discriminatory treatment; verbal abuse; and in rare instances physical abuse. Findings were consistent across respondent groups and districts. As a response to abuse, women described acquiescence or non-confrontational strategies: resigning oneself to abuse, returning home, or bypassing certain facilities or providers. Male respondents described more assertive approaches: requesting better care, paying a bribe, lodging a complaint and in one case assaulting a provider.

Conclusions

Many Tanzanian women included in this study experienced unfavorable conditions when delivering in facilities. Providers, women and their families must be made aware of women’s rights to respectful care. Recommendations for further research include investigations of the prevalence and dimensions of disrespectful care and abuse, on mechanisms for women and their families to effectively report and redress such events and on interventions that could mitigate neglect or isolation among delivering women. Respectful care is a critical component to improve maternal health.

Experiences of Women Planning a Home Birth Who Require Intrapartum Transfer to Hospital: A Metasynthesis of the Qualitative Literature

Recent evidence supports the safety of planned home birth for low-risk women when professional midwifery care and adequate collaborative arrangements for referral and transfer are in place. The purpose of this article is to synthesize the qualitative literature on the experiences of women planning a home birth, who are subsequently transferred from home to hospital. A metasynthesis approach was selected because it aims to create a rich understanding of women’s experiences of transfer by synthesizing and interpreting qualitative data. Three categories were synthesized: “communication, connection, and continuity,” “making the transition,” and “making sense of events.” Quality and clarity of communication, feeling connected to the backup hospital, and continuity of midwifery carer helps make the transfer process as seamless as possible for women. Arriving at the hospital is a time of vulnerability and fear, and retaining the care of a known midwife is reassuring. New caregivers must also be sensitive to women’s need to be reassured and accepted. The reasons for transfer need to be clearly communicated both at the time of transfer and in more detail during the postpartum period. Women need to talk through their experience and to acknowledge their feelings of disappointment in order to move forward in the next phase of their lives. Continuity of carer enables this to be done by a known caregiver in a sensitive and individualized manner. Further qualitative research to examine home birth transfer issues, specifically in the Australian context, is currently being planned as part of the Birthplace in Australia project.