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

Translating lessons to reinforce national stillbirth response; multi-stakeholder perspectives regarding priorities and opportunities to deliver quality evidence-based interventions within a limited-resource context in Uganda

BACKGROUND

There is noted increase in attention towards implementation of evidence-based interventions in response to the stillbirth burden in low- and middle-income countries including Uganda. Recent results reporting some of the strategies adopted have tended to focus much attention towards their overall effect on the stillbirth burden. More is needed regarding stakeholder reflections on priorities and opportunities for delivering quality services within a limited resource setting like Uganda. This paper bridges this knowledge gap.

METHODS

Data collection occurred between March and June 2019 at the national level. Qualitative interviews were analysed using a thematic analysis technique.

RESULTS

Identified priorities included; a focus on supportive functions such as the referral system, attention to the demand side component of maternal health services, and improvements in the support supervision particularly focusing on empowering subnational level actors. The need to strengthen the learning for better implementation of strategies which are compatible with context was also reported. A comprehensive and favourable policy environment with the potential to direct implementation of strategies, harnessing the private sector contribution as well as the role of national level champions and patient advocates to amplify national stillbirth reduction efforts for continued visibility and impact were recommended.

CONCLUSION

Great potential exists within the current strategies to address the national stillbirth burden. However, priorities such as improving the supportive functions of MCH service delivery and attention to the demand side need to be pursued more for better service delivery with opportunities including a favourable policy environment primed to better serve the current strategies. This calls for dedicated efforts targeted at addressing gaps within the existing priorities and opportunities for better delivery of national strategies to address the stillbirth burden in Uganda.

Exploring women's experiences of care during hospital childbirth in rural Tanzania: a qualitative study

BACKGROUND

Women's childbirth experiences provide a unique understanding of care received in health facilities from their voices as they describe their needs, what they consider good and what should be changed. Quality Improvement interventions in healthcare are often designed without inputs from women as end-users, leading to a lack of consideration for their needs and expectations. Recently, quality improvement interventions that incorporate women's childbirth experiences are thought to result in healthcare services that are more responsive and grounded in the end-user's needs.

AIM

This study aimed to explore women's childbirth experiences to inform a co-designed quality improvement intervention in Southern Tanzania.

METHODS

This exploratory qualitative study used semi-structured interviews with women after childbirth (n = 25) in two hospitals in Southern Tanzania. Reflexive thematic analysis was applied using the World Health Organization's Quality of Care framework on experiences of care domains.

RESULTS

Three themes emerged from the data: (1) Women's experiences of communication with providers varied (2) Respect and dignity during intrapartum care is not guaranteed; (3) Women had varying experience of support during labour. Verbal mistreatment and threatening language for adverse birthing outcomes were common. Women appreciated physical or emotional support through human interaction. Some women would have wished for more support, but most accepted the current practices as they were.

CONCLUSION

The experiences of care described by women during childbirth varied from one woman to the other. Expectations towards empathic care seemed low, and the little interaction women had during labour and birth was therefore often appreciated and mistreatment normalized. Potential co-designed interventions should include strategies to (i) empower women to voice their needs during childbirth and (ii) support healthcare providers to have competencies to be more responsive to women's needs.

Mistreatment of women during childbirth and its influencing factors in public maternity hospitals in Tehran, Iran: a multi-stakeholder qualitative study

BACKGROUND

Mistreatment during labour and childbirth is a common experience for many women around the world. This study aimed to explore the manifestations of mistreatment and its influencing factors in public maternity hospitals in Tehran.

METHODS

A formative qualitative study was conducted using a phenomenological approach in five public hospitals between October 2021 and May 2022. Sixty in-depth face-to-face interviews were conducted with a purposive sample of women, maternity healthcare providers, and managers. Data were analyzed with content analysis using MAXQDA 18.

RESULTS

Mistreatment of women during labour and childbirth was manifested in four form: (1) physical abuse (fundal pressure); (2) verbal abuse (judgmental comments, harsh and rude language, and threats of poor outcomes); (3) failure to meet professional standards of care (painful vaginal exams, neglect and abandonment, and refusal to provide pain relief); and (4) poor rapport between women and providers (lack of supportive care and denial of mobility). Four themes were also identified as influencing factors: (1) individual-level factors (e.g., providers' perception about women's limited knowledge on childbirth process), (2) healthcare provider-level factors (e.g., provider stress and stressful working conditions); (3) hospital-level factors (e.g., staff shortages); and (4) national health system-level factors (e.g., lack of access to pain management during labour and childbirth).

CONCLUSIONS

Our study showed that women experienced various forms of mistreatment during labour and childbirth. There were also multiple level drivers for mistreatment at individual, healthcare provider, hospital and health system levels. Addressing these factors requires urgent multifaceted interventions.

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.

