Service providers' experiences of disrespectful and abusive behavior towards women during facility based childbirth in Addis Ababa, Ethiopia

Health care providers' perspectives on the mistreatment towards women during maternity care: Do perceptions of the working environment and empathy level matter?

BACKGROUND

Mistreatment of women in maternity care violates human rights, erodes trust and disrupts the continuity of maternal healthcare services. Investigating Health Care Providers' (HCPs) perspectives is indispensable in uncovering drivers and designing targeted interventions.

AIM

To identify the roles of HCPs' perceptions of the working environment and levels of empathy on the mistreatment of women during maternity care.

METHODS

We conducted a self-administered survey among 148 maternal HCPs practising in ten health centres and four hospitals in the East Wollega Zone, Western Ethiopia, from June to September 2022.

FINDINGS

Most providers reported seeing other HCPs mistreating women (93.2%), while three-fourths (75.7%) admitted it as their actions. Violation of privacy and confidentiality was the most frequently reported category of mistreatment (44.6%), followed by physical abuse (37.1%) and verbal abuse (35.8%). The likelihood of mistreating women was reduced by 65% (AOR=0.35, 95% CI: [0.14, 0.86]) among individuals with positive perceptions of their working environment compared to those with negative perceptions. A unit increase in providers' empathy also led to a five per cent decrease in mistreatment (AOR=0.95, 95% CI: [0.91, 0.98].

CONCLUSIONS

HCPs' perceptions of their working environment and enhanced empathy levels were associated with the reduction of the odds of mistreatment of women. While empathic care should be cultivated as a component of HCPs' competencies, efforts should be made to improve the conditions of the demanding health system to realise a resilient, motivated, competent, and compassionate workforce. The interplay between gender, profession, and mistreatment level requires further investigation.

The mistreatment of women during maternity care and its association with the maternal continuum of care in health facilities

BACKGROUND

Mistreatment of childbearing women continues despite global attention to respectful care. In Ethiopia, although there have been reports of mistreatment of women during maternity care, the influence of this mistreatment on the continuum of maternity care remains unclear. In this paper, we report the prevalence of mistreatment of women from various dimensions, factors related to mistreatment and also its association to the continuum of maternity care in health facilities.

METHODS

We conducted an institution-based cross-sectional survey among women who gave birth within three months before the data collection period in Western Ethiopia. A total of 760 women participated in a survey conducted face-to-face at five health facilities during child immunization visits. Using a validated survey tool, we assessed mistreatment in four categories and employed a mixed-effects logistic regression model to identify its predictors and its association with the continuum of maternity care, presenting results as adjusted odds ratios (AORs) with their 95% confidence intervals (CIs).

RESULTS

Over a third of women (37.4%) experienced interpersonal abuse, 29.9% received substandard care, 50.9% had poor interactions with healthcare providers, and 6.2% faced health system constraints. The odds of mistreatment were higher among women from the lowest economic status, gave birth vaginally and those who encountered complications during pregnancy or birth, while having a companion of choice during maternity care was associated to reduced odds of mistreatment by 42% (AOR = 0.58, 95% CI: [0.42-0.81]). Women who experienced physical abuse, verbal abuse, stigma, or discrimination during maternity care had a significantly reduced likelihood of completing the continuum of care, with their odds decreased by half compared to those who did not face such interpersonal abuse (AOR = 0.49, 95% CI: [0.29-0.83]).

CONCLUSIONS

Mistreatment of women was found to be a pervasive problem that extends beyond labour and birth, it negatively affects upon maternal continuum of care. Addressing this issue requires an effort to prevent mistreatment through attitude and value transformation trainings. Such interventions should align with a system level actions, including enforcing respectful care as a competency, enhancing health centre functionality, improving the referral system, and influencing communities to demand respectful care.

Consented maternal care and associated factors among mothers who gave birth at public health institutions in South Wollo Zone, Amhara region, Ethiopia 2022

Introduction

Informed consent in healthcare services is a legal, ethical, and professional requirement on the part of all treating health providers and providing person-centered care. The methods of requesting consent during childbirth have not been extensively studied. In Ethiopia, there is not at all a single study done.

Objective

The purpose of this study is to determine associated factors among mothers who gave birth at health institutions in the South Wollo Zone, Amhara region, Ethiopia in 2022.

Methods

Mothers who gave birth at South Wollo Zone public health institutions, from 01 March to 30 April 2022 participated in a multi-center institutional-based cross-sectional study design. Systematic random sampling was used to select 423 study participants. A validated questionnaire was used for data collection, and the data were collected through face-to-face interviews. Data were entered into Epi-Data version 4.6 and exported to SPSS version 23 for analysis. A multivariable logistic regression analysis was performed to identify factors associated with the outcome variable. The level of significance was determined using an adjusted odds ratio with a 95% confidence interval.

Result

The study had 416 participants in total, with a response rate of 98.3%. Out of the 416 respondents interviewed, 67.1% of the women received consented care. The age group of 30-34, complications during childbirth, intended pregnancy, merchant, and primary and referral hospital were significantly associated with consented care.

Conclusion

The level of non-consented care during delivery was high compared with other literature reflecting substantial mistreatment. Therefore, stakeholders should strengthen monitoring and assessment systems to prevent abuse, and further study is required to look for practical ways to make improvements. Key elements of consented care have also been included in Basic and Emergency Obstetric Care training sessions and given to health providers.

Association of workload and practice of respectful maternity care among the healthcare providers, before and during the early phase of COVID-19 pandemic in South Western Nepal: a cross-sectional study

INTRODUCTION

Respectful maternity care is an approach that involves respecting women's belief, choices, emotions, and dignity during the childbirth process. As the workload among maternity care workforce affects intrapartum quality care, respectful maternity care might have also been affected, particularly during the pandemic. Thus, this study was conducted to examine the association between workload among healthcare providers and their practice of respectful maternity care, before and during the early phase of pandemic.

METHODS

A cross-sectional study was conducted in South Western Nepal. A total of 267 healthcare providers from 78 birthing centers were included. Data collection was done through telephone interviews. The exposure variable was workload among the healthcare providers, and the outcome variable was respectful maternity care practice before and during the COVID-19 pandemic. Multilevel mixed-effect linear regression was used to examine the association.

RESULTS

The median client-provider ratio before and during the pandemic was 21.7 and 13.0, respectively. The mean score of respectful maternity care practice was 44.5 (SD 3.8) before the pandemic, which was decreased to 43.6 (SD 4.5) during the pandemic. Client-provider ratio was negatively associated with respectful maternity care practice for both times; before (Coef. -5.16; 95% CI -8.41 to -1.91) and during (Coef. -7.47; 95% CI -12.72 to -2.23) the pandemic.

CONCLUSIONS

While a higher client-provider was associated with a lower respectful maternity care practice score both before and during the COVID-19 pandemic, the coefficient was larger during the pandemic. Therefore, workload among the healthcare providers should be considered before the implementation of respectful maternity care, and more attention should be given during the pandemic.

Theories for interventions to reduce physical and verbal abuse: A mixed methods review of the health and social care literature to inform future maternity care

Despite global attention, physical and verbal abuse remains prevalent in maternity and newborn healthcare. We aimed to establish theoretical principles for interventions to reduce such abuse. We undertook a mixed methods systematic review of health and social care literature (MEDLINE, SocINDEX, Global Index Medicus, CINAHL, Cochrane Library, Sept 29th 2020 and March 22nd 2022: no date or language restrictions). Papers that included theory were analysed narratively. Those with suitable outcome measures were meta-analysed. We used convergence results synthesis to integrate findings. In September 2020, 193 papers were retained (17,628 hits). 154 provided theoretical explanations; 38 were controlled studies. The update generated 39 studies (2695 hits), plus five from reference lists (12 controlled studies). A wide range of explicit and implicit theories were proposed. Eleven non-maternity controlled studies could be meta-analysed, but only for physical restraint, showing little intervention effect. Most interventions were multi-component. Synthesis suggests that a combination of systems level and behavioural change models might be effective. The maternity intervention studies could all be mapped to this approach. Two particular adverse contexts emerged; social normalisation of violence across the socio-ecological system, especially for 'othered' groups; and the belief that mistreatment is necessary to minimise clinical harm. The ethos and therefore the expression of mistreatment at each level of the system is moderated by the individuals who enact the system, through what they feel they can control, what is socially normal, and what benefits them in that context. Interventions to reduce verbal and physical abuse in maternity care should be locally tailored, and informed by theories encompassing all socio-ecological levels, and the psychological and emotional responses of individuals working within them. Attention should be paid to social normalisation of violence against 'othered' groups, and to the belief that intrapartum maternal mistreatment can optimise safe outcomes.

