Women's Preferences for Maternal Healthcare Services in Bangladesh: Evidence from a Discrete Choice Experiment

The burden of chronic diseases, disease-stratified exploration and gender-differentiated healthcare utilisation among patients in Bangladesh

BACKGROUND

Chronic diseases are considered one of the major causes of illness, disability, and death worldwide. Chronic illness leads to a huge health and economic burden, especially in low- and middle-income countries. This study examined disease-stratified healthcare utilisation (HCU) among Bangladesh patients with chronic diseases from a gender perspective.

METHODS

Data from the nationally representative Household Income and Expenditure Survey 2016-2017 consisting of 12,005 patients with diagnosed chronic diseases was used. Gender differentiated chronic disease stratified-analytical exploration was performed to identify the potential factors to higher or lower utilisation of healthcare services. Logistic regression with step-by-step adjustment for independent confounding factors was the method used.

RESULTS

The five most prevalent chronic diseases among patients were gastric/ulcer (Male/Female, M/F: 16.77%/16.40%), arthritis/rheumatism (M/F: 13.70%/ 13.86%), respiratory diseases/asthma/bronchitis (M/F: 12.09% / 12.55%), chronic heart disease (M/F: 8.30% / 7.41%), and blood pressure (M/F: 8.20% / 8.87%). Eighty-six percent of patients with chronic diseases utilised health care services during the previous 30 days. Although most patients received outpatient healthcare services, a substantial difference in HCU among employed male (53%) and female (8%) patients were observed. Chronic heart disease patients were more likely to utilise health care than other disease types, which held true for both genders while the magnitude of HCU was significantly higher in males (OR = 2.22; 95% CI:1.51-3.26) than their female counterparts (OR = 1.44; 1.02-2.04). A similar association was observed among patients with diabetes and respiratory diseases.

CONCLUSION

A burden of chronic diseases was observed in Bangladesh. Patients with chronic heart disease utilised more healthcare services than patients experiencing other chronic diseases. The distribution of HCU varied by patient's gender as well as their employment status. Risk-pooling mechanisms and access to free or low-cost healthcare services among the most disadvantaged people in society might enhance reaching universal health coverage.

Midwifery centers as enabled environments for midwifery: A quasi experimental design assessing women's birth experiences in three models of care in Bangladesh, before and during covid

BACKGROUND

The midwifery model of care is a human rights-based approach (HRBA) that is unique and appropriate for the majority of healthy pregnant women, yet full expression may be limited within the medical model. Midwifery centers are facilities designed specifically to enable the practice of midwifery. In high resource countries, they have been shown to be cost effective, evidence-based, avoid over medicalization, and provide safe, efficient and satisfying care.

METHODS

A quasi-experimental design was used to assess the impact of three models of care on women's experiences of respect, and trust in maternity care provision, both before and during the pandemic in Bangladesh, as well as their fear and knowledge around COVID-19, during the pandemic. The models were: "fully enabled midwifery" ("FEM") in freestanding midwifery centers; "midwifery and medicine" ("MAM") in medical facilities with midwives working alongside nurses and doctors; and "no midwifery" ("NoM") in medical facilities without midwives. Phone survey data were collected and analyzed from all women (n = 1,191) who delivered from Jan 2020-June 2020 at seven health care facilities in Bangladesh. Comparison of means, ANOVA, post hoc Tukey, and effect size were used to explore the differences in outcomes across time periods.

FINDINGS

Pre-pandemic, women served by the FEM model reported significantly higher rates of trust and respect (p<0·001) compared to the NoM model, and significantly higher rates of trust (p<0·001) compared to MAM. During the pandemic, in the FEM model, the experiences of respect and trust did not change significantly from the pre-pandemic rates, and were significantly higher than both the MAM and NoM models (p < 0·001). Additionally, during the pandemic, women served by the FEM model had the lowest experience of COVID fear (p<0·001).

INTERPRETATION

Fully enabled midwifery in midwifery centers had a significantly positive effect on woman's experience of respect and trust in care compared to the other models, even in the context of a pandemic.

The burden of chronic diseases and patients' preference for healthcare services among adult patients suffering from chronic diseases in Bangladesh

BACKGROUND

Low- and middle-income countries (LMICs) have a disproportionately high burden of chronic diseases, with inequalities in health care access and quality services. This study aimed to assess patients' preferences for healthcare services for chronic disease management among adult patients in Bangladesh.

