Prevalence of disrespect and abuse during facility based child birth and associated factors, Jimma University Medical Center, Southwest Ethiopia

In countries where the proportion of births attended by skilled providers is low, maternal mortality is high. According to the 2016 Ethiopian Demographic and Health Surveillance report, the proportion of births attended by skilled providers was only 26% and the maternal mortality ratio was 412 per 100,000 live-births. Disrespectful and abusive behavior of health workers and other facility staff experienced by women during facility-based childbirth is important, but the little-understood barrier of institutional delivery. This study assessed the prevalence of disrespect and abuse experienced by mothers during facility-based childbirth and associated factors.

October to December 2016, consecutively included 290 mothers were interviewed immediately prior to discharge from the hospital. The result showed that nearly 92 out of 100 mothers were disrespected and abused during childbirth. Three-fourths of mothers did not receive culturally appropriate care and were not encouraged to ask questions. The provider did not introduce him/herself to four-fifths of mothers. The provider also did not request consent or permission prior to any procedure from nearly two-thirds of mothers. The provider did not use curtains or other visual barriers to protect client for more than four-fifths of mothers. Non-married mother, para-II or above mother and mother attended by female care provider had reduced chance of reporting disrespect and abuse. However, mother who attended at least secondary school had a higher chance of reporting disrespect and abuse.

In conclusion, the magnitude of disrespect and abuse during childbirth was very high in the study area indicating a health system in crisis. A key implication of this finding is that efforts to increase facility delivery must address disrespect and abuse to ensure higher utilization by women. Making facility-based deliveries attended by female providers may reduce the problem.

In countries where the proportion of births attended by skilled providers is low, maternal mortality is high [1]. Reducing the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 is the first target of Sustainable Development Goal (SDG) 3. The proportion of births attended by skilled health personnel is a critical progress indicator explicitly adopted for this target [2, 3]. Ethiopia had a plan to decrease the maternal mortality ratio (MMR) from 871 to 267 maternal deaths per 100,000 live births between 1990 and 2015 to achieve the millennium development goal (MDG) 5. A key indicator of this achievement was the proportion of births attended by skilled health personnel [4]. However, according to the 2016 Ethiopian Demographic and Health Surveillance (EDHS) report, maternal mortality ratio was 412 deaths per 100,000 live births [5]. Although the coverage of trained midwives increased to 72.7% in fiscal year 2015/16 [6], the proportion of births attended by skilled providers was low (26%) [5].

Lack of respect and courtesy from providers, perceived poor service quality, fear to expose the body to strangers, perceived costs of using health facility, and fear of being attended by male providers during birth are all known to contribute to low institutional delivery rates [7, 8, 9, 10, 11, 12, 13, 14, 15]. In Addis Ababa, the capital city of Ethiopia, though the proportion of births occurring in health institutions is much higher than the national Fig. (82.3%), there are growing concerns about the respect and friendliness of safe delivery services [16].

Disrespectful and abusive behavior by health workers and other facility staff is important, but the little-understood component of the poor quality care experienced by women during childbirth in facilities. Non-abusive and respectful care at birth encompasses many points along a continuum spanning patient-centered and dignified care to overtly abusive and non-dignified maternal care. Maternal health experts and many stakeholders agree that disrespect and abuse (D&A) during facility-based childbirth represent important causes of suffering for women and are important barriers to women choosing to access skilled care [17, 18]. However, disrespect and abuse are often multi-factorial and may be perceived differently (or even normalized) depending on the specific setting.

According to Bowser and Hill’s comprehensive review, the seven categories of disrespect and abuse during childbirth are physical abuse, non-dignified care, discrimination based on specific patient attributes, non-consented care, non-confidential care, abandonment of care and detention in facilities. However, it is known that manifestations of abuse and disrespect often fall into more than one category, and these categories are not intended to be mutually exclusive. Categories should be rather seen as overlapping and representing a continuum. Numerous factors (individual and community-level) may contribute to the experiences of disrespect and abuse. Lack of legal and ethical foundations to address D&A, normalizing D&A, lack of standards and accountability, lack of leadership commitment, and provider prejudice due to training and lack of resources are some among many factors [17, 18].

Disrespect and abuse of women during childbirth at health facilities have been qualitatively described, but there is little quantitative evidence on the prevalence of D&A during facility-based maternity services delivered in low-resource settings. Few recent studies conducted in Kenya, Tanzania, Ethiopia, and Nigeria analyzed women’s experiences during childbirth and estimated prevalence of disrespect and abuse that ranged from 20 to 98% [19, 20, 21, 22, 23, 24]. Having a good understanding of the prevalence of D&A and factors that influence it is, however, critical for developing interventions and encouraging clients’ future facility utilization. This study, thus, aimed at quantitatively describing the level and types of disrespect and abuse women faced during facility-based childbirth.

This study investigated the prevalence of disrespect and abuse faced by women during facility-based childbirth at Jimma University Medical Centre. Both verbal report (anecdote) and literature indicated that clients are often discriminated on the grounds of race, ethnicity, religion, age, socio-economic, and HIV status [17, 18]. This study also assessed the relationship between D&A and socio-demographic/economic characteristic (age, religion, marital status, educational level, occupation, household monthly income, residence), obstetric characteristics (parity, AN utilization current birth complication), length of stay in the hospital, number of health professionals who attended the mother, sex of main provider and whether someone other than concerned health provider had got access to see the mother during labor.