The Parturient Women's Privacy Preservation in the Delivery Rooms: A Qualitative Study

Introduction: Parturient women's privacy preservation and respectful maternity care (RMC) in delivery room is an important principle in the high quality of midwifery care to achieve maternal satisfaction and positive childbirth experience. Hence, it is essential to make natural vaginal delivery (NVD) a positive experience and increase the mothers' satisfaction. This study aimed to investigate the privacy preservation of parturient women's in the delivery room. Methods: Using conventional content analysis, this qualitative study was conducted from June 2018 to December 2020 at two hospitals and three health centers in Shahroud, Iran. Purposeful sampling was employed and it was continued till data saturation through in-depth interviews with 37 participants. Results: The results of interviews with 21 women with NVD experience and 16 maternity health service providers resulted in the extraction of four themes including physical, spiritual-mental, informational, and social privacy. Conclusion: Various mechanisms were found to promote the privacy and satisfaction of parturient women in the delivery room. They included the necessity continuous education, monitoring about mother's privacy preservation and intervention to improve effective communication skills among staff in delivery rooms.

Evaluation of a comprehensive maternal newborn health intervention in rural Tanzania: single-arm pre-post coverage survey results

Background

In Tanzania, maternal and newborn deaths can be prevented via quality facility-based antenatal care (ANC), delivery, and postnatal care (PNC). Scalable, integrated, and comprehensive interventions addressing demand and service-side care-seeking barriers are needed.

Objective

Assess coverage survey indicators before and after a comprehensive maternal newborn health (MNH) intervention in Misungwi District, Tanzania.

Methods

A prospective, single-arm, pre- (2016) and post-(2019) coverage survey (ClinicalTrials.gov #NCT02506413) was used to assess key maternal and newborn health (MNH) outcomes. The Mama na Mtoto intervention included district activities (planning, leadership training, supportive supervision), health facility activities (training, equipment, infrastructure upgrades), and plus community health worker mobilization. Implementation change strategies, a process model, and a motivational framework incorporated best practices from a similar Ugandan intervention. Cluster sampling randomized hamlets then used ‘wedge sampling’ protocol as an alternative to full household enumeration. Key outcomes included: four or more ANC visits (ANC4+); skilled birth attendant (SBA); PNC for mother within 48 hours (PNC-woman); health facility delivery (HFD); and PNC for newborn within 48 hours (PNC-baby). Trained interviewers administered the ‘Real Accountability: Data Analysis for Results Coverage Survey to women 15–49 years old. Descriptive statistics incorporated design effect; the Lives Saved Tool estimated deaths averted based on ANC4+/HFD.

Results

Between baseline (n = 2,431) and endline (n = 2,070), surveys revealed significant absolute percentage increases for ANC4+ (+11.6, 95% CI [5.4, 17.7], p < 0.001), SBA (+16.6, 95% CI [11.1, 22.0], p < 0.001), PNC-woman (+9.2, 95% CI [3.2, 15.2], p = 0.002), and HFD (+17.2%, 95% CI [11.3, 23.1], p < 0.001). A PNC-baby increase (+6.1%, 95% CI [−0.5, 12.8], p = 0.07) was not statistically significant. An estimated 121 neonatal and 20 maternal lives were saved between 2016 and 2019.

Conclusions

Full-district scale-up of a comprehensive MNH package embedded government health system was successfully implemented over a short time and associated with significant maternal care-seeking improvements and potential for lives saved.

Women’s perspectives on disrespect and abuse experiences during childbirth in a teaching hospital in Southwest Ethiopia: a qualitative study

There is evidence that women in Ethiopia often face disrespect and abuse in health care facilities during childbirth. Disrespect and abuse (D&A) violate women’s right to dignified, respectful health care and decrease their trust in health care facilities. There is a need for more insight into women’s perspectives on D&A during childbirth in different contexts. Therefore, this study aimed to explore women’s perspectives on D&A during childbirth in a teaching hospital in South-West Ethiopia. A qualitative study was conducted from November 2017 to February 2018 using in-depth interviews and focus group discussions. Postnatal women were purposively chosen and scheduled for interviews six weeks postpartum. Data saturation occurred once 32 women were interviewed, and four focus group discussions were conducted. A thematic analysis method was used to analyse the data using MAXQDA qualitative analysis software. Three main themes emerged from the data: disrespect and abuse, its contributors, and perceived consequences. The subthemes of D&A include neglected care, non-consented care, physical abuse, lack of privacy, loss of autonomy, objectification, lack of companionship, and verbal abuse. The subthemes of contributors include health care provider-related, health care system-related, and women-related contributors. The subthemes of perceived consequences include the fear of using health care facilities. Women in Ethiopia experienced D&A. Health system factors, such as the teaching environment and scarcity of supplies, contribute the most to the identified D&A. Therefore, providers, administrators, training institutions, and researchers must collaborate to address these health system factors to reduce disrespect and abuse during childbirth in teaching hospitals.

Understanding variation in person-centered maternity care: Results from a household survey of postpartum women in 6 regions of Ethiopia

BACKGROUND

Effective communication, respect and dignity, and emotional support are critical for a positive childbirth experience that is responsive to the needs and preferences of women.

OBJECTIVE

This study evaluated the performance of a person-centered maternity care scale in a large, representative household sample of postpartum women, and it describes differences in person-centered maternity care across individuals and communities in Ethiopia.

STUDY DESIGN

The study used data from 2019 and 2020 from a representative sample of postpartum women in 6 regions of Ethiopia. It measured person-centered maternity care using a scale previously validated in other settings. To assess the scale validity in Ethiopia, we conducted cognitive interviews, measured internal consistency, and evaluated construct validity. Then, we fit univariable and multivariable linear regression models to test for differences in mean person-centered maternity care scores by individual and community characteristics. Lastly, multilevel modeling separated variance in person-centered maternity care scores within and between communities.

RESULTS

Effective communication and support of women's autonomy scored lowest among person-centered maternity care domains. Of 1575 respondents, 704 (44.7%) were never asked their permission before examinations and most said that providers rarely (n=369; 23.4%) or never (n=633; 40.2%) explained why procedures were done. Person-centered maternity care was significantly higher for women with greater wealth, more formal education, and those aged >20 years. Variation in person-centered maternity care scores between individuals within the same community (τ²=58.3) was nearly 3 times greater than variation between communities (σ²=21.2).

CONCLUSION

Ethiopian women reported widely varying maternity care experiences, with individuals residing within the same community reporting large differences in how they were treated by providers. Poor patient-provider communication and inadequate support of women's autonomy contributed most to poor person-centered maternity care.