METHODS

The present analysis was conducted among 10,385 patients suffering from chronic diseases, drawn from the latest Household Income and Expenditure Survey 2016-2017. We used the multinomial logistic regression to investigate the association of chronic comorbid conditions and healthcare service-related factors with patients' preferences for healthcare services.

RESULTS

The top four dimensions of patient preference for healthcare services in order of magnitude were quality of treatment (30.3%), short distance to health facility (27.6%), affordability of health care (21.7%) and availability of doctors (11.0%). Patients with heart disease had a 29% significantly lower preference for healthcare affordability than the quality of healthcare services (relative risk ratio [RRR] = 0.71; 0.56-0.90). Patients who received healthcare services from pharmacies or dispensaries were more likely to prefer a short distance to a health facility (RRR = 6.99; 4.80-9.86) or affordability of healthcare services (RRR = 3.13; 2.25-4.36). Patients with comorbid conditions were more likely to prefer healthcare affordability (RRR = 1.39; 1.15-1.68). In addition, patients who received health care from a public facility had 2.93 times higher preference for the availability of medical doctors (RRR = 2.93; 1.70-5.04) than the quality of treatment in the health facility, when compared with private service providers.

CONCLUSIONS

Patient preferences for healthcare services in chronic disease management were significantly associated with the type of disease and its magnitude and characteristics of healthcare providers. Therefore, to enhance service provision and equitable distribution and uptake of health services, policymakers and public health practitioners should consider patient preferences in designing national strategic frameworks for chronic disease management.

PATIENT OR PUBLIC CONTRIBUTION

Our research team includes four researchers (co-authors) with chronic diseases who have experience of living or working with people suffering from chronic conditions or diseases.

Determinants and Trends of Health Facility Delivery in Bangladesh: A Hierarchical Modeling Approach

Background

Most maternal deaths occur during childbirth and after childbirth. This study was aimed at determining the trends of health facilities during delivery in Bangladesh, as well as their influencing factors.

Methods

This study used secondary data from three Bangladesh Multiple Indicator Cluster Surveys (MICSs) in 2006, 2012–13, and 2019. The study's target sample was those women who gave birth in the last two years of the survey. A two-level logistic regression was applied to determine the effects on health facility delivery separately in these two survey points (MICSs 2012–13 and 2019).

Results

The results show that the delivery of health facilities has increased by almost 37.4% in Bangladesh, from 16% in 2006 to 53.4% in 2019. The results of two-level logistic regression show that the total variation in health facility delivery across the community has decreased over recent years. After adding community variables, various individual-level factors such as women with secondary education (OR = 0.55 in 2012-13 vs. OR =0.60 in 2019), women from middle wealth status (OR = 0.49 in 2012-13 vs. OR = 0.65 in 2019), religion, and child ever born showed a strong relationship with health facility delivery in both survey years. At the community level, residents showed significant association only in the 2012-13 survey and indicated a 43% (OR = 1.43 for 2012-13) greater availability of health facilities in urban residences than in rural residences. Using media showed a highly significant connection with health facility delivery in both years as well as an increasing trend over the years in Bangladesh (OR = 1.19 in 2012-13 vs. OR = 1.38 in 2019). However, division, prenatal care, and skilled services all contribute greatly to increasing the delivery of health facilities in Bangladesh.

Conclusions

The results of this study suggest that policymakers need to pay attention to individual and community-level factors, especially women's education, poverty reduction, and adequate prenatal care provided by well-trained caregivers.

Women's preferences for antenatal care in Tanzania: a discrete choice experiment

Background

The stillbirth rate in Tanzania remains high. Greater engagement with antenatal care may help to reduce stillbirths. We investigated which characteristics of antenatal care clinics are preferred by pregnant women in Tanzania.

Methods

We conducted an unlabelled discrete choice experiment (DCE) with think-aloud interviews. Participants were pregnant women, regardless of parity/gestation, from the Mwanza and Manyara regions of Tanzania. We asked participants to choose which of two hypothetical antenatal clinics they would rather attend. Clinics were described in terms of transport mode, cleanliness, comfort, visit content, and staff attitude. Each participant made 12 choices during the experiment, and a purposively selected sub-set simultaneously verbalised the rationale for their choices. We analysed DCE responses using a multinomial logit model adjusted for study region, and think-aloud data using the Framework approach.

Results

We recruited 251 participants split evenly between the 2 geographical regions. Staff attitude was the most important attribute in clinic choice and dominated the think-aloud narratives. Other significant attributes were mode of transport (walking was preferred) and content of clinic visit (preference was stronger with each additional element of care provided). Cleanliness of the clinic was not a significant attribute overall and the think-aloud exercise identified a willingness to trade-off cleanliness and comfort for respectful care.