Sources of stress and coping mechanisms: Experiences of maternal health care providers in Western Kenya

The dynamic and complex nature of care provision predisposes healthcare workers to stress, including physical, emotional, or psychological fatigue due to individual, interpersonal, or organizational factors. We conducted a convergent mixed-methods study with maternity providers to understand their sources of stress and coping mechanisms they adopt. Data were collected in Migori County in western Kenya utilizing quantitative surveys with n = 101 maternity providers and in-depth interviews with a subset of n = 31 providers. We conducted descriptive analyses for the quantitative data. For qualitative data, we conducted thematic analysis, where codes were deductively developed from interview guides, iteratively refined based on emergent data, and applied by a team of five researchers using Dedoose software. Code queries were then analysed to identify themes and organized using the socioecological (SE) framework to present findings at the individual, interpersonal, and organizational levels. Providers reported stress due to high workloads (61%); lack of supplies (37%), poor salary (32%), attitudes of colleagues and superiors (25%), attitudes of patients (21%), and adverse outcomes (16%). Themes from the qualitative analysis mirrored the quantitative analysis with more detailed information on the factors contributing to each and how these sources of stress affect providers and patient outcomes. Coping mechanisms adopted by providers are captured under three themes: addressing stress by oneself, reaching out to others, and seeking help from a higher power. Findings underscore the need to address organizational, interpersonal, and individual level stressors. Strategies are needed to support staff retention, provide adequate resources and incentives for providers, and ultimately improve patient outcomes. Interventions should support and leverage the positive coping mechanisms identified.

Transforming women’s and providers’ experience of care for improved outcomes: A theory of change for group antenatal care in Kenya and Nigeria

Background

Group antenatal care (G-ANC) is a promising model for improving quality of maternal care and outcomes in low- and middle-income countries (LMICs) but little has been published examining the mechanisms by which it may contribute to those improvements. Substantial interplay can be expected between pregnant women and providers’ respective experiences of care, but most studies report findings separately. This study explores the experience and effects of G-ANC on both women and providers to inform an integrated theory of change for G-ANC in LMICs.

Methods

This paper reports on multiple secondary outcomes from a pragmatic cluster randomized controlled trial of group antenatal care in Kenya and Nigeria conducted from October 2016—November 2018 including 20 clusters per country. We collected qualitative data from providers and women providing or receiving group antenatal care via focus group discussions (19 with women; 4 with providers) and semi-structured interviews (42 with women; 4 with providers). Quantitative data were collected via surveys administered to 1) providers in the intervention arm at enrollment and after facilitating 4 cohorts and 2) women in both study arms at enrollment; 3–6 weeks postpartum; and 1 year postpartum. Through an iterative approach with framework analysis, we explored the interactions of voiced experience and perceived effects of care and placed them relationally within a theory of change. Selected variables from baseline and final surveys were analyzed to examine applicability of the theory to all study participants.

Results

Findings support seven inter-related themes. Three themes relate to the shared experience of care of women and providers: forming supportive relationships and open communication; becoming empowered partners in learning and care; and providing and receiving meaningful clinical services and information. Four themes relate to effects of that experience, which are not universally shared: self-reinforcing cycles of more and better care; linked improvements in health knowledge, confidence, and healthy behaviors; improved communication, support, and care beyond G-ANC meetings; and motivation to continue providing G-ANC. Together these themes map to a theory of change which centers the shared experience of care for women and providers among multiple pathways to improved outcomes.

Discussion

The reported experience and effects of G-ANC on women and providers are consistent with other studies in LMICs. This study is novel because it uses the themes to present a theory of change for G-ANC in low-resource settings. It is useful for G-ANC implementation to inform model development, test adaptations, and continue exploring mechanisms of action in future research.

Midwives' perspectives on person-centred maternity care in public hospitals in South-east Nigeria: A mixed-method study

Background

Person-centred maternity care (PCMC) is acknowledged as essential for achieving improved quality of care during labour and childbirth. Yet, evidence of healthcare providers’ perspectives of person-centred maternity care is scarce in Nigeria. This study, therefore, examined the perceptions of midwives on person-centred maternity care (PCMC) in Enugu State, South-east Nigeria.

Materials and methods

This study was conducted in seven public hospitals in Enugu metropolis, Enugu State, South-east Nigeria. A mixed-methods design, involving a cross-sectional survey and focus group discussions (FGDs) was used. All midwives (n = 201) working in the maternity sections of the selected hospitals were sampled. Data were collected from February to May 2019 using a self-administered, validated PCMC questionnaire. A sub-set of midwives (n = 56), purposively selected using maximum variation sampling, participated in the FGDs (n = 7). Quantitative data were entered, cleaned, and analysed with SPSS version 20 using descriptive and bivariate statistics and multivariate regression. Statistical significance was set at alpha 0.05 level. Qualitative data were analysed thematically.