A scoping review of the impact of organisational factors on providers and related interventions in LMICs: Implications for respectful maternity care

We have limited understanding of the organisational issues at the health facility-level that impact providers and care as it relates to mistreatment in childbirth, especially in low- and middle-income countries (LMICs). By extension, it is not clear what types of facility-level organisational changes or changes in working environments in LMICs could support and enable respectful maternity care (RMC). While there has been relatively more attention to health system pressures related to shortages of staff and other resources as key barriers, other organisational challenges may be less explored in the context of RMC. This scoping review aims to consolidate evidence to address these gaps. We searched literature published in English between 2000-2021 within Scopus, PubMed, Google Scholar and ScienceDirect databases. Study selection was two-fold. Maternal health articles articulating an organisational issue at the facility- level and impact on providers and/or care in an LMIC setting were included. We also searched for literature on interventions but due to the limited number of related intervention studies in maternity care specifically, we expanded intervention study criteria to include all medical disciplines. Organisational issues captured from the non-intervention, maternal health studies, and solutions offered by intervention studies across disciplines were organised thematically and to establish linkages between problems and solutions. Of 5677 hits, 54 articles were included: 41 non-intervention maternal healthcare studies and 13 intervention studies across all medical disciplines. Key organisational challenges relate to high workload, unbalanced division of work, lack of professional autonomy, low pay, inadequate training, poor feedback and supervision, and workplace violence, and these were differentially influenced by resource shortages. Interventions that respond to these challenges focus on leadership, supportive supervision, peer support, mitigating workplace violence, and planning for shortages. While many of these issues were worsened by resource shortages, medical and professional hierarchies also strongly underpinned a number of organisational problems. Frontline providers, particularly midwives and nurses, suffer disproportionately and need greater attention. Transforming institutional leadership and approaches to supervision may be particularly useful to tackle existing power hierarchies that could in turn support a culture of respectful care.

Respectful maternity care among women who gave birth at public hospitals in Hadiya Zone, Southern Ethiopia

Background

A compassionate and respectful care during pregnancy and childbirth is one of the essential components of safe motherhood. However, most of the women in developing countries experience disrespectful and abusive maternity care during childbirth. Hence, this study assessed the status of respectful maternity care and associated factors to bridge the gap.

Methodology

Facility-based cross-sectional study was conducted among mothers who delivered in public Hospitals in the Hadiya Zone, South Ethiopia from March 01 to 30, 2020. Data were collected using a pretested questionnaire through face-to-face interviews. Descriptive statistics was computed and multivariable logistic regression was fitted to identify predictors. Adjusted Odds Ratio (AOR) with 95% Confidence Interval was used to show the strength of association and level of significance was declared at P-value < 0.05.

Result

This study showed that 67.8 % (95% CI: 62.4-70.8%) of mothers received respectful maternal care. Being married [AOR: 2.17, 95% CI (1.03-6.93)], Cesarean section delivery [AOR: 2.48, 95% CI (1.03-5.97)], and absence of complications during child birth [AOR: 4.37, 95% CI (1.41-13.56)], were significantly associated with respectful maternity care.

Conclusions

The level of RMC in this study was moderate. Being married, Cesarean section delivery, and absence of complications during child birth were identified predictors of respectful maternity care. Therefore, tailored interventions aimed at improving respectful maternity care should target unmarried women, and women with complications of labor regardless of mode of delivery.

“Do we even have a voice?” Health providers’ perspective on the patient accommodation strategies in Bangladesh

Objective

In a resource-constrained setting like Bangladesh, effective patient-provider communication is critical to the delivery of maternal healthcare services. Using communication accommodation theory, this study tried to understand how providers perceive, engage, and accommodate patients’ needs in maternity wards.

Methods

This qualitative exploratory study used a semi-structured interview guide to conduct in-depth face-to-face interviews of ten healthcare providers in two government-funded public health facilities in Bangladesh. The interview data were analyzed using MAXQDA 2020 software.

Results

The thematic analyses revealed that nurses and midwives faced conceivable neglect from patients and their attendees due to possible service and facility constraints, indicating their low status and control within the service operation. Despite efforts to address patients’ emotional and psychological concerns, providers appear to avoid (divergence strategy) confronting patients and their irate visitors. Unimodal convergence emerged when providers accepted patients’ arguments about the systematic inadequacy of service facilities. Providers have employed interpretability tactics to communicate medical opinions and applied nonverbal cues where necessary.

Conclusion

A lack of open communication between healthcare providers and patients necessitated various forms of accommodation. Integrated strategies addressing service restrictions and initiatives fostering patient understanding and cooperation may improve patient-provider communication.

Status of Respectful Maternity Care Among Women Availing Delivery Services at a Tertiary Care Center in Central India: A Cross-Sectional Study

Introduction

There are numerous reports of disrespectful, abusive, or neglectful treatment during childbirth from health facilities worldwide. Although India has substantially increased the number of hospital deliveries and reduced the maternal mortality ratio, the quality of intrapartum and immediate postpartum care for delivering mothers has not been given much importance. Therefore, assessing mistreatment and quality of care during childbirth is vital for promoting respectful maternity care. 

Methods

A descriptive hospital-based cross-sectional study was carried out in a tertiary care center in central India. A convenience sampling method was used, and a total of 150 consecutive consenting women aged 18-49 years who delivered in the study setting were included. Data was collected using a predesigned and pretested questionnaire based on seven major categories per the Respectful Maternity Care (RMC) Charter.

Results

All the 150 women in the present study, i.e., 100%, experienced at least one form of disrespect during their labor, childbirth, or postnatal period at the hospital. The mean scores for domains of non-confidential care (0.59), non-consented care (0.95), abandonment or denial of care (1.21), and physical abuse (1.26) are low.

Conclusion

The findings of the present study shed important light on the current state of respectful maternity care in the study area. Though mothers are noticing and reporting positive changes in maternity care practices, respectful maternity care still has a long way to go.

Promoting respectful maternity care using a behavioral design approach in Zambia: results from a mixed-methods evaluation

Background

Respectful maternity care (RMC) has been elevated in the global discourse, however, instances of disrespect and abuse remain prevalent. While several studies have highlighted promising approaches to promote RMC, this body of literature is still limited and few approaches have been scaled outside the initial study sites. Building on formative research conducted through a behavioral science lens, we sought to develop and test evidence-based, low-cost solutions to promote RMC which would be well-positioned for scale-up. Our study highlights the effectiveness of the solution package on provider provision of respectful care and client satisfaction, as well as intermediary outcomes and behavioral mechanisms.

Methods

A quasi-experimental evaluation, informed by the behavioral design approach, was completed to test the effectiveness of a 5-component solution package in Chipata, Zambia. Quantitative surveys were collected from health facility providers and postpartum clients at baseline and endline in intervention and comparison facilities. Additional qualitative interviews were conducted with health facility providers and postpartum clients at endline. We also conducted interviews with health facility in-charges and observed labor and delivery practices at intervention facilities over the course of implementation.

Results

Evidence suggested that at endline, clients at implementation facilities were less likely to experience disrespect and abuse compared to clients at comparison facilities (ß = − 0.15 p = 0.01). Clients at intervention facilities were more likely to request pain management compared to clients at comparison facilities (ß = 0.33, p = 0.003). The solutions were simple for providers to implement and were easily integrated into existing services by providers during labor and delivery. Providers at intervention facilities also described the pain management toolkit as helpful in expanding the types of pain management techniques used during labor.

Conclusions

The results of this small-scale study act as a proof of concept, demonstrating that the behavioral design approach can lead to solutions that show potential for impact. In other settings where providers face similar barriers to providing RMC, an adaptation of this solution package might lead to similarly positive results. Given the global scale of disrespectful care, these low-cost solutions hold promise for improving the quality of care women receive during labor and delivery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-022-01447-1.

Instances of disrespect and abuse during childbirth are prevalent around the world, particularly in low-resource settings. Few interventions have been designed and evaluated in these settings and even fewer in Southern Africa. This study aimed to understand the effects of a behaviorally informed intervention on the provision of respectful maternity care. We performed an evaluation of a health facility-based intervention, in Chipata District, Zambia. The study included quantitative and qualitative surveys with health care providers and women who recently delivered, as well as health facility observations and qualitative interviews with health facility supervisors. Our results show that clients who delivered at a facility where our intervention took place had a decreased likelihood of experiencing disrespect and abuse and an increased provision of pain management support. Our findings suggest that facility-based approaches informed by behavioral science have the potential to increase provision of respectful care and decrease the prevalence of mistreatment in low-resource settings. A large-scale evaluation of these interventions across settings could contribute valuable evidence around low-cost solutions to promote respectful maternity care.