Conclusion

Women would prefer to attend a clinic with kind staff which they can access easily. This study suggests that exploration of barriers to providing respectful care, and enabling staff to deliver it, are important areas for future investment. The DCE shows us what average preferences are; antenatal care that is aligned with identified preferences should increase uptake and engagement versus care which does not acknowledge them.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04634-x.

Stated Preference Research in Reproductive and Maternal Healthcare Services in Sub-Saharan Africa: A Systematic Review

BACKGROUND AND OBJECTIVE

Understanding the preferred choice of healthcare service attributes for women is important, particularly in sub-Saharan Africa where resources are constrained and improving reproductive and maternal healthcare services is of high importance. The aim of this systematic review was to identify attributes of reproductive and maternal healthcare services in sub-Saharan Africa, and summarise the factors shaping women's preference to access these services.

METHODS

PubMed/MEDLINE, EMBASE, PsycINFO and CINAHL were searched from the inception of each database until March 2021 for published studies reporting stated preferences for maternal and reproductive healthcare services in sub-Saharan Africa. Data were extracted using a predefined extraction sheet, and the quality of reporting of included studies was assessed using PREFS and ISPOR (International Society for Pharmacoeconomics and Outcomes Research) checklists. The Donabedian's model for quality of healthcare was used to categorise attributes into "structure", "process" and "outcome".

RESULTS

A total of 13 studies (12 discrete choice experiments and one best-worst scaling study) were included. Attributes related to the structure of healthcare services (e.g. availability of technical equipment, medications or diagnostic facilities, having good system conditions) are often included within the studies, and are considered the most important by women. Of the three dimensions of quality of healthcare, the outcome dimension was the least frequently studied across studies. All except one study explored women's preferences and the participants were pregnant women, women aged 18-49 years who had recently given birth and women living with human immunodeficiency virus. The included studies came from five sub-Saharan Africa countries of which Ethiopia and South Africa each contributed three studies. All of the included studies reported on the purpose, findings and significance of the study. However, none of the studies reported on the differences between responders vs non-responders. Nine of the 13 studies employed the ISPOR checklist and reported each item including the research question and the methods for identifying and selecting attributes, and provided the findings in sufficient detail and clarity.

CONCLUSIONS

Aligning maternal healthcare service provision with women's preferences may foster client-oriented services and thereby improve service uptake and better patient outcomes.

Factors influencing place of delivery: Evidence from three south-Asian countries

BACKGROUND

High maternal mortality is still a significant public health challenge in many countries of the South-Asian region. The majority of maternal deaths occur due to pregnancy and delivery-related complications, which can mostly be prevented by safe facility delivery. Due to the paucity of existing evidence, our study aimed to examine the factors associated with place of delivery, including women's preferences for such in three selected South-Asian countries.

METHODS

We extracted data from the most recent demographic and health surveys (DHS) conducted in Bangladesh (2014), Nepal (2016), and Pakistan (2017-18) and analyzed to identify the association between the outcome variable and socio-demographic characteristics. A total of 16,429 women from Bangladesh (4278; mean age 24.57 years), Nepal (3962; mean age 26.35 years), and Pakistan (8189; mean age 29.57 years) were included in this study. Following descriptive analyses, bivariate and multivariate logistic regressions were conducted.

RESULTS

Overall, the prevalence of facility-based delivery was 40%, 62%, and 69% in Bangladesh, Nepal, and Pakistan, respectively. Inequity in utilizing facility-based delivery was observed for women in the highest wealth quintile. Participants from Urban areas, educated, middle and upper household economic status, and with high antenatal care (ANC) visits were significantly associated with facility-based delivery in all three countries. Interestingly, watching TV was also found as a strong determinant for facility-based delivery in Bangladesh (aOR = 1.31, 95% CI:1.09-1.56, P = 0.003), Nepal (aOR = 1.42, 95% CI:1.20-1.67, P<0.001) and Pakistan (aOR = 1.17, 95% CI: 1.03-1.32, P = 0.013). Higher education of husband was a significant predictor for facility delivery in Bangladesh (aOR = 1.73, 95% CI:1.27-2.35, P = 0.001) and Pakistan (aOR = 1.19, 95% CI: 0.99-1.43, P = 0.065); husband's occupation was also a significant factor in Bangladesh (aOR = 1.30, 95% CI:1.04-1.61, P = 0.020) and Nepal (aOR = 1.26, 95% CI:1.01-1.58, P = 0.041).

