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Jeopardizing quality at the frontline of healthcare: prevalence and risk factors for disrespect and abuse during facility-based childbirth in Ethiopia

Jeopardizing quality at the frontline of healthcare: prevalence and risk factors for disrespect... Disrespect and abuse (D&A) experienced by women during facility-based childbirth has gained global recognition as a threat to eliminating preventable maternal mortality and morbidity. This study explored the frequency and associated factors of D&A in four rural health centres in Ethiopia. Experiences of women who delivered in these facilities were captured by direct observation of client-provider interaction (N¼ 193) and exit interview at time of discharge (N¼ 204). Incidence of D&A was observed in each facility, with failure to ask woman for preferred birth position most commonly observed [n¼ 162, 83.9%, 95% confidence interval (95% CI) 78.0–88.5%]. During exit interviews, 21.1% (n¼ 43, 95% CI 15.4–26.7%) of respondents reported at least one occurrence of D&A. Bivariate models using client characteristics and index birth experience showed that wom- en’s reporting of D&A was significantly associated with childbirth complications [odds ratio (OR)¼ 7.98, 95% CI 3.70, 17.22], weekend delivery (OR¼ 0.17, 95% CI 0.05, 0.63) and no previous delivery at the facility (OR¼ 3.20, 95% CI 1.27, 8.05). Facility-level fixed-effect models found that experience of complications (OR¼ 15.51, 95% CI 4.38, 54.94) and weekend delivery (OR¼ 0.05, 95% CI 0.01–0.32) remained significantly and most strongly associated with self-reported D&A. These data suggest that addressing D&A in health centres in Ethiopia will require a sustained effort to improve infrastructure, support the health workforce in rural settings, enforce professional stand- ards and target interventions to improve women’s experiences as part of quality of care initiatives. Keywords: Quality of care, maternal health, disrespect and abuse, primary health care, maternity services V The Author(s) 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. 317 Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 318 Health Policy and Planning, 2018, Vol. 33, No. 3 Key Messages Disrespect and abuse (D&A) experienced by women during facility-based childbirth has gained global recognition as a threat to eliminating preventable maternal mortality and morbidity. This study sought to quantify the frequency and categories of D&A experienced by women in four health centres in two rural regions of Ethiopia for the purposes of developing a community-led intervention. Experiences of women who deliv- ered in these facilities were captured by direct observation of client-provider interaction and exit interview at time of discharge. During exit interviews, 21.1% of respondents reported at least one occurrence of D&A. Failure to ask woman for pre- ferred birth position most commonly observed during client-provider interactions (83.9%). Complications during child- birth and time of delivery were significantly associated with reported D&A. Addressing D&A in health centres in Ethiopia will require a shift in priorities towards improving the experience and quality of care, a sustained effort to improve health care centres’ infrastructure and greater support of the rural health workforce. dramatically increasing the number of primary health centres Introduction (‘health centres’) and eliminating user fees, yet the national facility Complications from pregnancy and childbirth are the leading causes delivery rate in Ethiopia remains low at 15% (Central Statistical of maternal mortality and morbidity for women of reproductive age Agency 2014). Ethiopian women who have access to health facilities in developing countries (Kassebaum et al. 2014). It is widely often choose to give birth elsewhere, even among women for whom acknowledged that maternal deaths can be prevented if women have the benefits of facility-based childbirth have been demonstrated access to skilled childbirth services within a formal health care sys- (Kruk et al. 2010). Poor provider attitudes—including harassment, tem (Campbell et al. 2016). However, evidence has shown that lack of attention to complaints, and lack of follow-up in labour— access to maternal health services alone is insufficient to prevent have been cited as deterrents to the use of facility services (Belay maternal deaths, and that the quality of care received is integral to et al. 2007). Additional studies in Ethiopia have found that women ensuring good maternal health outcomes (Souza et al. 2013). This is perceive health care providers to be insensitive and unduly harsh reflected in the post-2015 development agenda, which underlines (Berhane et al. 2001) and unresponsive to community beliefs and the growing recognition of the importance of quality in health serv- ice delivery (Koblinsky et al. 2016). The WHO Quality of Care practices. Thus, women’s poor experiences with care at health framework for maternal and newborn health expanded the defini- centres may be deterring them from seeking childbirth services, tion of ‘quality of care’ to give equal value to clinical (or ‘technical’) undermining existing national efforts to prevent maternal mortality. quality and experiences of care, while the Strategies towards Ending Colleagues have investigated respect and dignity during perinatal Preventable Maternal Mortality (EPMM) working group high- care in tertiary hospitals in Ethiopia, (Asefa and Bekele 2015; Rosen lighted priority recommendations for eliminating discrimination and et al. 2015). However, to our knowledge, the prevalence of D&A developing health systems that can deliver interventions both effec- reported by women at health centres in rural Ethiopia, the level of tively and equitably (Tunc ¸alp et al. 2015; World Health the health system at which women are encouraged to seek facility- Organization 2015). based delivery, had never been investigated. This study sought to Disrespect and abuse (D&A) experienced by women during quantify the frequency and categories of D&A experienced by facility-based childbirth is gaining recognition as violation of wom- women in four health centres in two rural regions of Ethiopia for en’s rights (Ogangah et al. 2007; Freedman et al. 2014; Sando et al. the purposes of developing a community-led intervention. As part of 2014; Abuya et al. 2015). Further, D&A has been acknowledged as this endeavour, we identified factors associated with reporting D&A a deficiency in the delivery of high quality maternal health services, to identify the most appropriate area for intervention. threatening the ability of health systems to achieve good maternal Understanding the factors associated with D&A will assist in local health outcomes (Bowser and Hill 2010; Kruk et al. 2014; Abuya and national efforts to improve the quality of care, increase rates of et al. 2015a; Bohren et al. 2015; Vogel et al. 2015a,b; Sando et al. facility-based delivery and improve maternal health outcomes in a 2016). D&A manifests as physical violence, harsh language, stigma primary health care setting. and neglect suffered by women at the hands of health care providers (Bowser and Hill 2010; Kruk et al. 2014; Abuya et al. 2015a; Bohren et al. 2015; Ratcliffe et al. 2016a). Drivers of D&A can Methods include systemic failures, such as overwhelmed health care adminis- Study design tration, poor staffing and supervisory structures and inadequate The study was a cross-sectional design to assess manifestations of physical infrastructure (Bowser and Hill 2010; Freedman and Kruk D&A among women who gave birth in four rural health centres in 2014; Ratcliffe et al. 2016b). Women who experience D&A are Amhara and Southern Nations, Nationalities, and Peoples (SNNP) more likely to report lower satisfaction with their birth experience regions of Ethiopia during July–September 2013. Client-provider and are less likely to seek facility-based delivery for future pregnan- interactions during labour and delivery were observed for 193 cies (Kujawski et al. 2015). births, and 204 women who gave birth at these health centres were Such considerations are important for Ethiopia, which, with 353 interviewed at their time of discharge from the facility (n¼ 204). maternal deaths per 100 000 live births, has one of the highest Health workers in the participating health centres were aware that maternal mortality ratios in the world (WHO, UNICEF, UNFPA the quality of client-provider interactions was being captured 2015). The Ethiopian Federal Ministry of Health has worked to improve access to facility-based maternal health services by through direct observation and women surveyed. Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 Health Policy and Planning, 2018, Vol. 33, No. 3 319 Study setting Twelve data collectors and four supervisors with bachelor’s To ensure universal coverage of primary health care, the degrees in health sciences who were working concurrently as health- care providers in non-study health facilities were responsible for Government of Ethiopia has been investing substantially to develop data collection. One full day of training was provided to data collec- the district- or woreda -level health system, which encompasses a tors and supervisors to familiarize them with the instrument and primary hospital with four to five primary health care units methods for interview techniques for sensitive material, including (PHCUs). Each PHCU is comprised of one health centre that serves appropriate recording, acquiring informed consent and ensuring a population of approximately 25 000, and five satellite health confidentiality. Data collectors and supervisors were trained to posts. Designed to be the front line of service delivery for childbirth, administer both the client-provider interaction and women’s exit the health centres are staffed with health officers, nurses and mid- interview tools. Three data collectors and one supervisor were wives to provide primarily curative care, including basic emergency deployed to each health centre. Data collectors worked in 8-h shifts obstetric and newborn care (BEmONC). Additionally, the health to allow for continuous coverage at the health centre. centres receive referrals from the health posts, and provide essential 2 All women who gave birth in the four health centres during the supplies, technical and administrative support to the health posts. study period were eligible to participate in the study; there were no The study was conducted in four health centres that are sup- refusals. The expected sample size of 246 was based on an assumed ported by the Last Ten Kilometers (L10K), a technical support pro- prevalence of D&A of 20% across all study sites assuming 65% gram for the Ethiopian Federal Ministry of Health that aims to precision and 95% confidence interval (95% CI), an estimate based strengthen the links between households, communities and the for- on a similar study in Kenya (Warren et al. 2013). malized health care system. Two of the study health centres were in Client-provider interactions were captured through one-to-one Amhara region and two were in Southern Nations, Nationalities direct observation from a woman’s time of entry at the health centre, and Peoples’ region (SNNP). Amhara (population 20.3 million) and throughout the labour and delivery period, until her time of entry to the SNNP (population 18.9 million) are respectively the second and post-natal ward. The data collector used a structured observation tool third most populous regions in Ethiopia, representing about 46% of to capture specific manifestations of D&A. If the observation period the population of the country. The four health centres were purpo- continued beyond the 8-h shift, the data collector handed over the sively selected among fourteen health centres that were part of the observation tool to the arriving data collector. The exit interview was L10K’s ongoing clinical quality improvement activities. To account conducted at the time of discharge, approximately three to 6 h post-par- for any differences in D&A associated with patient flow, the four tum; the questionnaire focused on the woman’s perceived experiences health centres were sampled such that each region included one high of D&A during her labour and delivery at the health centre. volume health centre (>450 deliveries annually) and one low vol- Written consent was obtained from women during the first stage ume health centre (fewer than 150 deliveries annually). At each of labour at admittance. All records and data collection tools were health centre, maternity staff provided care in three units during the assigned an anonymous code, and identifiers were not used in the weekdays (family planning, antenatal care, and labour and delivery), analysis or final reporting. Ethical clearance was obtained from while only labour and delivery services were provided at night and Institutional Review Boards at the Amhara and SNNP Regional during the weekends. Health Bureaus and an ethical clearance waiver for secondary data analysis was obtained from the Harvard T.H. Chan School of Public Data collection Health Institutional Review Board. Study instruments were adapted from the tools developed by the Population Council in Kenya to fit the Ethiopian context (Abuya Measurements et al. 2015a). The client-provider interaction tool was administered D&A were operationalized using an adaptation of the seven categories in English, the ‘language of medicine’ in Ethiopia. The exit interview described in Bowser and Hill’s landscape analysis (Bowser and Hill tool was administered in Amharic; the original English tool was 2010)(see Figure 1). Indicators for observed events of D&A were iden- translated into Amharic and then translated back to English to tified through the literature and local BEmONC protocol. Since ensure consistency. observing D&A is inherently subjective and heavily based on local Figure 1. Categories of disrespect and abuse. Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 320 Health Policy and Planning, 2018, Vol. 33, No. 3 Figure 2. Independent variables. norms (Freedman et al. 2014), each item on the client-provider interac- characteristics varied significantly between health centres. More tion tool was reviewed during data collection training to determine women from the SNNP region were from a rural kebele (village) local consensus on the manifestation of D&A and practiced among than those in the Amhara region (P50.001). Religious affiliation differed substantially between the study sites as well (P50.001), data collectors to ensure consistency in recording. As part of a larger with all respondents who self-identified as Muslim concentrated in global consensus on describing and defining prevalence from the per- the SNNP region’s high volume (SHV) health centre. Wealth tercile spective and experience of the woman (Freedman et al. 2014; Kruk distribution varied significantly between health centres (P50.001), et al. 2014; Abuya et al. 2015a; Sando et al. 2016), prevalence of each with women from the SNNP region low volume health centre (SLV) of D&A category was calculated using the exit interview data. Women and the Amhara region high volume health centre (AHV) tending to who reported experiencing one or more sub-components of D&A be poorer than women from the Amhara region low volume health were included in the overall prevalence measure. centre (ALV) and SHV. Occupation (P50.001) was significantly Independent variables were chosen based on hypotheses that differentially distributed by health centre; 71% of women from women from certain sub-groups, previous history with the healthcare ALV identified as farmers and 71% of SLV identified as system and/or individual experiences with the index birth, including 3 homemaker. Educational attainment was significantly different birth complications, maybemorelikelytoreportD&A (see Figure 2). across sites (P50.05), with women from low volume health centres less likely to have formal education than women from high-volume Data management and analysis sites. Study instruments were thoroughly examined for completion and Nearly all respondents (95.1%) reported coming directly to the accuracy by the data supervisors. Ten percent of the data entries health centre for delivery without a referral. For most respondents, were randomly selected and checked for consistency; frequencies travel to the health centre took less than 1 h, though this varied sig- were used to check for outliers and cleaning of data. nificantly by health centre (P50.005) and women from ALV Differentials in socio-demographic and index birth variables of reported longer travel times overall. More than 85% of respondents women in the samples of the four health centres were assessed using completed at least three or four antenatal care visits. Approximately bivariate analyses. The prevalence of observed and reported D&A one-third of respondents reported that they or their infant experi- was estimated and whether it varied by facility were assessed using enced some type of complication; women from SNNP health centres Fisher’s exact test. Vast variations between observed and reported were less likely to report any form of complication. Nearly half of D&A were expected due to cultural norms, varying perspectives on deliveries occurred during the day on weekdays, with no significant quality of care, and previous experience using the tools in a related difference between health centre, and the majority of overall births study in Dar es Salaam, Tanzania (Sando et al. 2016). were attended by a midwife, although health officers were more Then, bivariate and multivariate analyses were performed to common attendants in the low volume health centres (P50.001). examine the unadjusted and adjusted relationships between selected Although most respondents (75.5%) had used the health centre pre- socio-demographic and index birth experience. Fisher’s exact test viously to receive care for themselves, their children, or their was used for the bivariate analysis and facility-level fixed effects spouses, the majority (70.1%) had not had a previous delivery at the logistic regression was used to estimate adjusted relationships same health centre. Previous health centre utilization differed signifi- between D&A and the independent variables. Statistical significance cantly by health centre (P50.001 for each); respondents from the was considered at two-tailed P-value50.05. Stata 14.0 was used for high-volume health centres were more likely to have previously used the analysis (StataCorp 2015). the health centre for any type of care and for delivery services. Facility characteristics Results Facility data collected from on-site record books revealed that each Demographic and index birth characteristics health centre was differentially staffed and equipped (see Table 2). The demographic characteristics and birth experiences of respond- In the year preceding data collection, the low-volume health centres ents from each health centre are shown in Table 1. Overall, client saw approximately one-third fewer births than the high-volume Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 Health Policy and Planning, 2018, Vol. 33, No. 3 321 Table 1. Background characteristics and birth experience of exit interview respondents in four facilities in Amhara & SNNP region, Ethiopia, Characteristics Total Amhara SNNP P-value (N¼ 204) High volume Low volume High volume Low volume (N¼ 77) (N¼ 21) (N¼ 71) (N¼ 35) n (%) n (%) n (%) n (%) n (%) Age group 16–24 73 (35.8) 29 (37.7) 7 (33.3) 20 (28.2) 17 (48.6) 0.180 25–34 106 (52.0) 35 (45.5) 11 (52.4) 43 (60.6) 17 (48.6) 35–45 25 (12.3) 13 (16.9) 3 (14.3) 8 (11.3) 1 (2.9) Education None 89 (43.6) 35 (45.5) 11 (52.4) 37 (52.1) 6 (17.1) 0.023*** Primary 73 (35.8) 25 (32.5) 7 (33.3) 21 (29.6) 20 (57.1) Secondaryþ 42 (20.6) 17 (22.1) 3 (14.3) 13 (18.3) 9 (25.7) Religion Christian 137 (67.2) 77 (100.0) 21 (100.0) 4 (5.6) 35 (100.0) 50.001* Muslim 67 (32.8) 0 (0.0) 0 (0.0) 67 (94.4) 0 (0.0) Marital status Other 14 (6.9) 6 (7.8) 2 (9.5) 4 (5.6) 2 (5.7) 0.871 Married 190 (93.1) 71 (92.2) 19 (90.5) 67 (94.4) 33 (94.3) Occupation Homemaker 78 (38.2) 26 (33.8) 3 (14.3) 24 (33.8) 25 (71.4) 50.001* Farming 71 (34.8) 30 (39.0) 15 (71.4) 22 (31.0) 4 (11.4) Other 55 (27.0) 21 (27.3) 3 (14.3) 25 (35.2) 6 (17.1) Wealth tercile Poorest 68 (33.3) 26 (33.8) 5 (23.8) 20 (28.2) 17 (48.6) 50.001* Medium 68 (33.3) 30 (39.0) 9 (42.9) 14 (19.7) 15 (42.9) Least poor 68 (33.3) 21 (27.3) 7 (33.3) 37 (52.1) 3 (8.6) Place of residence Rural 130 (63.7) 36 (46.8) 13 (61.9) 50 (70.4) 31 (88.6) 50.001* Urban 74 (36.3) 41 (53.3) 8 (38.1) 21 (29.6) 4 (11.4) Travel time to reach the facility 51 h 123 (60.3) 39 (50.7) 8 (38.1) 50 (70.4) 26 (74.3) 0.002** 1–2 h 52 (25.5) 25 (32.5) 7 (33.3) 17 (23.9) 3 (8.6) >2 h 29 (14.2) 13 (16.9) 6 (28.6) 4 (5.6) 6 (17.1) Referred to the facility Referred 10 (4.9) 3 (3.9) 3 (14.3) 2 (2.8) 2 (5.7) 0.194 Came directly 194 (95.1) 74 (96.1) 18 (85.7) 69 (97.2) 33 (94.3) Any complications No 129 (63.2) 45 (58.4) 9 (42.9) 46 (64.8) 29 (82.9) 0.014*** Yes 75 (36.8) 32 (41.6) 12 (57.1) 25 (35.2) 6 (17.1) Delivery time Weekdays day 91 (44.6) 38 (49.4) 8 (38.1) 30 (42.3) 15 (42.9) 0.883 Weekdays night 65 (31.9) 25 (32.5) 6 (28.6) 23 (32.4) 11 (31.4) Weekend 48 (23.5) 14 (18.2) 7 (33.3) 18 (25.4) 9 (25.7) Birth attendant Health officer 51 (25.0) 8 (10.4) 12 (57.1) 11 (15.5) 20 (57.1) 50.001* Nurse 36 (17.7) 24 (31.2) 0 (0.0) 1 (1.4) 11 (31.4) Midwife 117 (57.4) 45 (58.4) 9 (42.9) 59 (83.1) 4 (11.4) Number of ANC visits 0–2 29 (14.2) 13 (16.9) 6 (28.6) 5 (7.0) 5 (14.3) 0.062**** 3–4 175 (85.8) 64 (83.1) 15 (71.4) 66 (93.0) 30 (85.7) Previously delivered at the facility Yes 61 (29.9) 14 (18.2) 3 (14.3) 34 (47.9) 10 (28.6) 50.001* No 143 (70.1) 63 (81.8) 18 (85.7) 37 (52.1) 25 (71.4) Previously used the facility Yes 154 (75.5) 56 (72.7) 13 (61.9) 65 (91.6) 20 (57.1) 50.001* No 50 (24.5) 21 (27.3) 8 (38.1) 6 (8.5) 15 (42.9) *P50.001; **P50.01; ***P50.05; ****P50.1. Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 322 Health Policy and Planning, 2018, Vol. 33, No. 3 Table 2. Facility characteristics July 2013 Facility characteristics Amhara SNNP High volume Low volume High volume Low volume Number of midwives 3 2 5 2 Number of nurses and health officers 11 12 14 16 Number trained on BEmONC 1 2 2 3 Number of delivery couches 2 1 4 2 Number of beds in the pre/post-labour ward 2 2 3 2 Number of annual deliveries 453 130 433 144 Table 3. Observed disrespect and abuse Type of disrespect and abuse observed Total Frequency Fisher’s N¼ 193 exact Amhara Amhara SNNP SNNP n (%) P-value high low high low volume volume volume volume N¼ 78 N¼ 15 N¼ 65 N¼ 35 n (%) n (%) n (%) n (%) Physical abuse Fundal pressure applied 22 (11.4) 1 (1.3) 5 (33.3) 9 (13.9) 7 (20.0) 50.001* Non-consented care Lack of consent for first vaginal examination 132 (68.4) 50 (64.1) 13 (86.7) 61 (93.9) 8 (22.9) 50.001* Non-confidential care Mother’s history taking findings shared when others could hear 64 (33.2) 37 (47.4) 7 (46.7) 3 (4.6) 17 (48.6) 50.001* Auditory privacy not respected during post-natal examination 41 (21.2) 29 (37.2) 3 (20.0) 2 (3.08) 7 (20.0) 50.001* Lack of privacy No partitions separating beds for first examination 109 (56.5) 24 (30.8) 15 (100.0) 48 (73.9) 22 (62.9) 50.001* Partitions do not give privacy in prenatal ward 53 (27.5) 37 (47.4) 0 (0) 12 (18.5) 4 (11.4) 50.001* Mother not covered during examination in prenatal ward 68 (35.2) 21 (26.9) 4 (26.7) 27 (41.5) 16 (45.7) 0.127 Mother not covered while being moved from prenatal ward to delivery room 42 (21.8) 15 (19.2) 3 (20.0) 20 (30.8) 4 (11.4) 0.149 Mother not covered during delivery 107 (55.4) 35 (44.9) 3 (20.0) 45 (69.2) 24 (68.6) 50.001* Partitions not closed during delivery 109 (56.5) 44 (56.4) 14 (93.3) 50 (76.9) 1 (2.9) 50.001* Mother not well covered after third stage of labour 60 (31.1) 20 (25.6) 3 (20.0) 20 (30.8) 17 (48.6) 0.086 No partitions/curtains between beds in post-natal ward 145 (75.1) 59 (75.6) 14 (93.3) 47 (72.3) 25 (71.4) 0.353 Mother’s physical privacy not respected during post-natal examination 40 (20.7) 28 (35.9) 3 (20.0) 0 (0) 9 (25.7) 50.001* Non-dignified care Mother not welcomed in a kind and gentle manner 24 (12.4) 10 (12.8) 6 (40.0) 8 (12.3) 0 (0) 0.002* Provider did not introduce herself to mother (antenatal ward) 158 (81.9) 68 (87.2) 15 (100.0) 60 (92.3) 15 (42.9) 50.001* Use of non-dignified language during history taking 13 (6.7) 6 (7.7) 3 (20.0) 2 (3.1) 2 (5.7) 0.127 Delivery midwife did not introduce herself by name (if it was a provider 32 (16.6) 9 (11.5) 2 (13.3) 13 (20.0) 8 (22.9) 0.367 mother had not yet met) Delivering service provider did not congratulate mother after birth 62 (32.1) 12 (15.4) 10 (66.7) 32 (49.2) 8 (22.9) 50.001* Mother not cleaned after birth and third stage of labour 50 (25.9) 34 (43.6) 3 (20.0) 13 (20.0) 0 (0) 50.001* No pad provided to mother 88 (45.6) 59 (75.64) 2 (13.3) 19 (19.2) 8 (22.9) 50.001* Mother not allocated her own bed in post-natal ward 11 (5.7) 0 (0) 11 (73.3) 0 (0) 0 (0) 50.001* Bed in post-natal ward not clean 40 (20.7) 0 (0) 11 (73.3) 12 (18.5) 17 (48.6) 50.001* Mother not called by her name throughout interactions 65 (33.7) 43 (55.1) 5 (33.3) 16 (24.6) 1 (2.9) 50.001* Mother not asked about preferred birth position 162 (83.9) 70 (89.7) 15 (100.0) 46 (70.8) 31 (88.6) 0.005** Mother not allowed to practice religious/cultural custom, if requested 10 (5.2) 8 (10.3) 1 (6.7) 0 (0) 1 (2.9) 0.022*** *P50.001; **P50.01; ***P50.05. health centres in their respective regions, yet had more nurses and significant variation between health centres. The application of fun- health officers as well as more BEmONC trained providers. The dal pressure, an example of physical abuse, was recorded in as many low-volume health centres also had fewer midwives on staff. as one-third of deliveries in ALV and one in five deliveries in SLV. Lack of consent for vaginal examination differed significantly between health centres, occurring in nearly all deliveries in the ALV D&A and SHV, and less frequently in AHV and SLV. Observed D&A Instances of non-confidential care were observed in up to half of Of the 204 women who were sampled, 193 deliveries were directly observed and specific indicators of D&A were recorded (Table 3). all deliveries in three of four health centres, particularly during his- Frequencies of several manifestations of D&A were high, with tory taking in the admissions process. Lack of privacy—including Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 Health Policy and Planning, 2018, Vol. 33, No. 3 323 Table 4. Reported experiences of disrespect and abuse by facility Type of D&A Total Amhara SNNP P-value High volume Low volume High volume Low volume N¼ 77 N¼ 21 N¼ 71 N¼ 35 n (%) n (%) n (%) n (%) n (%) Any form of D&A 43 (21.1) 30 (39.0) 8 (38.1) 4 (5.6) 1 (2.9) 50.001* Physical abuse 1 (0.5) 1 (1.3) 0 (0) 0 (0) 0 (0) 1.000 Non-consented care 36 (17.8) 26 (33.8) 7 (33.3) 3 (4.2) 0 (0) 50.001* Lack of privacy 31 (15.2) 25 (32.5) 4 (19.1) 1 (1.4) 1 (2.9) 50.001* Non-confidential care 28 (13.7) 22 (28.6) 5 (23.8) 1 (1.4) 0 (0) 50.001* Non-dignified care 2 (1.0) 2 (2.6) 0 (0) 0 (0) 0 (0) 0.736 Abandonment 5 (2.5) 4 (5.2) 1 (4.8) 0 (0) 0 (0) 0.092 Detention 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) NA *P50.001. lack/misuse of privacy curtains and women not covered during to report D&A than those who delivered during the day, although examinations and/or labour and delivery—were frequently recorded the difference was not significant (OR¼ 0.69, 95% CI 0.33, 1.45). in all health centres, although specific manifestations differed signifi- Finally, women who had not previously delivered at the study health cantly between health centres. centre were 3.2 times more likely to report experiencing any form of Finally, a wide range of non-dignified behaviours were observed, D&A than women who had delivered previously at the health centre many with significantly