Effect of Intimate Partner Violence on Birth Preparedness and Complication Readiness at Public Health Facilities, Southwest Ethiopia, 2021: Comparative Cross-Sectional Study

Introduction

Birth preparedness and complication readiness (BPCR) strategy is a key to reducing delays of appropriate care for maternal and child health. Women’s autonomy in the decision of receiving care during pregnancy is essential for improvements in maternal health. However, there is a scarcity of information on the effect of intimate partner violence (IPV) on BPCR in Southwest Ethiopia.

Methods

A comparative cross-sectional study was conducted among 688 women (340: women who had experienced IPV and 348: women who had not experienced IPV). A multi-stage sampling technique was used to select study participants. Bivariate and multivariable logistic regression models were done. A P-value <0.05 at a 95% confidence interval was used to declare a statistical significance.

Results

BPCR among IPV women was 30.59%, lower compared with 46.84% women who did not experience IPV. Higher education [AOR=4.00 (1.20, 13.28)], partner did not drink alcohol [AOR=2.53 (1.34, 4.78)], no childhood violence [AOR=2.70 (1.37, 5.32)], partner’s pregnancy desire [AOR=3.61 (1.41, 9.21)], and good knowledge of BPCR [AOR=8.59 (3.56, 20.70)] were more likely to practice BPCR among women who experienced IPV, whereas among women who did not experience IPV, no previous pregnancy complications [AOR=2.22 (1.08, 4.55)], good knowledge of BPCR [AOR=4.90 (2.59, 9.26)] and pregnancy danger signs [AOR=5.23 (1.47, 18.56)] were more likely practice BPCR.

Conclusion

BPCR among IPV women was lower compared with women who did not experience IPV. Likewise, women’s knowledge of BPCR, obstetric danger signs during pregnancy, labor, and postpartum were lower among women who faced IPV. Therefore, minimizing women’s IPV help to improve BPCR.

An exploratory study of client and provider experience and perceptions of facility-based childbirth care in Quiché, Guatemala

INTRODUCTION

Respectful maternity care (RMC) is fundamental to women's and families' experience of care and their decision about where to give birth. Studies from multiple countries describe the mistreatment of women during facility-based childbirth, though only a small number of studies from Guatemala have been published. Less information is available on women's negative and positive experiences of childbirth care and health workers' perceptions and experiences of providing maternity care.

METHODS

As part of a program implemented in the Western Highlands of Guatemala to improve quality of reproductive maternal newborn and child health care, a mixed methods assessment was conducted in three hospitals and surrounding areas to understand women's and health workers' experience and perceptions of maternity care. The quantitative component included a survey of 31 maternity health workers and 140 women who had recently given birth in these hospitals. The qualitative component included in-depth interviews (IDIs) and focus group discussions (FGDs) with women and maternity health workers and managers.

RESULTS

Women reported a mix of positive and negative experiences of childbirth care related to interpersonal and health system factors. 81% of surveyed women reported that health workers had treated them with respect while 21.4% of women reported verbal abuse. Fifty-five percent and 12% of women, respectively, reported not having access to a private toilet and bath or shower. During IDIs and FGDs, many women described higher rates of verbal abuse directed at women who do not speak Spanish. A regression analysis of survey results indicated that speaking Ixil or K'iche at home was associated with a higher likelihood of women being treated negatively during childbirth in a facility. Health worker survey results corroborated negative aspects of care described by women and also reported mistreatment of health workers by clients and families (70.9%) and colleagues (48.2%).

CONCLUSIONS

This study adds to the literature on women's experience of institutional childbirth and factors that influence this experience by triangulating experience and perceptions of both women and health workers. This assessment highlights opportunities to address mistreatment of both women and health workers and to build on positive care attributes to strengthen RMC for all women.

Health system bottlenecks hindering provision of supportive and dignified maternity care in public health facilities

Mistreatment with women during childbirth is prevalent in many in low- and middle-income countries. There is dearth of evidence that informs development of health system interventions to promote supportive and respectful maternity care in facility-based settings. We examined health systems bottlenecks that impedes provision of supportive and respectful maternity care in secondary-level public healthcare system of Pakistan. Using a qualitative exploratory design, forty in-depth interviews conducted with maternity care staff of six public health facilities in southern Pakistan. Development of interview guide and data analyses were guided by the WHO's six health system building blocks. A combination of inductive and deductive approach was used for data analyses. Our study identified range of bottlenecks impeding provision of RMC. In terms of leadership/governance, there was lack of institutional guidelines, supervision and monitoring, and patient feedback mechanism. No systematic mechanism existed to screen and record patient psychosocial needs. Health workforce lacked training opportunities on RMC that resulted in limited knowledge and skills; there were also concerns about lack of recognition from leadership for good performers, and poor relationship and coordination between clinical and non-clinical staff. Regarding the domain of service delivery, we found that patients were perceived as un-cooperative, non-RMC manifestations were acceptable and normalized under certain conditions, and restrictive policies for active engagement of companions. Finally, lack of cleanliness, curtains for privacy, seating arrangement for companion were the identified issues infrastructural issues. A service-delivery intervention package is needed that effectively uses all six components of the health system: from investments in capacity building of maternity teams to creating a conducive facility environment via proper governance and accountability mechanisms. Such interventions should not only focus on provision of maternity care in a respectful and dignified manner, but also ensure that care is responsive to the psychosocial needs of pregnant women without any discrimination.

Respectful maternity care and associated factors among mothers who gave birth at public health institutions in South Gondar Zone, Northwest Ethiopia 2021

Introduction:

Respectful maternity care is essential for improving maternal and neonatal health. Lack of respectful maternity care during childbirth services is one of the deterrents to women seeking facility-based deliveries. It is a health system failure and a violation of women’s rights. There is limited data on respectful maternity care during childbirth and maternity care in Ethiopia, particularly at rural health facilities. But studies have shown that many women from rural areas were more likely to report disrespect and abuse than urban residents.

Objective:

This study aims to assess respectful maternity care and associated factors among mothers who gave birth at health institutions in the South Gondar zone, northwest Ethiopia, 2021.

Methods:

A multicenter institutional-based cross-sectional study design was conducted among mothers who gave birth at South Gondar Zone public health institutions, from 1 February to 30 March 2021. Six hundred twenty-two study participants were selected by using systematic random sampling. The data were collected through face-to-face interviews using a pretested and semi-structured questionnaire. Data were entered into Epi-Data version 4.6 and exported to SPSS version 23 for analysis. A multivariable logistic regression analysis was performed to identify factors associated with the outcome variable. An adjusted odds ratio with a 95% confidence interval was computed to determine the level of significance.

Result:

A total of 611 participants were included in the study with the response rate of 98.2%. The study revealed that only 39.4%, of (95% confidence interval: 35.4–43.2) women received respectful maternity care. Completed secondary education (adjusted odds ratio: 2.47, 95% confidence interval: 1.35–4.50), having antenatal care follow-up (adjusted odds ratio: 0.098, 95% confidence interval: 0.03–0.34), planned pregnancy (adjusted odds ratio: 3.21, 95% confidence interval: 1.69–6.08), cesarean section delivery (adjusted odds ratio: 0.47, 95% confidence interval: 0.25–0.89), and daytime delivery (adjusted odds ratio: 1.9, 95% confidence interval: 1.33–2.72)) were significantly associated with respectful maternity care.

Conclusion and Recommendation:

Only two out of five women received respectful maternity care during childbirth. Completed secondary education, having antenatal care follow-up, pregnancy intended/wanted, daytime delivery, and cesarean section delivery were identified factors. Therefore, giving emphasis to creating awareness of care providers on the standards and categories of respectful maternity care, improving care provider–client discussion, monitoring, and reinforcing accountability mechanisms for health workers to improve respectful maternity care during labor and childbirth were recommended.