CONCLUSION

Our findings suggest that the educational status of both women and their husbands, household economic situation, and the number of ANC visits influenced the place of delivery. There is an urgent need to promote facility delivery by building more birthing facilities, training and deployment of skilled birth attendants in rural and hard-to-reach areas, ensuring compulsory female education for all women, encouraging more ANC visits, and providing financial incentives for facility deliveries. There is a need to promote facility delivery by encouraging health facility visits through utilizing social networks and continuing mass media campaigns. Ensuring adequate Government funding for free maternal and newborn health care and local community involvement is crucial for reducing maternal and neonatal mortality and achieving sustainable development goals in this region.

Distribution of wealth-stratified inequalities on maternal and child health parameters and influences of maternal-related factors on improvements in child health survival rate in Bangladesh

This study investigates the influence of household socioeconomic status and maternal risk factors and health-care service availability on changes in the under-five mortality rate (U5MR) in Bangladesh. Potential risk factors that influence U5MRs were investigated using multilevel logistic regression analysis and 29,697 data points from the Bangladesh Demographic and Health Surveys, 2004-2014. Maternal and child health parameters such as childhood morbidity, low vaccination coverage, poor utilization of perinatal care, and malnutrition were found to be more concentrated in poorer households. Pooled estimates indicated that the aggregate odds of U5MR risk declined by 18% to 2007 to 38% to 2014 compared to 2004. However, inadequate antenatal care, short birth interval, primiparity, illiteracy, delayed conception, and low socioeconomic status were significantly associated with a higher risk of under-five mortality. The magnitude of inequality using these measures were significantly associated with large variations in U5MR changes. Although a significant reduction in U5MR in Bangladesh was found in this study, substantial socioeconomic variations still persist. The analysis suggests that decreasing inequality in society is required for further reductions in child mortality. This will help to achieve a more equitable distribution of child and neonatal outcomes and assist the achievement of Sustainable Development Goals 3.2 by 2030.

Does knowledge of pregnancy complications influence health facility delivery? Analysis of 2014 Bangladesh Demographic and Health Survey

Introduction

Only thirty-seven percent (37%) of deliveries occur in health facilities in Bangladesh despite the enormous benefits of health facility delivery. We investigated women’s recall of receiving counseling on pregnancy complications and how it affects health facility delivery in Bangladesh.

Materials and methods

Data from the 2014 Bangladesh Demographic and Health Survey was used for the study. After calculating the proportion of women who were informed about pregnancy complications during their last Antenatal Care (ANC) and the number of them who delivered in health facilities, Binary Logistic Regression was utilized in investigating chances of giving birth in health facilities among women who recalled they were told about pregnancy complications and those who were not told. The models were considered significant at 95%.

Results

A little above half of the women who were told about pregnancy complications during ANC delivered in health facilities (53.3%) and 43.6% of those who were not told delivered in health facilities. The findings revealed that women who were told about pregnancy complications during ANC were more likely to deliver at the health facility compared to those who were not told [COR = 1.56, CI = 1.31–1.87], and this persisted after controlling for the effect of covariates [AOR = 1.44, CI = 1.21–1.71].

Conclusion

This study has stressed the importance of telling women about pregnancy complications during ANC by revealing that telling women about pregnancy complications during ANC is likely to result in health facility delivery. Health workers should intensify health education on pregnancy complications during ANC and motivate women to deliver in health facilities.

Barriers to accessing maternal health care services in the Chittagong Hill Tracts, Bangladesh: A qualitative descriptive study of Indigenous women's experiences

BACKGROUND

Increased maternal health care (MHC) service utilisation in Bangladesh over the past decades has contributed to improvements in maternal health outcomes nationally, yet there is little understanding of Indigenous women's experiences of accessing MHC services in Bangladesh.

METHODS

Face-to-face semi-structured qualitative interviews with 21 Indigenous women (aged 15-49 years) within 36 months of delivery from three ethnic groups (Chakma, Marma and Tripura) were conducted between September 2017 and February 2018 in Khagrachhari district. Purposive sampling was used to recruit women representative of the population distribution in terms of age, ethnic community and service use experience. All interviews were conducted in Bangla language and audio-recorded with consent. Interviews were transcribed directly into English before being coded. Data were analysed thematically using a qualitative descriptive approach aided by NVivo12 software.