variable distribution between health centres. (OR¼ 3.2, 95% CI 1.27, 8.05). However, the cadre of birth attend- Two thirds of women in ALV were not congratulated after giving ant at the time of delivery was not significantly associated with birth compared to 15% in AHV and 23% in SLV. Despite having reporting of D&A. lower volume, women in ALV and SLV were more likely to be assigned to an unclean bed in the post-natal ward. Further, 83.9% Adjusted associations with reporting of D&A of women observed were not asked about their preferred birth posi- A facility-level fixed effects logistic regression model was estimated tion; however, cultural customs were allowed during most births to assess the associations between reported D&A and client charac- when requested by the woman. teristics (Table 5, Adjusted). Experience of maternal or neonatal complications and delivery time remained significant predictors of Client reports of D&A reporting of D&A, as did the specific health facility. Religious affili- During exit interviews, one in five respondents (21.1%) reported ation was collinear with the facility type indicator (i.e. Muslims experiencing some form of D&A during labour and delivery. were only in SHV), and thus not included in the model. Women Prevalence was significantly higher among health centres in the who experienced any complications or whose newborn experienced Amhara region (Table 4). The most commonly reported type of any complications were 15.51 times more likely to report any D&A D&A was non-consented care (17.8%), with abdominal palpations than women who did not (OR¼ 15.51, 95% CI 4.38, 54.94) when and vaginal examinations both commonly reported examples controlling for the facility and client characteristics. Women who (10.8% and 15.2% of respondents, respectfully, data not shown). delivered on the weekend were 95% less likely than women who Lack of privacy (15.2%) and non-confidential care (13.7%) were gave birth during the day on a weekday to report any D&A also highly reported. Every category of D&A was more frequently (OR¼ 0.05, 95% CI 0.01, 0.32). reported in the health centres in the Amhara region than those in SNNP region, and this difference was significant for overall D&A, Discussion non-consented care, lack of privacy, and non-confidential care (P50.001 for each). The objective of our study was to understand the manifestations of D&A in four rural health centres for the purposes of informing Unadjusted associations with reporting of D&A community-led interventions. To ensure a comprehensive approach, In bivariate analyses (Table 5, Unadjusted), religious affiliation was we employed tools that captured two perspectives: observed D&A highly associated with reporting of D&A, with Muslim women as recorded by clinicians trained to observe client-provider interac- being significantly less likely to report experiencing D&A than tions, and experienced D&A as reported by women who gave birth Christian women [odds ratio (OR)¼ 0.16, 95% CI 0.05, 0.47] (data in the health centres. During the client-provider interactions, non- not shown). Women from urban kebeles (villages) were 2.5 times as dignified care was observed most often (83.9%), although types var- likely to report experiencing D&A than those from rural areas ied significantly between health centres. Of the women interviewed (OR¼ 2.48, 95% CI 1.25, 4.92). Women who experienced any post-partum, 21.1% reported experiencing any type of D&A, and complications or had an infant who experienced complications were birth complications increased the odds of reporting D&A by nearly eight times more likely to report any D&A than women who did not eight-times in the unadjusted analyses, which doubled when (OR¼ 7.98, 95% CI 3.70, 17.22). Compared to women who deliv- adjusted for socio-demographic and index birth characteristics. ered during the day on a weekday, women who delivered on the The significant variance in frequencies and types of observed weekend were 83% less likely to report any D&A (OR¼ 0.17, 95% D&A between health centres reinforce the theory that efforts to CI 0.05, 0.063). Women who delivered at night were also less likely address D&A require a localized effort ‘where women live and Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 324 Health Policy and Planning, 2018, Vol. 33, No. 3 Table 5. Odds ratios of respondents experiencing any disrespect and abuse during childbirth, crude and adjusted analysis Characteristics Unadjusted Adjusted OR (95% CI) OR (95% CI) Age group 16–24 1.00 1.00 25–34 1.17 (0.56–2.46) 1.98 (0.59–6.66) 35–45 1.33 (0.45–3.95) 0.45 (0.08–2.44) Education None 1.00 1.00 Primary 1.19 (0.55–2.56) 3.11 (0.89–10.85) Secondaryþ 1.32 (0.55–3.21) 2.94 (0.55–15.66) Marital status Other 1.00 1.00 Married 0.65 (0.19–2.17) 0.84 (0.16–4.39) Occupation Homemaker 1.00 1.00 Farming 1.32 (0.60–2.90) 1.91 (0.37–9.8) Other 1.05 (0.44–2.50) 0.31 (0.06–1.48) Wealth tercile Poorest 1.00 1.00 Medium 1.41 (0.62–3.19) 3.20 (0.71–14.39) Least poor 1.00 (0.13–0.44) 3.37 (0.54–20.92) Place of residence Rural 1.00 1.00 Urbanþ 2.48* (1.25–4.92) 1.64 (0.29–9.32) Travel time to reach the facility 51 h 1.00 1.00 1–2 h 0.59 (0.25–1.39) 0.23* (0.06–0.89) >2 h 0.85 (0.31–2.28) 0.70 (0.17–3.00) Referred to the facility Referred 1.00 1.00 Came directly 0.38 (0.10–1.40) 0.40 (0.04–3.62) Any complications No 1.00 1.00 Yes 7.98* (3.70–17.22) 15.51* (4.38–54.94) Delivery time Weekdays day 1.00 1.00 Weekdays night 0.69 (0.33–1.45) 0.53 (0.15–1.80) Weekend 0.17* (0.05–0.63) 0.05* (0.01–0.32) Birth attendant Health officer 1.00 1.00 Nurse 2.37 (0.84–6.66) 2.11 (0.35–12.74) Midwife 1.39 (0.58–3.34) 1.21 (0.29–5.14) Number of ANC visits 0–2 1.00 1.00 3–4 0.66 (0.27–1.61) 0.55 (0.13–2.27) Previously delivered at the facility Yes 1.00 1.00 No 3.20* (1.27–8.05) 1.66 (0.47–5.8) Previously used the facility Yes 1.00 1.00 No 0.92 (0.42–2.03) 0.63 (0.19–2.13) *P50.05. labour’ (Freedman and Kruk 2014). However, frequencies of some measures reported by colleagues using similar tools (Kruk et al. manifestations were high across all health centres, including struc- 2014; Abuya et al. 2015a; Ratcliffe et al. 2016a; Sando et al. 2016). tural deficiencies (i.e. no partitions separating beds for first exami- Overall D&A varied significantly by health centre, and was more nation) and breakdowns in preferred client-provider interactions prevalent in Amhara region than SNNP region. (i.e. mother not asked about preferred birth position), indicating In using multiple methods to measure D&A, several interesting there is a role for larger systemic support for improved infrastruc- patterns emerged. The frequency of D&A was higher at direct obser- ture as well as increased accountability for standards of care. During vation than reported by women during the exit interview, which exit interviews, more than one in five women reported experiencing was consistent across all health facilities. The differences in fre- some type of D&A while giving birth, comparable to prevalence quency of observed D&A between regions was less straightforward, Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 Health Policy and Planning, 2018, Vol. 33, No. 3 325 and no clear pattern emerged as to which region had more D&A maternal and newborn survival (D’Oliveira et al. 2002; Bowser and observed. For example, the single non-consent variable (lack of con- Hill 2010). Thus, lower reports of D&A may reflect more personal- sent for first vaginal information) was observed in 68.4% of women ized attention given to women compared to women who give birth but non-consented care was reported by only 17.8% of women. during the weekday. These data are important considerations when This discrepancy varied significantly by facility: Amhara high vol- recommending that health systems examine supply-side factors that ume 64.1% observed vs 33.8% reported; Amhara low volume contribute to maternal death and morbidity (Knight et al. 2013). 86.7% observed vs 33.3% reported; SNNP high volume 93.9% This will be of particular importance to Ethiopia, where some observed vs 4.2% reported; and SNNP low volume 22.9% observed regions have reported a 10-fold increase in facility-based delivery vs 0% reported. These inconstant data underline the need to tailor over a 7 year period within the past decade (The Last Ten D&A interventions to facilities and their surrounding communities, Kilometers Project 2015), raising concerns about whether facilities while bearing in mind that individual birth characteristics may ren- are adequately equipped and staffed to accommodate this increased der a woman more at risk for experiencing D&A. patient flow. The discrepancies in observed vs experienced D&A are among Finally, although infrastructure challenges may have contributed the most discussed in the field (Rosen et al. 2015; Sando et al. to D&A observed during client-provider interactions, D&A has also 2017). Freedman et al. (2014) note that D&A is not a single defini- been documented in health care facilities that are well-staffed and tion, but a confluence of experiences, drivers and external factors; stocked (Jewkes et al. 1998). Our observations showed that pro- these include normalization of behaviour and circumstances by both viders were sometimes active perpetrators of D&A. Rarely were woman and provider, mistreatment due to failing infrastructure, women asked about their preferred birth position, nor did providers and deviations from professional norms and standards. One could routinely obtain consent for vaginal examinations, introduce them- presume that using data collectors with a background as health care selves to women or congratulate women after giving birth. These providers may have introduced bias towards underreporting of instances provide an opportunity to improve specific patient-centred D&A; yet, D&A prevalence was higher when scored by providers practices during routine training at the health centres. than reported by women. The larger difference between observed and reported D&A in SNNP region suggests that women may have Limitations normalized D&A to a greater degree than women from the Amhara The study had several limitations. First, as the study sites were region. selected based on a set of criteria, but were not representative of all Further examination of predictors shows that most client charac- clinics in these regions, the results of the study are not generalizable teristics in the unadjusted models were not significantly associated to other health facilities within Ethiopia. Additionally, the health with reporting of D&A. For example, women’s age and education centres were part of a larger initiative for community-led quality were not significantly associated with reporting of D&A in the improvement; therefore, it is possible that the study sites were more unadjusted or adjusted models, which was consistent with findings attuned to professional standards and were more attentive to from Tanzania, Kenya and Nigeria (Kruk et al. 2014; Okafor et al. required facility maintenance than other facilities in the region. 2014; Abuya et al. 2015a). Among index birth characteristics, Although all women giving birth at the facilities were invited to par- reported birth complications were most strongly associated with ticipate in the study, the sample is inherently biased, as the vast increased odds for reporting D&A, and the magnitude nearly majority of women in Ethiopia do not give birth in health facilities doubled when adjusted. It could be argued that more complicated (Central Statistical Agency 2014). Women who opted to give birth deliveries are more stressful for health care providers, which lowers in facilities may have been more or less likely to report D&A than the quality of services provided. Alternatively, we could hypothesize other women in Ethiopia. For example, more than half of women that women who have complicated pregnancies are more prone to interviewed reported living less than 1-h travel distance from the perceive the way they are treated as disrespectful. Further, the analy- health centre; it is possible that the sample were more likely to know ses were based on complications that women reported, as opposed their provider—whether through previous interactions with the to complications documented in a medical record, and it could be health system or social connections—and perhaps less likely to that those who experienced D&A were more likely to report compli- report D&A. cations. Although the directionality of the association cannot be Second, the sample size was powered to estimate overall D&A determined concretely, the association of birth complications and prevalence and not powered to detect variability of D&A by the D&A merits further investigation. independent variables. As such, some of non-significant effects of Of particular note were the unexpected associations with D&A. client characteristics (e.g. education and wealth) or index birth char- Although midwifery care has been identified as a contributing factor acteristics (e.g. number of ANC visits) that showed strong associa- to higher quality, respectful care (Renfrew et al. 2014), and the tions could be due to lack of power of the sample. Also, limiting the majority of births in our study were attended by midwives, there sample size to four facilities prevented the ability to examine associ- was no significant association between midwife attendance at birth ations between facility characteristics and D&A. and reporting of D&A. Weekend delivery, often considered a risk Third, exit interviews immediately post-partum are a debated factor for obstetric complications (Janakiraman et al. 2011), was method of obtaining data on D&A (Glick 2009; Kruk et al. 2014). protective across models, and the association was even stronger Three to 6 h post-partum may be too soon to interview women, as when adjusted for socio-demographic and index birth characteris- they may be exhausted, not wanting to engage, more focused on the tics. Childbirth was the only maternal health service offered