Promoting compassionate and respectful maternity care during facility-based delivery in Ethiopia: perspectives of clients and midwives

OBJECTIVE

The purpose of this qualitative study was to explore clients' and midwives' perceptions of compassionate and respectful care during facility-based delivery in Bishoftu District, the regional state of Oromia, Ethiopia.

SETTING

Public health facilities (two health centres and one district hospital).

STUDY DESIGN

A qualitative exploratory descriptive research design was used.

STUDY PARTICIPANTS

The research population included purposely sampled women who had given birth in a health facility in the previous 2 weeks and midwifery experts who provided maternity care in the health facility's labour and delivery wards. Data were gathered through an individual interview (with 10 midwives and 12 women in labour). Interviews were audio-recorded and transcribed immediately. For the research, thematic analysis was performed manually. Both a priori codes (from the query guide) and emerging inductive codes were used in the study. In the thematic data analysis, three inter-related stages were involved, namely data reduction, data display and data conclusion.

RESULTS

From the analysis of in-depth interviews with labouring women, three themes emerged, namely: dignified and respectful care, neglectful care and unqualified staff. Five main categories emerged from in-depth interviews with midwives: trusting relationships formed with labouring women, compassionate and respect-based behaviour, good communication skills and holistic care, intentional disrespect toward women, and barriers to compassionate and respectful maternity care due to structural factors. These themes were discovered to be a rich and detailed account of midwives' perspectives on compassionate and respectful maternity care.

CONCLUSION

The majority of women who witnessed or suffered disrespect and violence during labour and childbirth were dissatisfied with their maternity care during labour and delivery. Despite midwives' accounts showing that they were aware of the importance of compassionate and respectful maternity care, clients face verbal abuse, neglect, and a lack of supportive treatment during labour and childbirth. Clients' human rights were violated by disrespectful or abusive acts, whether perpetrated or observed. It is essential to address structural problems such as provider workload, and all other initiatives aimed at improving midwives' interpersonal relationships with women to provide compassionate and respectful client-centred maternity care.

Operationalizing respectful maternity care at the healthcare provider level: a systematic scoping review

BACKGROUND

Ensuring the right to respectful care for maternal and newborn health, a critical dimension of quality and acceptability, requires meeting standards for Respectful Maternity Care (RMC). Absence of mistreatment does not constitute RMC. Evidence generation to inform definitional standards for RMC is in an early stage. The aim of this systematic review is clear provider-level operationalization of key RMC principles, to facilitate their consistent implementation.

METHODS

Two rights-based frameworks define the underlying principles of RMC. A qualitative synthesis of both frameworks resulted in seven fundamental rights during childbirth that form the foundation of RMC. To codify operational definitions for these key elements of RMC at the healthcare provider level, we systematically reviewed peer-reviewed literature, grey literature, white papers, and seminal documents on RMC. We focused on literature describing RMC in the affirmative rather than mistreatment experienced by women during childbirth, and operationalized RMC by describing objective provider-level behaviors.

RESULTS

Through a systematic review, 514 records (peer-reviewed articles, reports, and guidelines) were assessed to identify operational definitions of RMC grounded in those rights. After screening and review, 54 records were included in the qualitative synthesis and mapped to the seven RMC rights. The majority of articles provided guidance on operationalization of rights to freedom from harm and ill treatment; dignity and respect; information and informed consent; privacy and confidentiality; and timely healthcare. Only a quarter of articles mentioned concrete or affirmative actions to operationalize the right to non-discrimination, equality and equitable care; less than 15%, the right to liberty and freedom from coercion. Provider behaviors mentioned in the literature aligned overall with seven RMC principles; yet the smaller number of available research studies that included operationalized definitions for some key elements of RMC illustrates the nascent stage of evidence-generation in this area.

CONCLUSIONS

Lack of systematic codification, grounded in empirical evidence, of operational definitions for RMC at the provider level has limited the study, design, implementation, and comparative assessment of respectful care. This qualitative systematic review provides a foundation for maternity healthcare professional policy, training, programming, research, and program evaluation aimed at studying and improving RMC at the provider level.

Presence of birth companion-a deterrent to disrespectful behaviours towards women during delivery: an exploratory mixed-method study in 18 public hospitals of India

Birthing women require support, particularly emotional support, during the process of labour and delivery. Traditionally, across cultures, this support was made available by the continuous presence of a companion during labour, childbirth and the immediate post-partum period. However, this practice is not universal, especially in health facilities in low- and middle-income countries. This cross-sectional study was conducted in 18 tertiary health care facilities of India using a mixed-method approach. The quantitative data were collected to document the number of birthing women, birth companions and healthcare providers in the labour rooms, and the typology of disrespect and abuse (D&A) faced by women. This was followed by in-depth interviews with 55 providers to understand their perspective on the various dimensions of D&A and the challenges they face to provide respectful care. This article explores the status of birth companionship in India and its plausible associations with D&A faced by birthing women in public facilities. Our study reveals that birth companionship is still not a common practice in Indian public hospitals. Birth companions were present during less than half of the observational period, also less than half of the birthing women were accompanied by a birth companion. Lack of hospital policy, space constraints, overcrowding and privacy concerns for other patients were cited as reasons for not allowing birth companions in the labour rooms, whose supportive roles, both for women and providers, were otherwise widely acknowledged during the qualitative interviews. Also, the presence of birth companions was found to be critically negatively associated with occurrences of D&A of birthing women. We contend that owing to the high pressure on the public hospitals in India, birth companions can be a low-cost intervention model for promoting respectful maternity care. However, adequate infrastructure is a critical aspect to be taken care of.

Imagining maternity care as a complex adaptive system: understanding health system constraints to the promotion of respectful maternity care

Evidence of the health system challenges to promoting respectful maternity care (RMC) is limited in Ethiopia and globally. This study investigated the health system constraints to RMC in three Southern Ethiopian hospitals. We conducted a qualitative study (7 focus group discussions (FGDs) with providers of RMC and 12 in-depth interviews with focal persons and managers) before and after the implementation of an RMC intervention. We positioned childbirth services within the health system and applied complex adaptive system theory to analyse the opportunities and constraints to the promotion of RMC. Both system “hardware” and “software” factors influencing the promotion of RMC were identified, and their interaction was complex. The “hardware” factors included bed availability, infrastructure and supplies, financing, and health workforce. “Software” factors encompassed service providers’ mindset, staff motivation, and awareness of RMC. Interactions between these factors included privacy breaches for women when birth companions were admitted in labour rooms. Delayed reimbursement following the introduction of fee-exemption for maternity services resulted in depleted revenues, supply shortages, and ultimately disrespectful behaviour among providers. Other financial constraints, including the insufficient and delayed release of funds, also led to complex interactions with the motivation of staff and the availability of workforce and supplies, resulting in poor adherence to RMC guidance. Interventions aimed at improving only behavioural components fall short of mitigating the mistreatment of women. System-wide interventions are required to address the complex interactions that constraint RMC.

Disrespect and abuse during facility-based childbirth in central Ethiopia

Background

Respectful maternity care is a fundamental human right, and an important component of quality maternity care.

Objective

The aim of this study was to quantify the frequency and categories of D&A and identify factors associated with reporting D&A among women in north Showa zone of Ethiopia.

Method

A cross-sectional study was conducted with 435 randomly selected women who had given birth at public health facility within the previous 12 months in North Showa zone of Ethiopia. A digital (tablet-based) structured and researcher administered tool was used for data collection. Frequencies of D&A items organised around the Bowser and Hill categories of D&A and presented in the White Ribbon Alliance’s Universal Rights of Childbearing Women Framework were calculated. Multivariable logistic regression was used to identify the association between experience of disrespect and abuse and interpersonal and structural factors at p-value <0.05 and odds ratio values with 95% confidence interval.