RESULTS

Of the 21 women interviewed, 14 had accessed at least one MHC service during their last pregnancy or childbirth and were categorised as the User group. The remaining seven participants were categorised as 'Non-users' as they had not access antenatal care, facility delivery or postnatal care services. Women reported that they wanted culturally relevant, respectful, home-based and affordable care, and generally perceived formal MHC services as being only for complications and emergencies. Barriers to accessing MHC services included low levels of understanding about the importance of MHC services, concerns about service costs, limited transport and fears of intrusive practices. Experiences within health services that deterred women from accessing future MHC services included demands for unofficial payments and abusive treatment by public facility staff.

CONCLUSION

Improving access to MHC services for the CHT Indigenous women requires improved understandings of cultural values, priorities and concerns. Multifaceted reform is needed at individual, community and health systems levels to offer culturally appropriate health education and flexible service delivery options.

What do women want? An analysis of preferences of women, involvement of men, and decision-making in maternal and newborn health care in rural Bangladesh

BACKGROUND

To improve the utilization of maternal and newborn health (MNH) care and to improve the quality of care, the World Health Organization (WHO) has strongly recommended men's involvement in pregnancy, childbirth, and after birth. In this article, we examine women's preferences for men's involvement in MNH care in rural Bangladesh and how this compares to husbands' reported involvement by women.

METHODS

A cross-sectional household survey of 1367 women was administered in 2018 in the district of Brahmanbaria. Outcomes of interest included supporting self-care during pregnancy, participation in birth planning, presence during antenatal care, childbirth, and postnatal care, and participation in newborn care. Binary and multiple logistic regressions were done to understand the associations between the outcomes of interest and background characteristics.

RESULTS

Although women preferred a high level of involvement of their husbands in MNH care, husbands' reported involvement varied across different categories of involvement. However, women's preferences were closely associated with husbands' reported involvement. Around three-quarters of the women reported having been the primary decision makers or reported that they made the decisions jointly with their husbands. The likelihood of women reporting their husbands were actively involved in MNH care was 2.89 times higher when the women preferred their husbands to be involved in 3-4 aspects of MNH care. The likelihood increased to 3.65 times when the women preferred their husbands to be involved in 5-6 aspects. Similarly, the likelihood of husbands' reported active involvement was 1.43 times higher when they jointly participated in 1-2 categories of decision-making. The likelihood increased to 2.02 times when they jointly participated in all three categories.

CONCLUSION

The findings of our study suggest that women in rural Bangladesh do indeed desire to have their husbands involved in their care during pregnancy, birth and following birth. Moreover, their preferences were closely associated with husbands' reported involvement in MNH care; that is to say, when women wanted their husbands to be involved, they were more likely to do so. Programmes and initiatives should acknowledge this, recognizing the many ways in which men are already involved and further allow women's preferences to be realized by creating an enabling environment at home and in health facilities for husbands to participate in MNH care.

Addressing the Linkages between Gender and Transport in Low- and Middle-Income Countries

The Millennium Development Goals (MDGs) specifies gender equality and sustainable development as their two central priorities. An area of critical importance for sustainable and gender-fair development is mobility and transport, which has so far been neglected and downplayed in research and policy making both at the national and global levels. Rooted in the history of the topic and the emerging ideas on smart, green and integrated transport, this paper presents a literature review of on gender and transport in the low- and middle-income countries. The paper presents a host of cross-cutting topics with a concentrated focus on spatial and transport planning. The paper further identifies existing research gaps and comments on the new conceptualizations on smart cities and smart mobilities in the Global South. Due attention is paid to intersections and synergies that can be created between different development sectors, emerging transport modes, data and modeling exercises, gender equality and sustainability.

Measuring perinatal and postpartum quality of life of women and associated factors in semi-urban Bangladesh

PURPOSE

The objective of this study was to measure the health-related quality of life (HRQoL) among pregnant women in the perinatal and postpartum periods and determine influencing factors that predict their HRQoL.

METHODS

The study was conducted among pregnant women who live in a semi-urban area of Chandpur, Bangladesh. A total of 465 women were recruited. The EuroQoL 5-Dimension 3-Level (EQ-5D-3L) and EuroQoL visual analog scale (EQ-VAS) instruments were used to measure the HRQoL of participants. Two-sample mean test (t test) was performed to examine the changes in HRQoL between the perinatal and postnatal periods of the same individuals. Multivariate linear regression was employed to identify the factors influencing HRQoL during the two periods.