on status of their infant, and/or have not yet reflected on the birthing weekends at the study health centres, which may have contributed experience. Other studies have complemented exit interviews with to lower caseload per provider. Patient flow has been suggested as community interviews conducted four to ten weeks post-delivery to an environmental factor that may contribute to D&A, and that high patient volume or low staff count would be associated with high compare reported D&A (Kruk et al. 2014; Sando et al. 2016); D&A because staff are overworked, possibly burned out, and/or not unfortunately, the study budget did not allow for this method. able to perform tasks beyond what is considered necessary to ensure Fourth, although every effort was made to assure women that data Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 326 Health Policy and Planning, 2018, Vol. 33, No. 3 collectors were not affiliated with the health centre and that their Funding responses were anonymous, interviewing women on facility grounds This project was made possible through generous support from The John and may have increased the chance of courtesy bias. It is also possible Katie Hansen Family Foundation and from the Bill & Melinda Gates that women felt fear of retaliation from health care providers and Foundation through award OPP1033808 for the Maternal Health Task Force staff should they report negative experiences while at the health at the Women and Health Initiative at the Harvard T.H. Chan School of centre. Public Health. Additional support for the level of effort for WB and AMK on this manuscript was awarded by the Bill & Melinda Gates Foundation Finally, it is highly complex to measure D&A through observa- through opportunity OPP1131042. tion. Despite recent progress, D&A has yet to be universally defined or operationalized (Freedman et al. 2014; Bohren et al. 2015; Vogel Conflict of interest statement. None declared. et al. 2015a,b) and some instances of D&A are entirely subjective, and may not be captured by a third-party observer. While the data Notes collectors came to consensus on how to observe each item during 1. Woredas are administrative areas with an average population training, we are limited in that the operationalization was not for- of about 100 000 people. mally documented. Further, the presence of the observer him/herself 2. Staffed with two female health extension workers (HEWs), the may influence the prevalence of some D&A behaviours. However, if health posts provide community-based basic promotive, pre- behaviours are normalized enough within the clinical setting, then it ventive and curative health services to a kebele (i.e. villages) is less likely to affect practice. The tool employed by this study was with about 5000 people. designed to capture specific instances of D&A, but did not ask data 3. Maternal and fetal complications included extreme pain, high collectors to comprehensively document any instances of D&A. For blood pressure/seizures/blurred vision/severe headache, swel- example, observers noted incidence of fundal pressure as physical ling in hands/feet, fetal distress; or high birthweight, prolonged abuse, but were not prompted throughout the observation to docu- labour (more than 12 h), post-partum haemorrhage, infection ment all instances of physical abuse, such as pinching and slapping, (fever). Newborn complications included respiratory distress, which have been observed and reported in other settings (Jewkes signs of infection, difficulty feeding and jaundice. et al. 1998; Okafor et al. 2014; Abuya et al. 2015b; Ratcliffe et al. 4. The wealth index score was constructed for each of the 2016b). Therefore, the information collected through this tool is respondents with the principal component analysis of the somewhat incomplete and does not yield a comprehensive observed household possessions (electricity, watch, radio, television, prevalence of D&A. Because of this limitation, direct comparisons mobile phone, telephone, refrigerator, table, chair, bed, electric of overall observed prevalence to overall prevalence from women’s stove and kerosene lamp), and household characteristics (main reports are not possible. We recommend that those intending to material of roof, type of latrine, water source). The households measure observed D&A include a prompt to document all instances were ranked according to the wealth score and then divided of D&A during client-provider interactions. While the maternal into three terciles indicating poorest, medium and least poor health field is debating what method is the ‘best’ or ‘most accurate’ households (Filmer and Pritchett, 2001). to define, describe, and report D&A, studies should seek to test dif- ferent approaches and methodologies, given previous research and practical constraints, and report on them and their findings to allow for comparison between methods to build the evidence base for the References field. Abuya T, Ndwiga C, Ritter J et al. 2015a. The effect of a multi-component intervention on disrespect and abuse during childbirth in Kenya. BMC Conclusion Pregnancy and Childbirth 15: 224. Abuya T, Warren CE, Miller N et al. 2015b. Exploring the prevalence of disre- D&A is a violation of human rights and a threat to achieving good spect and abuse during childbirth in Kenya. PloS One 10: e0123606. maternal health outcomes. To date, this is one of the first studies to Asefa A, Bekele D. 2015. Status of respectful and non-abusive care during quantify the prevalence of D&A at the PHCU level in Ethiopia, the facility-based childbirth in a hospital and health centers in Addis Ababa, frontline of facility-based childbirth in the national health care sys- Ethiopia. Reproductive Health 12: 33. tem. As access to facility-based childbirth increases across the coun- Belay T, Abdullah M, Mengistu H. (2007). Making pregnancy safer initia- try, the data presented here provide evidence of a much-needed shift tive—program impact in selected pilot areas. Ethiopian Medical Journal 45: in priorities towards improving the quality of care, including respect 115–22. Berhane Y, Gossaye Y, Emmelin M et al. 2001. Women’s health in a rural set- and dignity during childbirth. Future efforts should include nation- ting in societal transition in Ethiopia. Social Science & Medicine 53: wide policies and initiatives in improving facility infrastructure and 1525–39. enforcing accountability of professional standards, as well as local, Bohren MA, Vogel JP, Hunter EC et al. 2015. The mistreatment of women facility-specific interventions to improve comprehensive quality of during childbirth in health facilities globally: a mixed-methods systematic care that benefits women and their babies, health care providers, review. PLoS Medicine 12: e1001847. and the community at large. Bowser D, Hill K. (2010). Exploring evidence for disrespect and abuse in facili- ty-based childbirth: report of a landscape analysis. Harvard school of public health and university research corporation. Acknowledgements Campbell OMR, Calvert C, Testa A et al. 2016. The scale, scope, coverage, and The authors express the utmost gratitude to the health care providers and capability of childbirth care. Lancet (London, England) 388: 2193–208. women who shared their stories and time for this project. They wish to Central Statistical Agency. (2014). 2014 Ethiopia Mini Demographic and acknowledge the Regional Health Bureaus of Amhara and SNNPR for their Health Survey (EMDHS). support. Finally, the authors thank Melaku Muleta and Dr. Solomon D’Oliveira AFPL, Diniz SG, Schraiber LB. 2002. Violence against women in Shiferaw for data management and field coordination, and Ludovic Trinquart health-care institutions: an emerging problem. Lancet (London, England) for statistical review of the manuscript. 359: 1681–5. Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 Health Policy and Planning, 2018, Vol. 33, No. 3 327 Filmer D, Pritchett LH. 2001. Estimating wealth effects without expenditure Renfrew MJ, McFadden A, Bastos MH et al. 2014. Midwifery and quality data—or tears. Demography 38: 115–32. care: findings from a new evidence-informed framework for maternal and Freedman LP, Kruk ME. 2014. Disrespect and abuse of women in childbirth: newborn care. Lancet (London, England) 384: 1129–45. challenging the global quality and accountability agendas. Lancet (London, Rosen HE, Lynam PF, Carr C et al. 2015. Direct observation of respectful England) 384: e42–4. maternity care in five countries: a cross-sectional study of health facili- Freedman LP, Ramsey K, Abuya T et al. 2014. Defining disrespect and abuse ties in East and Southern Africa. BMC Pregnancy and Childbirth 15: of women in childbirth: a research, Policy and rights agenda. Bulletin of the 306. World Health Organization 92: 915–7. Sando D, Kendall T, Lyatuu G et al. 2014. Disrespect and abuse during child- Glick P. 2009. How reliable are surveys of client satisfaction with healthcare birth in Tanzania: are women living with HIV more vulnerable? Journal of services? Evidence from matched facility and household data in Acquired Immune Deficiency Syndromes (1999) 67: S228–34. Madagascar. Social Science & Medicine 68: 368–79. Sando D, Ratcliffe H, McDonald K et al. 2016. The prevalence of disrespect Janakiraman V, Lazar J, Joynt KE et al. 2011. Hospital volume, provider vol- and abuse during facility-based childbirth in urban Tanzania. BMC ume, and complications after childbirth in U.S. hospitals. Obstetrics and Pregnancy and Childbirth 16: 1–10. Gynecology 118: 521–7. Sando D, Abuya T, Asefa A et al. 2017. Methods used in prevalence studies of Jewkes R, Abrahams N, Mvo Z. 1998. Why do nurses abuse patients? disrespect and abuse during facility based childbirth: lessons learned. Reflections from South African obstetric services. Social Science & Reproductive Health 14: 127. Medicine 47: 1781–95. Souza JP, Gu ¨ lmezoglu AM, Vogel J et al. 2013. Moving beyond essential inter- Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS et al. 2014. Global, regional, ventions for reduction of maternal mortality (the WHO Multicountry and national levels and causes of maternal mortality during 1990-2013: a Survey on Maternal and Newborn Health): a cross-sectional study. Lancet systematic analysis for the Global Burden of Disease Study 2013. Lancet (London, England) 381: 1747–55. (London, England) 384: 980–1004. StataCorp. (2015). Stata: Release 14. Statistical Software. College Station, Knight HE, Self A, Kennedy SH, Young RC. 2013. Why are women dying TX: StataCorp LLC. when they reach hospital on time? A systematic review of the third delay. The Last Ten Kilometers Project. 2015. Trends in Reproductive, Maternal, PLoS One 8: e63846. Newborn and Child Health Care Practices in 115 L10K Woredas: Analyses Koblinsky M, Moyer CA, Calvert C et al. 2016. Quality maternity care for every of Three Rounds of Survey Data. Addis Ababa. http://l10k.jsi.com/ woman, everywhere: a call to action. Lancet (London, England) 388: 2307–20. Resources/Docs/L10KsRoundIIISurveyFinalReport.pdf, accessed 26 Kruk M, Kujawski S, Mbaruku G et al. 2014. Disrespectful and abusive treat- September 2016. ment during facility delivery in Tanzania: a facility and community survey. Tunc ¸alp O, Were WM, MacLennan C et al. 2015. Quality of care for pregnant Health Policy and Planning: 1–8. doi:10.1093/heapol/czu079. women and newborns-the WHO vision. BJOG: An International Journal of Kruk ME, Paczkowski MM, Tegegn A et al. 2010. Women’s preferences for Obstetrics and Gynaecology 122: 1045–9. obstetric care in rural Ethiopia: a population-based discrete choice experi- Vogel JP, Bohren MA, Tunc¸alp O et al. 2015a. Promoting respect and prevent- ment in a region with low rates of facility delivery. Journal of Epidemiology ing mistreatment during childbirth. BJOG: An International Journal of and Community Health 64: 984–8. Obstetrics and Gynaecology doi:10.1111/1471-0528.13750. Kujawski S, Mbaruku G, Freedman LP et al. 2015. Association between disre- Vogel JP, Bohren MA, Tunc¸alp O et al. 2015b. How women are treated during spect and abuse during childbirth and women’s? Confidence in health facili- facility-based childbirth: development and validation of measurement tools ties in Tanzania. Maternal and Child Health Journal 19: 2243–50. in four countries—phase 1 formative research study protocol. Reproductive Ogangah C, Slattery E, Mehta A. (2007). Failure to Deliver: Violations of Health 12: 60. Women’s Human Rights in Kenyan Health Facilities. Warren C, Njuki R, Abuya T et al. 2013. Study protocol for promoting Okafor II, Ugwu EO, Obi SN. 2015. Disrespect and abuse during respectful maternity care initiative to assess, measure and design interven- facility-based childbirth in a low-income country. International Journal of tions to reduce disrespect and abuse during childbirth in Kenya. BMC Gynecology and Obstetrics 128: 110–3. Pregnancy and Childbirth 13: 21. Ratcliffe HL, Sando D, Lyatuu GW et al. 2016a. Mitigating disrespect and WHO, UNICEF, UNFPA, World Bank Group and the United Nations abuse during childbirth in Tanzania: an exploratory study of the effects of Population Division. 2015. Trends in Maternal Mortality 1990 to 2015. two facility-based interventions in a large public hospital. Reproductive http://datatopics.worldbank.org/hnp/files/Trends in Maternal Mortality Health 13: 79. 1990 to 2015 full report.PDF, accessed 29 February 2016. Ratcliffe HL, Sando D, Mwanyika-Sando M et al. 2016b. Applying a partici- World Health Organization. 2015. Strategies Toward Ending Preventable patory approach to the promotion of a culture of respect during childbirth. Maternal Mortality (EPMM), 6736, pp. 1–4. http://apps.who.int/iris/bit Reproductive Health 13: 80. stream/10665/153544/1/9789241508483_eng.pdf? ua¼1. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health Policy and Planning Oxford University Press

Jeopardizing quality at the frontline of healthcare: prevalence and risk factors for disrespect and abuse during facility-based childbirth in Ethiopia