Results

All participants reported at least one form of disrespect and abuse during childbirth. Types of disrespect and abuse experienced by participants were physical abuse 435 (100%), non-consented care 423 (97.2%), non-confidential care 288 (66.2%), abandonment/neglect (34.7%), non-dignified care 126 (29%), discriminatory care 99 (22.8%) and detention 24 (5.5%). Hospital birth [AOR: 3.04, 95% CI: 1.75, 5.27], rural residence [AOR: 1.44, 95% CI: 0.76, 2.71], monthly household income less than 1,644 Birr (USD 57) [AOR: 2.26, 95% CI: 1.20, 4.26], being attended by female providers [AOR: 1.74, 95% CI: 1.06, 2.86] and midwifery nurses [AOR: 2.23, 95% CI: 1.13, 4.39] showed positive association with experience of disrespect and abuse.

Conclusion

Hospital birth showed consistent association with all forms of disrespect and abuse. Expanding the size and skill mix of professionals in the hospitals, sensitizing providers consequences of disrespect and abuse could promote dignified and respectful care.

Compassionate and respectful care among outpatient clients at public health facilities in Northwest Ethiopia: A mixed-methods study

Introduction

Compassionate and respectful care is a pillar for improving health-seeking behaviour. It has given much attention globally, following the concerns that healthcare often falls significantly; however, less research emphasis was paid in the last decade. Therefore, this study aims to assess compassionate and respectful care and associated factors among outpatient clients at public health facilities in Northwest Ethiopia, 2020.

Methods

A facility-based quantitative cross-sectional study supplemented with the qualitative findings was conducted from 30 February to 30 March 2020. A semi-structured interviewer-administered questionnaire was used to collect the quantitative data among 593 participants. Systematic and purposive sampling techniques were used to select the quantitative and qualitative participants, respectively. A semi-structured interview guide was also employed for the qualitative data collection. Epi-Data version 4.6 and SPSS version 25 were used for data entry and analysis, respectively. The bi-variable and multivariable logistic regression model was fitted to identify the factors associated with each outcome variable (compassionate and respectful care separately). Adjusted odds ratio (AOR) with 95% confidence interval (CI) and p-value less than 0.05 were used to declare the strength and factors statistically associated with the outcome variables.

Results

Overall, 72.8% and 82.6% of the respondents experienced compassionate and respectful care, respectively. Patients attending primary or above education (AOR: 0.35; 95% CI: 0.21–0.59), attending at the hospital (AOR: 0.59; 95% CI: 0.39–0.88), new clients (AOR: 0.33; 95% CI: 0.16–0.70) and service users who had three or more visits (AOR: 0.34; 95% CI: 0.17–0.71) were negatively associated with compassionate care. On the other hand, female patients (AOR = 0.53; 95% CI: 0.32–0.87), aged over 36 years (AOR = 0.43; 95% CI: 0.20–0.90), primary or above school attended clients (AOR = 0.18; 95% CI: 0.09–0.36), waiting two or more hours (AOR = 0.28; 95% CI: 0.13–0.62), and use public or private transport access (AOR: 0.49; 95% CI: 0.29–0.83) were negatively associated with a respectful care.

Conclusion

Compassionate and respectful care provided to the outpatient clients in public health facilities of northwest Ethiopia was high. However, our result suggests that immediate actions are necessary to address respectful and compassionate care at hospitals, and hospital management should adopt mitigation measures. Consideration should be given to foster patient-centric services and educate the health care workers about compassionate and respectful care.

"I Would Have Stayed Home if I Could Manage It Alone": A Case Study of Ethiopian Mother Abandoned by Care Providers During Facility-Based Childbirth

Background

Every woman is entitled to respectful care during pregnancy and childbirth as a basic human right. However, not all women are being treated equally well.

Case Presentation

This case study highlights some of the common disrespectful practices that women face. This is a testimony of a 28-year-old mother of two, narrated in her own words. The data were collected during an in-depth interview in November 2019. The interview was conducted in her house and her name has been changed to protect her identity. The interview was audio-taped using a digital voice recorder, later transcribed, and translated verbatim from the local language – Amharic, to English.

Conclusion

This woman’s story highlights the unfortunate reality for some women. Five themes emerged from her narrative: denial of care: the provider left her unattended at a critical moment and denied her the care that she came for; non-consented care: she did not consent to the episiotomy; non-dignified care: she was carried by her arms and legs to the delivery couch, and left naked and bleeding on the couch after birth; taking a sick baby home without medical assistance: she was forced to leave the hospital even though her child had breathing difficulties and was not able to suck or breastfeed; and loss of trust in care providers: for her second birth this woman went to a facility where a relative works, as she no longer trusted these providers.

Women's experiences of mistreatment during childbirth and their satisfaction with care: findings from a multicountry community-based study in four countries

Introduction

Experiences of care and satisfaction are intrinsically linked, as user’s experiences of care may directly impact satisfaction, or indirectly impact user’s expectations and values. Both experiences of care and satisfaction are important to measure so that quality can be monitored and improved. Globally, women experience mistreatment during childbirth at facilities; however, there is limited evidence exploring the mistreatment and women’s satisfaction with care during childbirth.

Methods

This is a secondary analysis of a cross-sectional survey within the WHO study ‘How women are treated during facility-based childbirth’ exploring the mistreatment of women during childbirth in Ghana, Guinea, Myanmar and Nigeria. Women’s experiences of mistreatment and satisfaction with care during childbirth was explored. Multivariable logistic regression modelling was conducted to evaluate the association between mistreatment, women’s overall satisfaction with the care they received, and whether they would recommend the facility to others.

Results

2672 women were included in this analysis. Despite over one-third of women reporting experience of mistreatment (35.4%), overall satisfaction for services received and recommendation of the facility to others was high, 88.4% and 90%, respectively. Women who reported experiences of mistreatment were more likely to report lower satisfaction with care: women were more likely to be satisfied if they did not experience verbal abuse (adjusted OR (AOR) 4.52, 95% CI 3.50 to 5.85), or had short waiting times (AOR 5.12, 95% CI 3.94 to 6.65). Women who did not experience any physical or verbal abuse or discrimination were more likely to recommend the facility to others (AOR 3.89, 95% CI 2.98 to 5.06).

Conclusion

Measuring both women’s experiences and their satisfaction with care are critical to assess quality and provide actionable evidence for quality improvement. These measures can enable health systems to identify and respond to root causes contributing to measures of satisfaction.

Providers' perceptions of disrespect and abuse during childbirth: a mixed-methods study in Kenya

Disrespect and abuse during childbirth are violations of women's human rights and an indicator of poor-quality care. Disrespect and abuse during childbirth are widespread, yet data on providers' perspectives on the topic are limited. We examined providers' perspectives on the frequency and drivers of disrespect and abuse during facility-based childbirth in a rural county in Kenya. We used data from a mixed-methods study in a rural county in Western Kenya with 49 maternity providers (32 clinical and 17 non-clinical) in 2016. Providers were asked structured questions on disrespect and abuse, followed by open-ended questions on why certain behaviours were exhibited (or not). Most providers reported that women were often treated with dignity and respect. However, 53% of providers reported ever observing other providers verbally abuse women and 45% reported doing so themselves. Observation of physical abuse was reported by 37% of providers while 35% reported doing so themselves. Drivers of disrespect and abuse included perceptions of women being difficult, stress and burnout, facility culture and lack of accountability, poor facility infrastructure and lack of medicines and supplies, and provider attitudes. Provider bias, training and women's empowerment influenced how different women were treated. We conclude that disrespect and abuse are driven by difficult situations in a health system coupled with a facilitating sociocultural environment. Providers resorted to disrespect and abuse as a means of gaining compliance when they were stressed and feeling helpless. Interventions to address disrespect and abuse need to tackle the multiplicity of contributing factors. These should include empowering providers to deal with difficult situations, develop positive coping mechanisms for stress and address their biases. We also need to change the culture in facilities and strengthen the health systems to address the system-level stressors.