RESULTS

Overall, the HRQoL scores improved significantly from the perinatal (0.49) to postpartum (0.86) period. Approximately 58% of women experienced moderate or extreme levels of health problems during the perinatal period regardless of their health status. However, most women had significantly improved health status in the postpartum period. Gestational weight gain and recommended postnatal care were significantly associated with improved HRQoL. Factors that negatively influenced changes in HRQoL included adolescent motherhood, caesarean delivery, inadequate antenatal care consultations and living in a poor household, during both the perinatal and postpartum periods.

CONCLUSIONS

Overall health status is found to be poor among women during the perinatal period compared with the postpartum period. The study indicates that interventions to address the influencing factors are needed to ensure better quality of life for women both pre- and post-birth. Community-based initiatives, such as awareness building, might address negative factors and subsequently improve health status and reduce adverse health outcomes related to pregnancy and postnatal care.

Utilisation and preferences of family planning services among women in Ikosi-Isheri, Kosofe Local Government area, Lagos, Nigeria

BACKGROUND

Despite women's adequate knowledge and the obvious unmet need for family planning (FP), contraceptive prevalence in Nigeria is low. A greater understanding of the barriers to FP that informs service utilisation and preferences is needed to improve service delivery.

AIM

This study was aimed at assessing the use and preferences of FP services among women.

SUBJECTS AND METHODS

A community-based, descriptive, cross-sectional survey was carried out among 367 women (15-49 years of age) residing in Ikosi-Isheri, Kosofe local government area, who were selected by multistage sampling method. Data were collected using a pre-tested, semi-structured, interviewer-administered questionnaire and were analysed using SPSS software version 20. Frequency distributions and cross tabulations were generated. The Chi-square and Fisher's exact tests were used to determine associations, and the level of significance was set at P ≤ 0.05.

RESULTS

Although 64.0% were aware of FP, only 26.4% had ever used FP services. The contraceptive prevalence was 17.9%. Traditional or religious restrictions were given as the reasons for not using FP (40.9%). The preferred FP services were those offered at primary healthcare centres (45.2%) and teaching hospitals (33.9%) because of proximity (38.7%), privacy (14.5%) and health workers being female (22.6%). Age, level of education and marital status were associated with the utilisation of FP services (P < 0.001, P = 0.020 and P < 0.001, respectively).

CONCLUSION

Although awareness was high, uptake was low. Government health facilities were preferred. Primary healthcare should be strengthened, and FP services should be scaled up to make FP more accessible. Services should be closer to where people live while providing the privacy they desire.

Women's experiences of disrespectful and abusive maternal health care in a low resource rural setting in eastern Zimbabwe

BACKGROUND

There has been an increase in recent publications, in high and medium resource settings, documenting women's dissatisfaction with the quality of maternity care they receive. Their discontent is mostly related to their midwives' disrespectful or negative attitudes.

OBJECTIVE

To explore women's experiences and perceptions of disrespect and abuse from their maternity care providers in a low resource rural setting in Zimbabwe.

DESIGN

A critical, qualitative research methodology, using in-depth interviews and two focus group discussions, was employed to capture rural women's experiences during antenatal care, postpartum care, and the use of maternity waiting homes' services.

SETTING

Three rural health centres in Mutare district, Manicaland Province in eastern Zimbabwe.

PARTICIPANTS

A total of 20 purposively sampled women, 16-30 years of age, who were accessing various stages of maternal health services, were recruited from three conveniently selected rural health centres. Eight women participated in the in-depth interviews. A further eight women were discussants in the first focus group, and a further four women participated in the second focus group.

FINDINGS

Multifaceted and interconnected factors contribute to midwives' attitudes and behaviours towards their clients. Midwives' subjective perceptions, women's social status, and health system constraints (i.e., availability of trained midwives and quality of midwifery training) in rural and poorly resourced community, often result in inappropriate services, negative attitudes, abusive treatment, and disrespectful behaviour towards women. Poor treatment in maternity care directly contribute to adverse health outcomes and women's satisfaction with services.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

Women's social status, level of education and age, were perceived to influence the quality of care or treatment they received. Improving women's experience of maternal care requires targeted interventions at the interpersonal level between a woman and her health care providers, as well as at the level of the health care facility and the health system. The results of this study challenge all tiers of health personnel including policy makers, in low resource settings to reappraise the present situation thereby challenging these established behaviours, to ensure that the continuum of maternity care is respectfully and socio-culturally delivered.