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Copyright © 2022 The London School of Hygiene and Tropical Medicine and Oxford University Press
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10.1093/heapol/czx180
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Abstract

Disrespect and abuse (D&A) experienced by women during facility-based childbirth has gained global recognition as a threat to eliminating preventable maternal mortality and morbidity. This study explored the frequency and associated factors of D&A in four rural health centres in Ethiopia. Experiences of women who delivered in these facilities were captured by direct observation of client-provider interaction (N¼ 193) and exit interview at time of discharge (N¼ 204). Incidence of D&A was observed in each facility, with failure to ask woman for preferred birth position most commonly observed [n¼ 162, 83.9%, 95% confidence interval (95% CI) 78.0–88.5%]. During exit interviews, 21.1% (n¼ 43, 95% CI 15.4–26.7%) of respondents reported at least one occurrence of D&A. Bivariate models using client characteristics and index birth experience showed that wom- en’s reporting of D&A was significantly associated with childbirth complications [odds ratio (OR)¼ 7.98, 95% CI 3.70, 17.22], weekend delivery (OR¼ 0.17, 95% CI 0.05, 0.63) and no previous delivery at the facility (OR¼ 3.20, 95% CI 1.27, 8.05). Facility-level fixed-effect models found that experience of complications (OR¼ 15.51, 95% CI 4.38, 54.94) and weekend delivery (OR¼ 0.05, 95% CI 0.01–0.32) remained significantly and most strongly associated with self-reported D&A. These data suggest that addressing D&A in health centres in Ethiopia will require a sustained effort to improve infrastructure, support the health workforce in rural settings, enforce professional stand- ards and target interventions to improve women’s experiences as part of quality of care initiatives. Keywords: Quality of care, maternal health, disrespect and abuse, primary health care, maternity services V The Author(s) 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. 317 Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 318 Health Policy and Planning, 2018, Vol. 33, No. 3 Key Messages Disrespect and abuse (D&A) experienced by women during facility-based childbirth has gained global recognition as a threat to eliminating preventable maternal mortality and morbidity. This study sought to quantify the frequency and categories of D&A experienced by women in four health centres in two rural regions of Ethiopia for the purposes of developing a community-led intervention. Experiences of women who deliv- ered in these facilities were captured by direct observation of client-provider interaction and exit interview at time of discharge. During exit interviews, 21.1% of respondents reported at least one occurrence of D&A. Failure to ask woman for pre- ferred birth position most commonly observed during client-provider interactions (83.9%). Complications during child- birth and time of delivery were significantly associated with reported D&A. Addressing D&A in health centres in Ethiopia will require a shift in priorities towards improving the experience and quality of care, a sustained effort to improve health care centres’ infrastructure and greater support of the rural health workforce. dramatically increasing the number of primary health centres Introduction (‘health centres’) and eliminating user fees, yet the national facility Complications from pregnancy and childbirth are the leading causes delivery rate in Ethiopia remains low at 15% (Central Statistical of maternal mortality and morbidity for women of reproductive age Agency 2014). Ethiopian women who have access to health facilities in developing countries (Kassebaum et al. 2014). It is widely often choose to give birth elsewhere, even among women for whom acknowledged that maternal deaths can be prevented if women have the benefits of facility-based childbirth have been demonstrated access to skilled childbirth services within a formal health care sys- (Kruk et al. 2010). Poor provider attitudes—including harassment, tem (Campbell et al. 2016). However, evidence has shown that lack of attention to complaints, and lack of follow-up in labour— access to maternal health services alone is insufficient to prevent have been cited as deterrents to the use of facility services (Belay maternal deaths, and that the quality of care received is integral to et al. 2007). Additional studies in Ethiopia have found that women ensuring good maternal health outcomes (Souza et al. 2013). This is perceive health care providers to be insensitive and unduly harsh reflected in the post-2015 development agenda, which underlines (Berhane et al. 2001) and unresponsive to community beliefs and the growing recognition of the importance of quality in health serv- ice delivery (Koblinsky et al. 2016). The WHO Quality of Care practices. Thus, women’s poor experiences with care at health framework for maternal and newborn health expanded the defini- centres may be deterring them from seeking childbirth services, tion of ‘quality of care’ to give equal value to clinical (or ‘technical’) undermining existing national efforts to prevent maternal mortality. quality and experiences of care, while the Strategies towards Ending Colleagues have investigated respect and dignity during perinatal Preventable Maternal Mortality (EPMM) working group high- care in tertiary hospitals in Ethiopia, (Asefa and Bekele 2015; Rosen lighted priority recommendations for eliminating discrimination and et al. 2015). However, to our knowledge, the prevalence of D&A developing health systems that can deliver interventions both effec- reported by women at health centres in rural Ethiopia, the level of tively and equitably (Tunc ¸alp et al. 2015; World Health the health system at which women are encouraged to seek facility- Organization 2015). based delivery, had never been investigated. This study sought to Disrespect and abuse (D&A) experienced by women during quantify the frequency and categories of D&A experienced by facility-based childbirth is gaining recognition as violation of wom- women in four health centres in two rural regions of Ethiopia for en’s rights (Ogangah et al. 2007; Freedman et al. 2014; Sando et al. the purposes of developing a community-led intervention. As part of 2014; Abuya et al. 2015). Further, D&A has been acknowledged as this endeavour, we identified factors associated with reporting D&A a deficiency in the delivery of high quality maternal health services, to identify the most appropriate area for intervention. threatening the ability of health systems to achieve good maternal Understanding the factors associated with D&A will assist in local health outcomes (Bowser and Hill 2010; Kruk et al. 2014; Abuya and national efforts to improve the quality of care, increase rates of et al. 2015a; Bohren et al. 2015; Vogel et al. 2015a,b; Sando et al. facility-based delivery and improve maternal health outcomes in a 2016). D&A manifests as physical violence, harsh language, stigma primary health care setting. and neglect suffered by women at the hands of health care providers (Bowser and Hill 2010; Kruk et al. 2014; Abuya et al. 2015a; Bohren et al. 2015; Ratcliffe et al. 2016a). Drivers of D&A can Methods include systemic failures, such as overwhelmed health care adminis- Study design tration, poor staffing and supervisory structures and inadequate The study was a cross-sectional design to assess manifestations of physical infrastructure (Bowser and Hill 2010; Freedman and Kruk D&A among women who gave birth in four rural health centres in 2014; Ratcliffe et al. 2016b). Women who experience D&A are Amhara and Southern Nations, Nationalities, and Peoples (SNNP) more likely to report lower satisfaction with their birth experience regions of Ethiopia during July–September 2013. Client-provider and are less likely to seek facility-based delivery for future pregnan- interactions during labour and delivery were observed for 193 cies (Kujawski et al. 2015). births, and 204 women who gave birth at these health centres were Such considerations are important for Ethiopia, which, with 353 interviewed at their time of discharge from the facility (n¼ 204). maternal deaths per 100 000 live births, has one of the highest Health workers in the participating health centres were aware that maternal mortality ratios in the world (WHO, UNICEF, UNFPA the quality of client-provider interactions was being captured 2015). The Ethiopian Federal Ministry of Health has worked to improve access to facility-based maternal health services by through direct observation and women surveyed. Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 Health Policy and Planning, 2018, Vol. 33, No. 3 319 Study setting Twelve data collectors and four supervisors with bachelor’s To ensure universal coverage of primary health care, the degrees in health sciences who were working concurrently as health- care providers in non-study health facilities were responsible for Government of Ethiopia has been investing substantially to develop data collection. One full day of training was provided to data collec- the district- or woreda -level health system, which encompasses a tors and supervisors to familiarize them with the instrument and primary hospital with four to five primary health care units methods for interview techniques for sensitive material, including (PHCUs). Each PHCU is comprised of one health centre that serves appropriate recording, acquiring informed consent and ensuring a population of approximately 25 000, and five satellite health confidentiality. Data collectors and supervisors were trained to posts. Designed to be the front line of service delivery for childbirth, administer both the client-provider interaction and women’s exit the health centres are staffed with health officers, nurses and mid- interview tools. Three data collectors and one supervisor were wives to provide primarily curative care, including basic emergency deployed to each health centre. Data collectors worked in 8-h shifts obstetric and newborn care (BEmONC). Additionally, the health to allow for continuous coverage at the health centre. centres receive referrals from the health posts, and provide essential 2 All women who gave birth in the four health centres during the supplies, technical and administrative support to the health posts. study period were eligible to participate in the study; there were no The study was conducted in four health centres that are sup- refusals. The expected sample size of 246 was based on an assumed ported by the Last Ten Kilometers (L10K), a technical support pro- prevalence of D&A of 20% across all study sites assuming 65% gram for the Ethiopian Federal Ministry of Health that aims to precision and 95% confidence interval (95% CI), an estimate based strengthen the links between households, communities and the for- on a similar study in Kenya (Warren et al. 2013). malized health care system. Two of the study health centres were in Client-provider interactions were captured through one-to-one Amhara region and two were in Southern Nations, Nationalities direct observation from a woman’s time of entry at the health centre, and Peoples’ region (SNNP). Amhara (population 20.3 million) and throughout the labour and delivery period, until her time of entry to the SNNP (population 18.9 million) are respectively the second and post-natal ward. The data collector used a structured observation tool third most populous regions in Ethiopia, representing about 46% of to capture specific manifestations of D&A. If the observation period the population of the country. The four health centres were purpo- continued beyond the 8-h shift, the data collector handed over the sively selected among fourteen health centres that were part of the observation tool to the arriving data collector. The exit interview was L10K’s ongoing clinical quality improvement activities. To account conducted at the time of discharge, approximately three to 6 h post-par- for any differences in D&A associated with patient flow, the four tum; the questionnaire focused on the woman’s perceived experiences health centres were sampled such that each region included one high of D&A during her labour and delivery at the health centre. volume health centre (>450 deliveries annually) and one low vol- Written consent was obtained from women during the first stage ume health centre (fewer than 150 deliveries annually). At each of labour at admittance. All records and data collection tools were health centre, maternity staff provided care in three units during the assigned an anonymous code, and identifiers were not used in the weekdays (family planning, antenatal care, and labour and delivery), analysis or final reporting. Ethical clearance was obtained from while only labour and delivery services were provided at night and Institutional Review Boards at the Amhara and SNNP Regional during the weekends. Health Bureaus and an ethical clearance waiver for secondary data analysis was obtained from the Harvard T.H. Chan School of Public Data collection Health Institutional Review Board. Study instruments were adapted from the tools developed by the Population Council in Kenya to fit the Ethiopian context (Abuya Measurements et al. 2015a). The client-provider interaction tool was administered D&A were operationalized using an adaptation of the seven categories in English, the ‘language of medicine’ in Ethiopia. The exit interview described in Bowser and Hill’s landscape analysis (Bowser and Hill tool was administered in Amharic; the original English tool was 2010)(see Figure 1). Indicators for observed events of D&A were iden- translated into Amharic and then translated back to English to tified through the literature and local BEmONC protocol. Since ensure consistency. observing D&A is inherently subjective and heavily based on local Figure 1. Categories of disrespect and abuse. Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 320 Health Policy and Planning, 2018, Vol. 33, No. 3 Figure 2. Independent variables. norms (Freedman et al. 2014), each item on the client-provider interac- characteristics varied significantly between health centres. More tion tool was reviewed during data collection training to determine women from the SNNP region were from a rural kebele (village) local consensus on the manifestation of D&A and practiced among than those in the Amhara region (P50.001). Religious affiliation differed substantially between the study sites as well (P50.001), data collectors to ensure consistency in recording. As part of a larger with all respondents who self-identified as Muslim concentrated in global consensus on describing and defining prevalence from the per- the SNNP region’s high volume (SHV) health centre. Wealth tercile spective and experience of the woman (Freedman et al. 2014; Kruk distribution varied significantly between health centres (P50.001), et al. 2014; Abuya et al. 2015a; Sando et al. 2016), prevalence of each with women from the SNNP region low volume health centre (SLV) of D&A category was calculated using the exit interview data. Women and the Amhara region high volume health centre (AHV) tending to who reported experiencing one or more sub-components of D&A be poorer than women from the Amhara region low volume health were included in the overall prevalence measure. centre (ALV) and SHV. Occupation (P50.001) was significantly Independent variables were chosen based on hypotheses that differentially distributed by health centre; 71% of women from women from certain sub-groups, previous history with the healthcare ALV identified as farmers and 71% of SLV identified as system and/or individual experiences with the index birth, including 3 homemaker. Educational attainment was significantly different birth complications, maybemorelikelytoreportD&A (see Figure 2). across sites (P50.05), with women from low volume health centres less likely to have formal education than women from high-volume Data management and analysis sites. Study instruments were thoroughly examined for completion and Nearly all respondents (95.1%) reported coming directly to the accuracy by the data supervisors. Ten percent of the data entries health centre for delivery without a referral. For most respondents, were randomly selected and checked for consistency; frequencies travel to the health centre took less than 1 h, though this varied sig- were used to check for outliers and cleaning of data. nificantly by health centre (P50.005) and women from ALV Differentials in socio-demographic and index birth variables of reported longer travel times overall. More than 85% of respondents women in the samples of the four health centres were assessed using completed at least three or four antenatal care visits. Approximately bivariate analyses. The prevalence of observed and reported D&A one-third of respondents reported that they or their infant experi- was estimated and whether it varied by facility were assessed using enced some type of complication; women from SNNP health centres Fisher’s exact test. Vast variations between observed and reported were less likely to report any form of complication. Nearly half of D&A were expected due to cultural norms, varying perspectives on deliveries occurred during the day on weekdays, with no significant quality of care, and previous experience using the tools in a related difference between health centre, and the majority of overall births study in Dar es Salaam, Tanzania (Sando et al. 2016). were attended by a midwife, although health officers were more Then, bivariate and multivariate analyses were performed to common attendants in the low volume health centres (P50.001). examine the unadjusted and adjusted relationships between selected Although most respondents (75.5%) had used the health centre pre- socio-demographic and index birth experience. Fisher’s exact test viously to receive care for themselves, their children, or their was used for the bivariate analysis and facility-level fixed effects spouses, the majority (70.1%) had not had a previous delivery at the logistic regression was used to estimate adjusted relationships same health centre. Previous health centre utilization differed signifi- between D&A and the independent variables. Statistical significance cantly by health centre (P50.001 for each); respondents from the was considered at two-tailed P-value50.05. Stata 14.0 was used for high-volume health centres were more likely to have previously used the analysis (StataCorp 2015). the health centre for any type of care and for delivery services. Facility characteristics Results Facility data collected from on-site record books revealed that each Demographic and index birth characteristics health centre was differentially staffed and equipped (see Table 2). The demographic characteristics and birth experiences of respond- In the year preceding data collection, the low-volume health centres ents from each health centre are shown in Table 1. Overall, client saw approximately one-third fewer births than the high-volume Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 Health Policy and Planning, 2018, Vol. 33, No. 3 321 Table 1. Background characteristics and birth experience of exit interview respondents in four facilities in Amhara & SNNP region, Ethiopia, Characteristics Total Amhara SNNP P-value (N¼ 204) High volume Low volume High volume Low volume (N¼ 77) (N¼ 21) (N¼ 71) (N¼ 35) n (%) n (%) n (%) n (%) n (%) Age group 16–24 73 (35.8) 29 (37.7) 7 (33.3) 20 (28.2) 17 (48.6) 0.180 25–34 106 (52.0) 35 (45.5) 11 (52.4) 43 (60.6) 17 (48.6) 35–45 25 (12.3) 13 (16.9) 3 (14.3) 8 (11.3) 1 (2.9) Education None 89 (43.6) 35 (45.5) 11 (52.4) 37 (52.1) 6 (17.1) 0.023*** Primary 73 (35.8) 25 (32.5) 7 (33.3) 21 (29.6) 20 (57.1) Secondaryþ 42 (20.6) 17 (22.1) 3 (14.3) 13 (18.3) 9 (25.7) Religion Christian 137 (67.2) 77 (100.0) 21 (100.0) 4 (5.6) 35 (100.0) 50.001* Muslim 67 (32.8) 0 (0.0) 0 (0.0) 67 (94.4) 0 (0.0) Marital status Other 14 (6.9) 6 (7.8) 2 (9.5) 4 (5.6) 2 (5.7) 0.871 Married 190 (93.1) 71 (92.2) 19 (90.5) 67 (94.4) 33 (94.3) Occupation Homemaker 78 (38.2) 26 (33.8) 3 (14.3) 24 (33.8) 25 (71.4) 50.001* Farming 71 (34.8) 30 (39.0) 15 (71.4) 22 (31.0) 4 (11.4) Other 55 (27.0) 21 (27.3) 3 (14.3) 25 (35.2) 6 (17.1) Wealth tercile Poorest 68 (33.3) 26 (33.8) 5 (23.8) 20 (28.2) 17 (48.6) 50.001* Medium 68 (33.3) 30 (39.0) 9 (42.9) 14 (19.7) 15 (42.9) Least poor 68 (33.3) 21 (27.3) 7 (33.3) 37 (52.1) 3 (8.6) Place of residence Rural 130 (63.7) 36 (46.8) 13 (61.9) 50 (70.4) 31 (88.6) 50.001* Urban 74 (36.3) 41 (53.3) 8 (38.1) 21 (29.6) 4 (11.4) Travel time to reach the facility 51 h 123 (60.3) 39 (50.7) 8 (38.1) 50 (70.4) 26 (74.3) 0.002** 1–2 h 52 (25.5) 25 (32.5) 7 (33.3) 17 (23.9) 3 (8.6) >2 h 29 (14.2) 13 (16.9) 6 (28.6) 4 (5.6) 6 (17.1) Referred to the facility Referred 10 (4.9) 3 (3.9) 3 (14.3) 2 (2.8) 2 (5.7) 0.194 Came directly 194 (95.1) 74 (96.1) 18 (85.7) 69 (97.2) 33 (94.3) Any complications No 129 (63.2) 45 (58.4) 9 (42.9) 46 (64.8) 29 (82.9) 0.014*** Yes 75 (36.8) 32 (41.6) 12 (57.1) 25 (35.2) 6 (17.1) Delivery time Weekdays day 91 (44.6) 38 (49.4) 8 (38.1) 30 (42.3) 15 (42.9) 0.883 Weekdays night 65 (31.9) 25 (32.5) 6 (28.6) 23 (32.4) 11 (31.4) Weekend 48 (23.5) 14 (18.2) 7 (33.3) 18 (25.4) 9 (25.7) Birth attendant Health officer 51 (25.0) 8 (10.4) 12 (57.1) 11 (15.5) 20 (57.1) 50.001* Nurse 36 (17.7) 24 (31.2) 0 (0.0) 1 (1.4) 11 (31.4) Midwife 117 (57.4) 45 (58.4) 9 (42.9) 59 (83.1) 4 (11.4) Number of ANC visits 0–2 29 (14.2) 13 (16.9) 6 (28.6) 5 (7.0) 5 (14.3) 0.062**** 3–4 175 (85.8) 64 (83.1) 15 (71.4) 66 (93.0) 30 (85.7) Previously delivered at the facility Yes 61 (29.9) 14 (18.2) 3 (14.3) 34 (47.9) 10 (28.6) 50.001* No 143 (70.1) 63 (81.8) 18 (85.7) 37 (52.1) 25 (71.4) Previously used the facility Yes 154 (75.5) 56 (72.7) 13 (61.9) 65 (91.6) 20 (57.1) 50.001* No 50 (24.5) 21 (27.3) 8 (38.1) 6 (8.5) 15 (42.9) *P50.001; **P50.01; ***P50.05; ****P50.1. Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 322 Health Policy and Planning, 2018, Vol. 33, No. 3 Table 2. Facility characteristics July 2013 Facility characteristics Amhara SNNP High volume Low volume High volume Low volume Number of midwives 3 2 5 2 Number of nurses and health officers 11 12 14 16 Number trained on BEmONC 1 2 2 3 Number of delivery couches 2 1 4 2 Number of beds in the pre/post-labour ward 2 2 3 2 Number of annual deliveries 453 130 433 144 Table 3. Observed disrespect and abuse Type of disrespect and abuse observed Total Frequency Fisher’s N¼ 193 exact Amhara Amhara SNNP SNNP n (%) P-value high low high low volume volume volume volume N¼ 78 N¼ 15 N¼ 65 N¼ 35 n (%) n (%) n (%) n (%) Physical abuse Fundal pressure applied 22 (11.4) 1 (1.3) 5 (33.3) 9 (13.9) 7 (20.0) 50.001* Non-consented care Lack of consent for first vaginal examination 132 (68.4) 50 (64.1) 13 (86.7) 61 (93.9) 8 (22.9) 50.001* Non-confidential care Mother’s history taking findings shared when others could hear 64 (33.2) 37 (47.4) 7 (46.7) 3 (4.6) 17 (48.6) 50.001* Auditory privacy not respected during post-natal examination 41 (21.2) 29 (37.2) 3 (20.0) 2 (3.08) 7 (20.0) 50.001* Lack of privacy No partitions separating beds for first examination 109 (56.5) 24 (30.8) 15 (100.0) 48 (73.9) 22 (62.9) 50.001* Partitions do not give privacy in prenatal ward 53 (27.5) 37 (47.4) 0 (0) 12 (18.5) 4 (11.4) 50.001* Mother not covered during examination in prenatal ward 68 (35.2) 21 (26.9) 4 (26.7) 27 (41.5) 16 (45.7) 0.127 Mother not covered while being moved from prenatal ward to delivery room 42 (21.8) 15 (19.2) 3 (20.0) 20 (30.8) 4 (11.4) 0.149 Mother not covered during delivery 107 (55.4) 35 (44.9) 3 (20.0) 45 (69.2) 24 (68.6) 50.001* Partitions not closed during delivery 109 (56.5) 44 (56.4) 14 (93.3) 50 (76.9) 1 (2.9) 50.001* Mother not well covered after third stage of labour 60 (31.1) 20 (25.6) 3 (20.0) 20 (30.8) 17 (48.6) 0.086 No partitions/curtains between beds in post-natal ward 145 (75.1) 59 (75.6) 14 (93.3) 47 (72.3) 25 (71.4) 0.353 Mother’s physical privacy not respected during post-natal examination 40 (20.7) 28 (35.9) 3 (20.0) 0 (0) 9 (25.7) 50.001* Non-dignified care Mother not welcomed in a kind and gentle manner 24 (12.4) 10 (12.8) 6 (40.0) 8 (12.3) 0 (0) 0.002* Provider did not introduce herself to mother (antenatal ward) 158 (81.9) 68 (87.2) 15 (100.0) 60 (92.3) 15 (42.9) 50.001* Use of non-dignified language during history taking 13 (6.7) 6 (7.7) 3 (20.0) 2 (3.1) 2 (5.7) 0.127 Delivery midwife did not introduce herself by name (if it was a provider 32 (16.6) 9 (11.5) 2 (13.3) 13 (20.0) 8 (22.9) 0.367 mother had not yet met) Delivering service provider did not congratulate mother after birth 62 (32.1) 12 (15.4) 10 (66.7) 32 (49.2) 8 (22.9) 50.001* Mother not cleaned after birth and third stage of labour 50 (25.9) 34 (43.6) 3 (20.0) 13 (20.0) 0 (0) 50.001* No pad provided to mother 88 (45.6) 59 (75.64) 2 (13.3) 19 (19.2) 8 (22.9) 50.001* Mother not allocated her own bed in post-natal ward 11 (5.7) 0 (0) 11 (73.3) 0 (0) 0 (0) 50.001* Bed in post-natal ward not clean 40 (20.7) 0 (0) 11 (73.3) 12 (18.5) 17 (48.6) 50.001* Mother not called by her name throughout interactions 65 (33.7) 43 (55.1) 5 (33.3) 16 (24.6) 1 (2.9) 50.001* Mother not asked about preferred birth position 162 (83.9) 70 (89.7) 15 (100.0) 46 (70.8) 31 (88.6) 0.005** Mother not allowed to practice religious/cultural custom, if requested 10 (5.2) 8 (10.3) 1 (6.7) 0 (0) 1 (2.9) 0.022*** *P50.001; **P50.01; ***P50.05. health centres in their respective regions, yet had more nurses and significant variation between health centres. The application of fun- health officers as well as more BEmONC trained providers. The dal pressure, an example of physical abuse, was recorded in as many low-volume health centres also had fewer midwives on staff. as one-third of deliveries in ALV and one in five deliveries in SLV. Lack of consent for vaginal examination differed significantly between health centres, occurring in nearly all deliveries in the ALV D&A and SHV, and less frequently in AHV and SLV. Observed D&A Instances of non-confidential care were observed in up to half of Of the 204 women who were sampled, 193 deliveries were directly observed and specific indicators of D&A were recorded (Table 3). all deliveries in three of four health centres, particularly during his- Frequencies of several manifestations of D&A were high, with tory taking in the admissions process. Lack of privacy—including Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 Health Policy and Planning, 2018, Vol. 33, No. 3 323 Table 4. Reported experiences of disrespect and abuse by facility Type of D&A Total Amhara SNNP P-value High volume Low volume High volume Low volume N¼ 77 N¼ 21 N¼ 71 N¼ 35 n (%) n (%) n (%) n (%) n (%) Any form of D&A 43 (21.1) 30 (39.0) 8 (38.1) 4 (5.6) 1 (2.9) 50.001* Physical abuse 1 (0.5) 1 (1.3) 0 (0) 0 (0) 0 (0) 1.000 Non-consented care 36 (17.8) 26 (33.8) 7 (33.3) 3 (4.2) 0 (0) 50.001* Lack of privacy 31 (15.2) 25 (32.5) 4 (19.1) 1 (1.4) 1 (2.9) 50.001* Non-confidential care 28 (13.7) 22 (28.6) 5 (23.8) 1 (1.4) 0 (0) 50.001* Non-dignified care 2 (1.0) 2 (2.6) 0 (0) 0 (0) 0 (0) 0.736 Abandonment 5 (2.5) 4 (5.2) 1 (4.8) 0 (0) 0 (0) 0.092 Detention 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) NA *P50.001. lack/misuse of privacy curtains and women not covered during to report D&A than those who delivered during the day, although examinations and/or labour and delivery—were frequently recorded the difference was not significant (OR¼ 0.69, 95% CI 0.33, 1.45). in all health centres, although specific manifestations differed signifi- Finally, women who had not previously delivered at the study health cantly between health centres. centre were 3.2 times more likely to report experiencing any form of Finally, a wide range of non-dignified behaviours were observed, D&A than women who had delivered previously at the health centre many with