Perspectives on implementing a quality improvement collaborative to improve person-centered care for maternal and reproductive health in Kenya

OBJECTIVE

To understand perspectives and experiences related to participation in a quality improvement collaborative (QIC) to improve person-centered care (PCC) for maternal health and family planning (FP) in Kenya.

DESIGN AND SETTING

Semi-structured qualitative interviews were conducted with members of the QIC in four public health facilities in Kenya.

PARTICIPANTS

Clinical and nonclinical public health facility staff who had participated in the QIC were purposively sampled to participate in the semi-structured interviews.

INTERVENTION

A QIC was implemented across four public health facilities in Nairobi and Kiambu Counties in Kenya to improve PCC experiences for women seeking maternity or FP services.

MAIN OUTCOME MEASURE

Semi-structured interviews with participants of the QIC to understand perspectives and experiences associated with sensitization to and implementation of PCC behaviors in maternity and FP services.

RESULTS

Respondents reported that sensitization to PCC principles resulted in multiple perceived benefits for staff and patients alike, including improved interactions with patients and clients, deeper awareness of patient and client preferences, and improved interpersonal skills and greater job satisfaction. Respondents also highlighted system-level challenges that impeded their ability to consistently provide high-quality PCC to women, namely staff shortages and frequent turnover, high patient volumes and lack of space in their respective health facilities.

CONCLUSION

Respondents were easily able to articulate perceived benefits derived from participation in this QIC, although they were equally able to identify challenges that hindered their ability to consistently provide high-quality PCC to women seeking maternity or FP services.

Providing respectful maternity care in northern Ghana: A mixed-methods study with maternity care providers

OBJECTIVE

This study explored providers' perspectives and behavior regarding respectful maternity care, including knowledge, attitudes, and practices.

DESIGN

Mixed-methods cross-sectional study combining quantitative survey data, qualitative interviews, and observations of labor and delivery across four health facilities SETTING: Government health facilities in rural northern Ghana PARTICIPANTS: 43 front-line maternity care providers completed a survey of practice patterns before a quality of care training. We then used purposive and convenience sampling to recruit a sub-sample for in-depth interviews (N=17), and convenience sampling and self-selection to observe approximately half (N=8) providing clinical care.

MEASUREMENTS AND FINDINGS

We calculated descriptive statistics from quantitative data and used the framework approach for qualitative analysis. Observational data were examined using the CHANGE Project's Assessment Tools for Caring Providers. We utilized split frame methodology to make comparisons across data sources. Quantitative survey results (N=43) indicate most providers report explaining procedures to women (89.5%), involving women and families in care decisions (84.1%), and covering or screening women for privacy (81.5%). At the same time, 38.9% reported they have shouted at, scolded, insulted, threatened, or talked rudely to a woman, and 26.4% said they have treated a woman differently because of her personal attributes. Qualitative interview data (N=17) suggested that providers can articulate a vision of respectful care, aspire to offer respectful care, and recognize they do not always meet those aspirations. Among those (N=8) volunteering to be observed, introductions and explanations for procedures were rare, privacy screening was infrequent, and participants were observed slapping, scolding, and restraining women in labor, often associated with patient non-compliance to provider instructions.

KEY CONCLUSIONS

Even among providers knowledgeable about respectful maternity care and who agreed to be observed providing delivery care, disrespect and abuse were present.

IMPLICATIONS FOR PRACTICE

Further research and programmatic efforts are needed to address the gap between knowledge and behavior.

Disrespect and Abuse during Childbirth in Ethiopia: A Systematic Review

Background

Disrespect and abuse are recognized for the restricting impact of women from seeking maternal care, psychological humiliations, grievances, and unspoken sufferings on women during childbirth. Individual primary studies are limited in explaining of extent of disrespect and abusive care. Hence, this review considers the synthesis of comprehensive evidence on the extent, contributing factors, and consequences of disrespectful and abusive intrapartum care from the women's and providers' perspectives in Ethiopia.

Methods

Articles had been systematically searched from the databases of PubMed, Cochrane Library, POPLINE, Google Scholar, HINARI, African Journals Online, and WHO Global Health Library. A qualitative and quantitative synthesis was performed using the Bowser and Hill landscape analytical framework.

Result

Twenty-two studies comprised of the 16 quantitative; 5 qualitative and one mixed studies were included. The most repeatedly dishonored right during facility-based childbirth in Ethiopia was nondignified care, and the least commonly reported abuse was detention in health facilities. These behaviors were contributed by normalization of care, lack of empowerment and education of women, weak health system, and lack of training of providers. Women subjected to disrespectful and abusive behavior distanced themselves from the use of facility-based childbirth-related services and have endured psychological humiliations.

Conclusion

Disrespectful and abusive care of women during childbirth is repeatedly practiced care in Ethiopia. This result specifically described the contributing factors and their effects as a barrier to the utilization of facility-based childbirth. Therefore, to overcome this alarming problem, health systems and care providers must be responsive to the specific needs of women during childbirth, and implementing policies for standard care of respectful maternity care must be compulsory. In addition, observational, qualitative, and mixed types of studies are required to provide comprehensive evidences on disrespect and abusive behavior during childbirth in Ethiopia.

Work place violence (WPV) against healthcare workers in Africa: A systematic review

Background

WPV amongst healthcare workers has been reported as a public health challenge across the countries of the world, with more in the developing countries where condition of care and service is very poor.

Objectives

We aimed to systematically produce empirical evidence on the WPV against health care workers in Africa through the review of relevant literature.

Method

We sourced for evidence through the following databases: PubMed, Science direct and Scopus from 30^th November to 31^st December 2019 as well as the reference list of the studies included. A total of 22 peer reviewed articles were included in the review (8065 respondents). Quality appraisal of the included studies was assessed using critical appraisal tools for cross-sectional studies.

Result

Across the studies, diverse but high prevalence of WPV ranging from 9% to 100% was reported with the highest in South Africa (54%–100%) and Egypt (59.7%–86.1%). The common types were verbal, physical, sexual harassment and psychological violence. The correlates of WPV reported were gender, age, shift duty, emergency unit, psychiatric unit, nursing, marital status and others. Various impacts were reported including psychological impacts and desire to quit nursing. Patients and their relatives, the coworkers and supervisors were the mostly reported perpetrators of violence. Doctors were mostly implicated in the sexual violence against nurses. Policy on violence and management strategies were non-existent across the studies.

Conclusion

High prevalence of WPV against healthcare workers exists in Africa but there is still paucity of research on the subject matter. However, urgent measures like policy formulation and others must be taken to address the WPV as to avert the impact on the healthcare system.

Disrespect and abuse of women during the process of childbirth at health facilities in sub-Saharan Africa: a systematic review and meta-analysis

Background

Disrespectful and abusive treatment of women by health care providers during the process of childbirth at health facility is an international problem. There is a lack of data on disrespect and abuse of women during the process of childbirth at health facilities in Sub-Saharan Africa. The purpose of this study was to determine the prevalence of disrespect and abuse of women during the process of childbirth at health facilities in sub-Saharan Africa.

Methods

The PRISMA guideline protocol was followed to write the systematic review and meta-analysis. Published studies were searched from Medline, PubMed, CINAHL, EMBASE, Maternal and infant care, science direct, and PsycINFO. Articles were accessed by three reviewers (ZY, BT and AA) using the following key terms, “attitude of health personnel” AND “delivery obstetrics*/nursing” OR “maternity care” AND “disrespect” OR “abuse” OR “professional misconduct” AND “parturition” AND “prevalence” AND “professional-patient relations” AND “Sub-Saharan Africa”. Additional articles were retrieved by cross referencing of reference. The heterogeneity of studies were weighed using Cochran’s Q test and I² test statistics. Publication bias was assessed by Egger’s test.