The overall prevalence of disrespect and abuse (91.7%) observed in this study was higher than 81.8% prevalence reported by the study conducted in Addis Ababa, Ethiopia [21]. This could be because of the difference in settings where the culture of participants and composition of professionals caring for mothers differ. Though final year undergraduate medicine students also involved in facility-based childbirth attendance in both setups, the difference in how they were involved might have increased the magnitude of the problem in our setup. Three-fourths of respondents in our study were Muslims who don’t want to be attended by male providers because of religious interest and culture of the surrounding community. Contrary to this, more than four-fifths of deliveries were attended by male providers. This contradiction might also have increased the report of disrespect and abuse in our setup.

Our finding was also more than four times higher than 19.5, 20 and 21% prevalence reported by studies done in Tanzania [20], Kenya [19] and Ethiopia [22] respectively. It was also more than six times higher than 15% prevalence reported by another study done in Tanzania [24]. Unlike our setup, participants might have normalized or under-reported disrespect and abuse during an immediate postpartum interview (courtesy bias) in both setups as evidenced by the increase of the prevalence to 70% during community follow up interview of Tanzanian study [24]. Kenyan and Tanzanian studies also included a significant proportion of mothers who gave birth by Cesarean section [19, 20]. This might have led to the underestimation of prevalence as mothers are consented and better cared for (e.g. received anesthesia for pain) in such situation and thus, odds was reduced [19]. Providers have greater control over timing and setting of Caesarean section births and may perceive these cases as more serious, therefore behaving more professionally with the patient. A study conducted in Ethiopia was a health center based where client load was much lower and students were not involved in service delivery. Our finding was; however, lower than 98% prevalence reported by the study undertaken in Nigeria [23].

Three-fourths of mothers were not given the care in a culturally appropriate way by the care provider which was more than eight times higher than the report of study from Addis Ababa, Ethiopia [21]. In more than three-fourths of the cases, the care provider did not encourage the client to ask questions and didn’t introduce him/herself during childbirth similar to the report of studies conducted in Ethiopia [21, 22]. The provider did not explain to the client what to be done and what to expect throughout labor and birth and did not give periodic updates on the status and progress of labor in half of the cases. This is higher than the finding of the study undertaken in Addis Ababa, Ethiopia [21]. In two-thirds of clients, the provider did not obtain consent or permission prior to any procedure similar to the report of a health center based study conducted in Ethiopia [22] and Nigeria [23] but, higher than the report of a study done in Addis Ababa, Ethiopia [21] and Tanzania [20, 24]. The provider did not use curtains or other visual barriers to protect the client in four-fifths of the cases which was higher than the report of studies from Ethiopia [21, 22] and Tanzania [24].

In general, this figure indicates a worrisome picture of the quality of care during labor and delivery in the study facility. This is because, in many urban areas of resource-limited countries, improved access to services (especially in hospitals) has led to an increase in women seeking facility-based care during childbirth. As a result, many urban hospitals including our study facility had high patient flow and faced significant resource and staff shortages which are likely to be one of the key drivers of disrespect and abuse.

Women who attended secondary education or greater were more likely to report D&A similar to the finding of Tanzanian study [20]. This is likely due to a combination of higher expectations of care quality and greater empowerment to report abuse. Those with experienced births (para two or above) were less likely to report D&A similar to the finding of Tanzanian study [20, 22]. This may indicate quicker and easier deliveries and/or greater resistance to or normalization of abusive remarks or behavior. It may also reflect anxiety about the birth experience as well as a greater need for care of those with first birth.

Previous studies have reported that married women were less likely to have experienced disrespect than unmarried women may be because of negative attitude among medical staff towards unmarried pregnant women [20]. However, we found that married women were more likely to have experienced disrespect than unmarried women may be because of more expectation of respectful care by this group.

Unlike previous studies, stay in the facility for delivery [20] and childbirth complications [19, 22] were not found associated with reporting D&A. However, a woman whose delivery was attended by female healthcare provider was less likely to report D&A. This could because of religious and cultural preference. In the current study, three-fourths of participants were Muslims and most were housewives which could be the reason for preferring female professionals.

This study had some limitations. Disrespect and abuse is a complex concept to measure. Our assessment was based on self-report rather than objectively measuring the frequency of disrespectful and abusive care in the facility. However, given that disrespect and abuse are determined by women’s own view of what is disrespectful and abusive, we believe that a self-reported measure is appropriate. Some studies have complemented exit interviews with community interviews conducted four to 10 weeks post-delivery to compare reported D&A [20, 24]; others complemented it with observation [24]. Unfortunately, the study budget did not allow us for this method approach. Our analysis also did not include details of provider and facility-level factors as contributors to disrespect and abuse and thus, future research should explore these. Although interviews were conducted at the time of hospital discharge, the fact that women were asked about their care in the place where they give birth and by staff employed by the hospital, albeit not part of their care provision, may still induce social desirability bias.

The finding that nine out of 10 women experienced abuse or disrespect during facility-based delivery shows a health system in crisis. Abuse during childbirth may have far-reaching consequences in future health care utilization. A key implication of this finding is that efforts to increase facility-based delivery must address disrespect and abuse to ensure higher utilization by women and to safeguard women’s fundamental rights during facility delivery. Making facility-based deliveries attended by female providers may reduce the problem.