significantly variable distribution between health centres. (OR¼ 3.2, 95% CI 1.27, 8.05). However, the cadre of birth attend- Two thirds of women in ALV were not congratulated after giving ant at the time of delivery was not significantly associated with birth compared to 15% in AHV and 23% in SLV. Despite having reporting of D&A. lower volume, women in ALV and SLV were more likely to be assigned to an unclean bed in the post-natal ward. Further, 83.9% Adjusted associations with reporting of D&A of women observed were not asked about their preferred birth posi- A facility-level fixed effects logistic regression model was estimated tion; however, cultural customs were allowed during most births to assess the associations between reported D&A and client charac- when requested by the woman. teristics (Table 5, Adjusted). Experience of maternal or neonatal complications and delivery time remained significant predictors of Client reports of D&A reporting of D&A, as did the specific health facility. Religious affili- During exit interviews, one in five respondents (21.1%) reported ation was collinear with the facility type indicator (i.e. Muslims experiencing some form of D&A during labour and delivery. were only in SHV), and thus not included in the model. Women Prevalence was significantly higher among health centres in the who experienced any complications or whose newborn experienced Amhara region (Table 4). The most commonly reported type of any complications were 15.51 times more likely to report any D&A D&A was non-consented care (17.8%), with abdominal palpations than women who did not (OR¼ 15.51, 95% CI 4.38, 54.94) when and vaginal examinations both commonly reported examples controlling for the facility and client characteristics. Women who (10.8% and 15.2% of respondents, respectfully, data not shown). delivered on the weekend were 95% less likely than women who Lack of privacy (15.2%) and non-confidential care (13.7%) were gave birth during the day on a weekday to report any D&A also highly reported. Every category of D&A was more frequently (OR¼ 0.05, 95% CI 0.01, 0.32). reported in the health centres in the Amhara region than those in SNNP region, and this difference was significant for overall D&A, Discussion non-consented care, lack of privacy, and non-confidential care (P50.001 for each). The objective of our study was to understand the manifestations of D&A in four rural health centres for the purposes of informing Unadjusted associations with reporting of D&A community-led interventions. To ensure a comprehensive approach, In bivariate analyses (Table 5, Unadjusted), religious affiliation was we employed tools that captured two perspectives: observed D&A highly associated with reporting of D&A, with Muslim women as recorded by clinicians trained to observe client-provider interac- being significantly less likely to report experiencing D&A than tions, and experienced D&A as reported by women who gave birth Christian women [odds ratio (OR)¼ 0.16, 95% CI 0.05, 0.47] (data in the health centres. During the client-provider interactions, non- not shown). Women from urban kebeles (villages) were 2.5 times as dignified care was observed most often (83.9%), although types var- likely to report experiencing D&A than those from rural areas ied significantly between health centres. Of the women interviewed (OR¼ 2.48, 95% CI 1.25, 4.92). Women who experienced any post-partum, 21.1% reported experiencing any type of D&A, and complications or had an infant who experienced complications were birth complications increased the odds of reporting D&A by nearly eight times more likely to report any D&A than women who did not eight-times in the unadjusted analyses, which doubled when (OR¼ 7.98, 95% CI 3.70, 17.22). Compared to women who deliv- adjusted for socio-demographic and index birth characteristics. ered during the day on a weekday, women who delivered on the The significant variance in frequencies and types of observed weekend were 83% less likely to report any D&A (OR¼ 0.17, 95% D&A between health centres reinforce the theory that efforts to CI 0.05, 0.063). Women who delivered at night were also less likely address D&A require a localized effort ‘where women live and Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 324 Health Policy and Planning, 2018, Vol. 33, No. 3 Table 5. Odds ratios of respondents experiencing any disrespect and abuse during childbirth, crude and adjusted analysis Characteristics Unadjusted Adjusted OR (95% CI) OR (95% CI) Age group 16–24 1.00 1.00 25–34 1.17 (0.56–2.46) 1.98 (0.59–6.66) 35–45 1.33 (0.45–3.95) 0.45 (0.08–2.44) Education None 1.00 1.00 Primary 1.19 (0.55–2.56) 3.11 (0.89–10.85) Secondaryþ 1.32 (0.55–3.21) 2.94 (0.55–15.66) Marital status Other 1.00 1.00 Married 0.65 (0.19–2.17) 0.84 (0.16–4.39) Occupation Homemaker 1.00 1.00 Farming 1.32 (0.60–2.90) 1.91 (0.37–9.8) Other 1.05 (0.44–2.50) 0.31 (0.06–1.48) Wealth tercile Poorest 1.00 1.00 Medium 1.41 (0.62–3.19) 3.20 (0.71–14.39) Least poor 1.00 (0.13–0.44) 3.37 (0.54–20.92) Place of residence Rural 1.00 1.00 Urbanþ 2.48* (1.25–4.92) 1.64 (0.29–9.32) Travel time to reach the facility 51 h 1.00 1.00 1–2 h 0.59 (0.25–1.39) 0.23* (0.06–0.89) >2 h 0.85 (0.31–2.28) 0.70 (0.17–3.00) Referred to the facility Referred 1.00 1.00 Came directly 0.38 (0.10–1.40) 0.40 (0.04–3.62) Any complications No 1.00 1.00 Yes 7.98* (3.70–17.22) 15.51* (4.38–54.94) Delivery time Weekdays day 1.00 1.00 Weekdays night 0.69 (0.33–1.45) 0.53 (0.15–1.80) Weekend 0.17* (0.05–0.63) 0.05* (0.01–0.32) Birth attendant Health officer 1.00 1.00 Nurse 2.37 (0.84–6.66) 2.11 (0.35–12.74) Midwife 1.39 (0.58–3.34) 1.21 (0.29–5.14) Number of ANC visits 0–2 1.00 1.00 3–4 0.66 (0.27–1.61) 0.55 (0.13–2.27) Previously delivered at the facility Yes 1.00 1.00 No 3.20* (1.27–8.05) 1.66 (0.47–5.8) Previously used the facility Yes 1.00 1.00 No 0.92 (0.42–2.03) 0.63 (0.19–2.13) *P50.05. labour’ (Freedman and Kruk 2014). However, frequencies of some measures reported by colleagues using similar tools (Kruk et al. manifestations were high across all health centres, including struc- 2014; Abuya et al. 2015a; Ratcliffe et al. 2016a; Sando et al. 2016). tural deficiencies (i.e. no partitions separating beds for first exami- Overall D&A varied significantly by health centre, and was more nation) and breakdowns in preferred client-provider interactions prevalent in Amhara region than SNNP region. (i.e. mother not asked about preferred birth position), indicating In using multiple methods to measure D&A, several interesting there is a role for larger systemic support for improved infrastruc- patterns emerged. The frequency of D&A was higher at direct obser- ture as well as increased accountability for standards of care. During vation than reported by women during the exit interview, which exit interviews, more than one in five women reported experiencing was consistent across all health facilities. The differences in fre- some type of D&A while giving birth, comparable to prevalence quency of observed D&A between regions was less straightforward, Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 Health Policy and Planning, 2018, Vol. 33, No. 3 325 and no clear pattern emerged as to which region had more D&A maternal and newborn survival (D’Oliveira et al. 2002; Bowser and observed. For example, the single non-consent variable (lack of con- Hill 2010). Thus, lower reports of D&A may reflect more personal- sent for first vaginal information) was observed in 68.4% of women ized attention given to women compared to women who give birth but non-consented care was reported by only 17.8% of women. during the weekday. These data are important considerations when This discrepancy varied significantly by facility: Amhara high vol- recommending that health systems examine supply-side factors that ume 64.1% observed vs 33.8% reported; Amhara low volume contribute to maternal death and morbidity (Knight et al. 2013). 86.7% observed vs 33.3% reported; SNNP high volume 93.9% This will be of particular importance to Ethiopia, where some observed vs 4.2% reported; and SNNP low volume 22.9% observed regions have reported a 10-fold increase in facility-based delivery vs 0% reported. These inconstant data underline the need to tailor over a 7 year period within the past decade (The Last Ten D&A interventions to facilities and their surrounding communities, Kilometers Project 2015), raising concerns about whether facilities while bearing in mind that individual birth characteristics may ren- are adequately equipped and staffed to accommodate this increased der a woman more at risk for experiencing D&A. patient flow. The discrepancies in observed vs experienced D&A are among Finally, although infrastructure challenges may have contributed the most discussed in the field (Rosen et al. 2015; Sando et al. to D&A observed during client-provider interactions, D&A has also 2017). Freedman et al. (2014) note that D&A is not a single defini- been documented in health care facilities that are well-staffed and tion, but a confluence of experiences, drivers and external factors; stocked (Jewkes et al. 1998). Our observations showed that pro- these include normalization of behaviour and circumstances by both viders were sometimes active perpetrators of D&A. Rarely were woman and provider, mistreatment due to failing infrastructure, women asked about their preferred birth position, nor did providers and deviations from professional norms and standards. One could routinely obtain consent for vaginal examinations, introduce them- presume that using data collectors with a background as health care selves to women or congratulate women after giving birth. These providers may have introduced bias towards underreporting of instances provide an opportunity to improve specific patient-centred D&A; yet, D&A prevalence was higher when scored by providers practices during routine training at the health centres. than reported by women. The larger difference between observed and reported D&A in SNNP region suggests that women may have Limitations normalized D&A to a greater degree than women from the Amhara The study had several limitations. First, as the study sites were region. selected based on a set of criteria, but were not representative of all Further examination of predictors shows that most client charac- clinics in these regions, the results of the study are not generalizable teristics in the unadjusted models were not significantly associated to other health facilities within Ethiopia. Additionally, the health with reporting of D&A. For example, women’s age and education centres were part of a larger initiative for community-led quality were not significantly associated with reporting of D&A in the improvement; therefore, it is possible that the study sites were more unadjusted or adjusted models, which was consistent with findings attuned to professional standards and were more attentive to from Tanzania, Kenya and Nigeria (Kruk et al. 2014; Okafor et al. required facility maintenance than other facilities in the region. 2014; Abuya et al. 2015a). Among index birth characteristics, Although all women giving birth at the facilities were invited to par- reported birth complications were most strongly associated with ticipate in the study, the sample is inherently biased, as the vast increased odds for reporting D&A, and the magnitude nearly majority of women in Ethiopia do not give birth in health facilities doubled when adjusted. It could be argued that more complicated (Central Statistical Agency 2014). Women who opted to give birth deliveries are more stressful for health care providers, which lowers in facilities may have been more or less likely to report D&A than the quality of services provided. Alternatively, we could hypothesize other women in Ethiopia. For example, more than half of women that women who have complicated pregnancies are more prone to interviewed reported living less than 1-h travel distance from the perceive the way they are treated as disrespectful. Further, the analy- health centre; it is possible that the sample were more likely to know ses were based on complications that women reported, as opposed their provider—whether through previous interactions with the to complications documented in a medical record, and it could be health system or social connections—and perhaps less likely to that those who experienced D&A were more likely to report compli- report D&A. cations. Although the directionality of the association cannot be Second, the sample size was powered to estimate overall D&A determined concretely, the association of birth complications and prevalence and not powered to detect variability of D&A by the D&A merits further investigation. independent variables. As such, some of non-significant effects of Of particular note were the unexpected associations with D&A. client characteristics (e.g. education and wealth) or index birth char- Although midwifery care has been identified as a contributing factor acteristics (e.g. number of ANC visits) that showed strong associa- to higher quality, respectful care (Renfrew et al. 2014), and the tions could be due to lack of power of the sample. Also, limiting the majority of births in our study were attended by midwives, there sample size to four facilities prevented the ability to examine associ- was no significant association between midwife attendance at birth ations between facility characteristics and D&A. and reporting of D&A. Weekend delivery, often considered a risk Third, exit interviews immediately post-partum are a debated factor for obstetric complications (Janakiraman et al. 2011), was method of obtaining data on D&A (Glick 2009; Kruk et al. 2014). protective across models, and the association was even stronger Three to 6 h post-partum may be too soon to interview women, as when adjusted for socio-demographic and index birth characteris- they may be exhausted, not wanting to engage, more focused on the tics. Childbirth was the only maternal health service