Results

The mean age of midwives was 41.8 years ±9.6 years. About 53% of midwives have worked for ≥10 years, while 60% are junior midwives. Overall, the prevalence of low, medium, and high PCMC among midwives were 26%, 49% and 25%. The mean PCMC score was 54.06 (10.99). High perception of PCMC subscales ranged from 6.5% (dignity and respect) to 19% (supportive care). Midwives’ perceived PCMC was not significantly related to any socio-demographic characteristics. Respectful care, empathetic caregiving, prompt initiation of care, paying attention to women, psychosocial support, trust, and altruism enhanced PCMC. In contrast, verbal and physical abuses were common but normalised. Midwives’ weakest components of autonomy and communication were low involvement of women in decision about their care and choice of birthing position. Supportive care was constrained by restrictive policy on birth companion, poor working conditions, and cost of childbirth care.

Conclusion

PCMC is inadequate in public hospitals as seen from midwives’ perspectives. Demographic characteristics of midwives do not seem to play a significant role in midwives’ delivery of PCMC. The study identified areas where midwives must build competencies to deliver PCMC.

What factors are associated with forms of mistreatment during facility-based childbirth? A survey of referral health facilities in south-east Nigeria

Mistreatment during childbirth in health facilities contributes significantly to suboptimal levels of skilled birth attendance. This study determined the factors associated with mistreatment during facility-based childbirth in two referral facilities in south-east Nigeria. A survey of 620 women whose childbirth occurred in two high-patronage referral hospitals of Ebonyi, Nigeria, was conducted in July-September 2018 using interviewer-administered questionnaires. Data analysis was performed using SPSS version 20. Logistic regression was used to identify predictors. The mean age of the respondents was 29.86 ± 4.4 years. Most had post-secondary education (71.0%), and had attended at least four antenatal visits (83.4%). The prevalence of any mistreatment during childbirth was 56%. Rural residence (adjusted odds ratio [AOR]: 0.53; CI: 0.35, 0.78, p = 0.002) and childbirth facilitated by a doctor (AOR: 1.7; CI: 1.14, 2.39, p = 0.007) were predictors of reporting at least one form of mistreatment during childbirth. Childbirth facilitated by a doctor (AOR: 1.66; CI: 1.05, 2.63, p = 0.031) and unemployment (AOR: 1.84; CI: 1.01, 3.07, p = 0.011) increased the odds of non-consented and non-dignified care, respectively. Rural residence (AOR: 0.57; CI: 0.37, 0.88, p = 0.011) and childbirth facilitated by a doctor (AOR: 0.65; CI: 0.45, 0.94, p = 0.020) were protective against abandonment/neglect. Vaginal birth (AOR: 0.33; CI: 0.16, 0.69, p = 0.003) reduced the odds of detention in the health facility following childbirth. Almost three-fifths of the women whose childbirths occurred in the surveyed facilities experienced at least one form of mistreatment during childbirth. Place of residence, health professional type, mode of childbirth, employment status and frequency of antenatal attendance were predictors of mistreatment during childbirth. Rights-based sensitization for women, especially in the rural areas, female empowerment, provider capacity-building on respectful client care and provision of subsidized maternal health services are recommended.

Is the Training, Knowledge, and Perception of Maternal Health Providers Adequate for the Provision of Respectful Maternity Care? Policy Implications for Practice in a Nigerian Tertiary Hospital

Background

Health providers play pivotal roles in achieving respectful maternity care (RMC). This study assessed the training, knowledge, and perception of respectful maternity care among maternal health providers in a Nigerian tertiary hospital.

Methodology

This was across-sectional study conducted among 156 maternal health providers in Ebonyi Nigeria. Self-administered questionnaires were used for data collection.

Results

The respondents had a mean age of 31.97±6. 8years. Females constituted 35.9% of the respondents while 25.6% were midwives. Less than half had received undergraduate (48.7%) and postgraduate (42.3%) training on RMC. The majority were aware (72.4%) and had good knowledge (78.8%) of respectful maternity care. Medical books (33.3%) was the major source of information on RMC. Most respondents (90.4%) desired more education on RMC. Over four-fifths (82.1%) had a positive perception of RMC. Only 27.6% of respondents agreed that mistreatment during childbirth was a common phenomenon in their clinical practice context. About three-fourths (76.6%) did not agree that mistreatment during childbirth was harmful to maternal health. Undergraduate training on RMC (AOR=0.33, 95% CI=0.13-0.81), postgraduate training on RMC (AOR=0.30, 95% CI=0.11-0.82) and higher monthly income (AOR=0.20 95% CI=0.05-0.88) were predictors of awareness of RMC. Knowledge of RMC was a predictor of perception about RMC (AOR=0.29, 95% CI=0.11-0.71).

Conclusion

There was good awareness, knowledge and perception of RMC predicted by training exposures and income status However, gaps existed in the perception of the occurrence and consequences of mistreatment during childbirth. We recommend the inclusion of RMC training in both undergraduate and postgraduate medical training curricula.