offered on status of their infant, and/or have not yet reflected on the birthing weekends at the study health centres, which may have contributed experience. Other studies have complemented exit interviews with to lower caseload per provider. Patient flow has been suggested as community interviews conducted four to ten weeks post-delivery to an environmental factor that may contribute to D&A, and that high patient volume or low staff count would be associated with high compare reported D&A (Kruk et al. 2014; Sando et al. 2016); D&A because staff are overworked, possibly burned out, and/or not unfortunately, the study budget did not allow for this method. able to perform tasks beyond what is considered necessary to ensure Fourth, although every effort was made to assure women that data Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 326 Health Policy and Planning, 2018, Vol. 33, No. 3 collectors were not affiliated with the health centre and that their Funding responses were anonymous, interviewing women on facility grounds This project was made possible through generous support from The John and may have increased the chance of courtesy bias. It is also possible Katie Hansen Family Foundation and from the Bill & Melinda Gates that women felt fear of retaliation from health care providers and Foundation through award OPP1033808 for the Maternal Health Task Force staff should they report negative experiences while at the health at the Women and Health Initiative at the Harvard T.H. Chan School of centre. Public Health. Additional support for the level of effort for WB and AMK on this manuscript was awarded by the Bill & Melinda Gates Foundation Finally, it is highly complex to measure D&A through observa- through opportunity OPP1131042. tion. Despite recent progress, D&A has yet to be universally defined or operationalized (Freedman et al. 2014; Bohren et al. 2015; Vogel Conflict of interest statement. None declared. et al. 2015a,b) and some instances of D&A are entirely subjective, and may not be captured by a third-party observer. While the data Notes collectors came to consensus on how to observe each item during 1. Woredas are administrative areas with an average population training, we are limited in that the operationalization was not for- of about 100 000 people. mally documented. Further, the presence of the observer him/herself 2. Staffed with two female health extension workers (HEWs), the may influence the prevalence of some D&A behaviours. However, if health posts provide community-based basic promotive, pre- behaviours are normalized enough within the clinical setting, then it ventive and curative health services to a kebele (i.e. villages) is less likely to affect practice. The tool employed by this study was with about 5000 people. designed to capture specific instances of D&A, but did not ask data 3. Maternal and fetal complications included extreme pain, high collectors to comprehensively document any instances of D&A. For blood pressure/seizures/blurred vision/severe headache, swel- example, observers noted incidence of fundal pressure as physical ling in hands/feet, fetal distress; or high birthweight, prolonged abuse, but were not prompted throughout the observation to docu- labour (more than 12 h), post-partum haemorrhage, infection ment all instances of physical abuse, such as pinching and slapping, (fever). Newborn complications included respiratory distress, which have been observed and reported in other settings (Jewkes signs of infection, difficulty feeding and jaundice. et al. 1998; Okafor et al. 2014; Abuya et al. 2015b; Ratcliffe et al. 4. The wealth index score was constructed for each of the 2016b). Therefore, the information collected through this tool is respondents with the principal component analysis of the somewhat incomplete and does not yield a comprehensive observed household possessions (electricity, watch, radio, television, prevalence of D&A. Because of this limitation, direct comparisons mobile phone, telephone, refrigerator, table, chair, bed, electric of overall observed prevalence to overall prevalence from women’s stove and kerosene lamp), and household characteristics (main reports are not possible. We recommend that those intending to material of roof, type of latrine, water source). The households measure observed D&A include a prompt to document all instances were ranked according to the wealth score and then divided of D&A during client-provider interactions. While the maternal into three terciles indicating poorest, medium and least poor health field is debating what method is the ‘best’ or ‘most accurate’ households (Filmer and Pritchett, 2001). to define, describe, and report D&A, studies should seek to test dif- ferent approaches and methodologies, given previous research and practical constraints, and report on them and their findings to allow for comparison between methods to build the evidence base for the References field. Abuya T, Ndwiga C, Ritter J et al. 2015a. The effect of a multi-component intervention on disrespect and abuse during childbirth in Kenya. BMC Conclusion Pregnancy and Childbirth 15: 224. Abuya T, Warren CE, Miller N et al. 2015b. Exploring the prevalence of disre- D&A is a violation of human rights and a threat to achieving good spect and abuse during childbirth in Kenya. PloS One 10: e0123606. maternal health outcomes. To date, this is one of the first studies to Asefa A, Bekele D. 2015. Status of respectful and non-abusive care during quantify the prevalence of D&A at the PHCU level in Ethiopia, the facility-based childbirth in a hospital and health centers in Addis Ababa, frontline of facility-based childbirth in the national health care sys- Ethiopia. Reproductive Health 12: 33. tem. As access to facility-based childbirth increases across the coun- Belay T, Abdullah M, Mengistu H. (2007). Making pregnancy safer initia- try, the data presented here provide evidence of a much-needed shift tive—program impact in selected pilot areas. Ethiopian Medical Journal 45: in priorities towards improving the quality of care, including respect 115–22. Berhane Y, Gossaye Y, Emmelin M et al. 2001. Women’s health in a rural set- and dignity during childbirth. Future efforts should include nation- ting in societal transition in Ethiopia. Social Science & Medicine 53: wide policies and initiatives in improving facility infrastructure and 1525–39. enforcing accountability of professional standards, as well as local, Bohren MA, Vogel JP, Hunter EC et al. 2015. The mistreatment of women facility-specific interventions to improve comprehensive quality of during childbirth in health facilities globally: a mixed-methods systematic care that benefits women and their babies, health care providers, review. PLoS Medicine 12: e1001847. and the community at large. Bowser D, Hill K. (2010). Exploring evidence for disrespect and abuse in facili- ty-based childbirth: report of a landscape analysis. Harvard school of public health and university research corporation. Acknowledgements Campbell OMR, Calvert C, Testa A et al. 2016. The scale, scope, coverage, and The authors express the utmost gratitude to the health care providers and capability of childbirth care. Lancet (London, England) 388: 2193–208. women who shared their stories and time for this project. They wish to Central Statistical Agency. (2014). 2014 Ethiopia Mini Demographic and acknowledge the Regional Health Bureaus of Amhara and SNNPR for their Health Survey (EMDHS). support. Finally, the authors thank Melaku Muleta and Dr. Solomon D’Oliveira AFPL, Diniz SG, Schraiber LB. 2002. Violence against women in Shiferaw for data management and field coordination, and Ludovic Trinquart health-care institutions: an emerging problem. Lancet (London, England) for statistical review of the manuscript. 359: 1681–5. Downloaded from https://academic.oup.com/heapol/article/33/3/317/4772862 by DeepDyve user on 19 July 2022 Health Policy and Planning, 2018, Vol. 33, No. 3 327 Filmer D, Pritchett LH. 2001. Estimating wealth effects without expenditure Renfrew MJ, McFadden A, Bastos MH et al. 2014. Midwifery and quality data—or tears. Demography 38: 115–32. care: findings from a new evidence-informed framework for maternal and Freedman LP, Kruk ME. 2014. Disrespect and abuse of women in childbirth: newborn care. Lancet (London, England) 384: 1129–45. challenging the global quality and accountability agendas. Lancet (London, Rosen HE, Lynam PF, Carr C et al. 2015. Direct observation of respectful England) 384: e42–4. maternity care in five countries: a cross-sectional study of health facili- Freedman LP, Ramsey K, Abuya T et al. 2014. Defining disrespect and abuse ties in East and Southern Africa. BMC Pregnancy and Childbirth 15: of women in childbirth: a research, Policy and rights agenda. Bulletin of the 306. World Health Organization 92: 915–7. Sando D, Kendall T, Lyatuu G et al. 2014. Disrespect and abuse during child- Glick P. 2009. How reliable are surveys of client satisfaction with healthcare birth in Tanzania: are women living with HIV more vulnerable? Journal of services? Evidence from matched facility and household data in Acquired Immune Deficiency Syndromes (1999) 67: S228–34. Madagascar. Social Science & Medicine 68: 368–79. Sando D, Ratcliffe H, McDonald K et al. 2016. The prevalence of disrespect Janakiraman V, Lazar J, Joynt KE et al. 2011. Hospital volume, provider vol- and abuse during facility-based childbirth in urban Tanzania. BMC ume, and complications after childbirth in U.S. hospitals. Obstetrics and Pregnancy and Childbirth 16: 1–10. Gynecology 118: 521–7. Sando D, Abuya T, Asefa A et al. 2017. Methods used in prevalence studies of Jewkes R, Abrahams N, Mvo Z. 1998. Why do nurses abuse patients? disrespect and abuse during facility based childbirth: lessons learned. Reflections from South African obstetric services. Social Science & Reproductive Health 14: 127. Medicine 47: 1781–95. Souza JP, Gu ¨ lmezoglu AM, Vogel J et al. 2013. Moving beyond essential inter- Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS et al. 2014. Global, regional, ventions for reduction of maternal mortality (the WHO Multicountry and national levels and causes of maternal mortality during 1990-2013: a Survey on Maternal and Newborn Health): a cross-sectional study. Lancet systematic analysis for the Global Burden of Disease Study 2013. Lancet (London, England) 381: 1747–55. (London, England) 384: 980–1004. StataCorp. (2015). Stata: Release 14. Statistical Software. College Station, Knight HE, Self A, Kennedy SH, Young RC. 2013. Why are women dying TX: StataCorp LLC. when they reach hospital on time? A systematic review of the third delay. The Last Ten Kilometers Project. 2015. Trends in Reproductive, Maternal, PLoS One 8: e63846. Newborn and Child Health Care Practices in 115 L10K Woredas: Analyses Koblinsky M, Moyer CA, Calvert C et al. 2016. Quality maternity care for every of Three Rounds of Survey Data. Addis Ababa. http://l10k.jsi.com/ woman, everywhere: a call to action. Lancet (London, England) 388: 2307–20. Resources/Docs/L10KsRoundIIISurveyFinalReport.pdf, accessed 26 Kruk M, Kujawski S, Mbaruku G et al. 2014. Disrespectful and abusive treat- September 2016. ment during facility delivery in Tanzania: a facility and community survey. Tunc ¸alp O, Were WM, MacLennan C et al. 2015. Quality of care for pregnant Health Policy and Planning: 1–8. doi:10.1093/heapol/czu079. women and newborns-the WHO vision. BJOG: An International Journal of Kruk ME, Paczkowski MM, Tegegn A et al. 2010. Women’s preferences for Obstetrics and Gynaecology 122: 1045–9. obstetric care in rural Ethiopia: a population-based discrete choice experi- Vogel JP, Bohren MA, Tunc¸alp O et al. 2015a. Promoting respect and prevent- ment in a region with low rates of facility delivery. Journal of Epidemiology ing mistreatment during childbirth. BJOG: An International Journal of and Community Health 64: 984–8. Obstetrics and Gynaecology doi:10.1111/1471-0528.13750. Kujawski S, Mbaruku G, Freedman LP et al. 2015. Association between disre- Vogel JP, Bohren MA, Tunc¸alp O et al. 2015b. How women are treated during spect and abuse during childbirth and women’s? Confidence in health facili- facility-based childbirth: development and validation of measurement tools ties in Tanzania. Maternal and Child Health Journal 19: 2243–50. in four countries—phase 1 formative research study protocol. Reproductive Ogangah C, Slattery E, Mehta A. (2007). Failure to Deliver: Violations of Health 12: 60. Women’s Human Rights in Kenyan Health Facilities. Warren C, Njuki R, Abuya T et al. 2013. Study protocol for promoting Okafor II, Ugwu EO, Obi SN. 2015. Disrespect and abuse during respectful maternity care initiative to assess, measure and design interven- facility-based childbirth in a low-income country. International Journal of tions to reduce disrespect and abuse during childbirth in Kenya. BMC Gynecology and Obstetrics 128: 110–3. Pregnancy and Childbirth 13: 21. Ratcliffe HL, Sando D, Lyatuu GW et al. 2016a. Mitigating disrespect and WHO, UNICEF, UNFPA, World Bank Group and the United Nations abuse during childbirth in Tanzania: an exploratory study of the effects of Population Division. 2015. Trends in Maternal Mortality 1990 to 2015. two facility-based interventions in a large public hospital. Reproductive http://datatopics.worldbank.org/hnp/files/Trends in Maternal Mortality Health 13: 79. 1990 to 2015 full report.PDF, accessed 29 February 2016. Ratcliffe HL, Sando D, Mwanyika-Sando M et al. 2016b. Applying a partici- World Health Organization. 2015. Strategies Toward Ending Preventable patory approach to the promotion of a culture of respect during childbirth. Maternal Mortality (EPMM), 6736, pp. 1–4. http://apps.who.int/iris/bit Reproductive Health 13: 80. stream/10665/153544/1/9789241508483_eng.pdf? ua¼1.

Journal

Health Policy and Planning – Oxford University Press

Published: Apr 1, 2018

Keywords: maternal health

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