Results

Thirty three studies met the inclusion and included in this systematic review and meta–analysis of disrespect and abuse of women during the process of childbirth at health facilities. The pooled prevalence of disrespect and abuse women during the process of childbirth at health facilities in Sub-Saharan Africa was 44.09% (95% CI: 29.94–58.24).Particularly physical abuse was 15.77% (95% CI: 13.38–18.15), non-confidential care was 16.87% (95% CI: 14.49–19.24), abandonment was 16.86% (95% CI: 13.88–19.84) and detention was 4.81% (95% CI: 3.96–5.67).

Conclusion

In this study disrespect and abuse of women during the process of childbirth at health facilities are high compared with other studies, particularly non-confidential care and abandonment his high compared with other studies. This study points out that the ministry of health, health care providers, maternal health experts shall due attention to women’s right during the process of childbirth at health facilities.

Mitigating the mistreatment of childbearing women: evaluation of respectful maternity care intervention in Ethiopian hospitals

OBJECTIVES

There is a lack of evidence on approaches to mitigating mistreatment during facility-based childbirth. This study compares the experiences of mistreatment reported by childbearing women before and after implementation of a respectful maternity care intervention.

DESIGN

A pre-post study design was undertaken to quantify changes in women's experiences of mistreatment during facility-based childbirth before and after the respectful maternity care intervention.

INTERVENTION

A respectful maternity care intervention was implemented in three hospitals in southern Ethiopia between December 2017 and September 2018 and it included training of service providers, placement of wall posters in labour rooms and post-training supportive visits for quality improvement.

OUTCOME MEASURES

A 25-item questionnaire asking women about mistreatment experiences was administered to 388 women (198 in the pre-intervention, 190 in the post-intervention). The outcome variable was the number of mistreatment components experienced by women, expressed as a score out of 25. Multilevel mixed-effects Poisson modelling was used to assess the change in mistreatment score from pre-intervention to post-intervention periods.

RESULTS

The number of mistreatment components experienced by women was reduced by 18% when the post-intervention group was compared with the pre-intervention group (adjusted regression coefficient (Aβ)=0.82, 95% CI 0.74 to 0.91). Women who had a complication during pregnancy (Aβ=1.17, 95% CI 1.01 to 1.34) and childbirth (Aβ=1.16, 95% CI 1.03 to 1.32) experienced a greater number of mistreatment components. On the other hand, women who gave birth by caesarean birth after trial of vaginal birth (Aβ=0.76, 95% CI 0.63 to 0.92) and caesarean birth without trial of vaginal birth (Aβ=0.68, 95% CI 0.47 to 0.98) experienced a lesser number of mistreatment components compared with those who had vaginal birth.

CONCLUSIONS

Women reported significantly fewer mistreatment experiences during childbirth following implementation of the intervention. Given the variety of factors that lead to mistreatment in health facilities, interventions designed to mitigate mistreatment need to involve structural changes.

Respectful maternity care during labor and childbirth and associated factors among women who gave birth at health institutions in the West Shewa zone, Oromia region, Central Ethiopia

Background

Skilled assistance during pregnancy and childbirth is one of the key interventions in reducing maternal morbidity and mortality. But studies have shown that many women across the globe experience disrespectful and abusive treatment during labor and childbirth in institutions, which forms an important barrier to improving skilled care utilization and improving maternal health outcomes. Although there are few studies done in Ethiopia, information on the status of respectful maternity care (RMC) among women during childbirth at health institutions in the West-Shewa zone is lacking. Therefore, the study aimed to assess RMC during Labor and Childbirth and associated factors among women who gave-birth at health-institutions in the West Shewa zone, Central Ethiopia.

Methods

Cross-sectional study was conducted at Health institutions in the West Shewa zone, Oromia region, Central Ethiopia. A systematic random sampling technique that uses women’s delivery registration number was used to collect data. Data was collected through an exit-interview. Both bivariate and multivariable logistic regressions were used to identify associated factors.

Results

From a total of 567 women who fully responded, only 35.8% received RMC. From categories of RMC, 76.5% of the woman is protected from physical harm/ill-treatment and 89.2% received equitable care free of discrimination. But, only 39.3% of woman’s right to information, informed consent and preferences were protected. Giving birth at health center (AOR:5.44), discussion on the place of delivery (AOR:4.42), daytime delivery (AOR:5.56), longer duration of stay (≥ 13 h) (AOR:2.10), involvement in decision-making (AOR:8.24), asking for consent before the procedure(AOR:3.45), current pregnancy unintended (AOR:5.56), the presence of < 3 health-workers during childbirth (AOR:2.23) and satisfied on waiting-time to be seen (AOR:2.08) were found to be significantly associated with RMC.

Conclusions

The proportion of RMC during labor and childbirth in the study area was low. Type of institution, discussion during ANC, time of delivery, duration of stay, involvement in decision-making, the number of health workers, waiting time and consent were identified factors. Therefore, giving emphasis to creating awareness of care providers on the standards and categories of RMC, improving care provider-client discussion, monitor and reinforcing accountability mechanisms for health workers to avoid mistreatments during labor and childbirth were recommended.

Lessons learned through respectful maternity care training and its implementation in Ethiopia: an interventional mixed methods study

Background

Improving respectful maternity care (RMC) is a recommended practice during childbirth as a strategy to eliminate the mistreatment of women and improve maternal health. There is limited evidence on the effectiveness of RMC interventions and implementation challenges, especially in low-resource settings. This study describes lessons learned in RMC training and its implementation from the perspectives of service providers’ perceptions and experiences.

Methods

Our mixed methods study employed a pre- and post-intervention quantitative survey of training participants to assess their perceptions of RMC and focus group discussions, two months following the intervention, investigated the experiences of implementing RMC within birthing facilities. The intervention was a three-day RMC training offered to 64 service providers from three hospitals in southern Ethiopia. We performed McNemar’s test to analyse differences in participants’ perceptions of RMC before and after the training. The qualitative data were analysed using hybrid thematic analysis. Integration of the quantitative and qualitative methods was done throughout the design, analysis and reporting of the study.

Results

Mistreatment of women during childbirth was widely reported by participants, including witnessing examinations without privacy (39.1%), and use of physical force (21.9%) within the previous 30 days. Additionally, 29.7% of participants reported they had mistreated a woman. The training improved the participants’ awareness of the rights of women during childbirth and their perceptions and attitudes about RMC were positively influenced. However, participants believed that the RMC training did not address providers’ rights. Structural and systemic issues were the main challenges providers reported when trying to implement RMC in their contexts.

Conclusion

Training alone is insufficient to improve the provision of RMC unless RMC is addressed through a lens of health systems strengthening that addresses the bottlenecks, including the rights of providers of childbirth care.

Providers' perceptions of communication and women's autonomy during childbirth: a mixed methods study in Kenya

Background

Effective communication and respect for women’s autonomy are critical components of person-centered care. Yet, there is limited evidence in low-resource settings on providers’ perceptions of the importance and extent of communication and women’s autonomy during childbirth. Similarly, few studies have assessed the potential barriers to effective communication and maintenance of women’s autonomy during childbirth. We sought to bridge these gaps.

Methods

Data are from a mixed-methods study in Migori County in Western Kenya with 49 maternity providers (32 clinical and 17 non-clinical). Providers were asked structured questions on various aspects of communication and autonomy followed by open ended questions on why certain practices were performed or not. We conducted descriptive analysis of the quantitative data and thematic analysis of the qualitative data.

Results

Despite acknowledging the importance of various aspects of communication and women’s autonomy, providers reported incidences of poor communication and lack of respect for women’s autonomy: 57% of respondents reported that providers never introduce themselves to women and 38% reported that women are never able to be in the birthing position of their choice. Also, 33% of providers reported that they did not always explain why they are doing exams or procedures and 73% reported that women were not always asked for permission before exams or procedures. The reasons for lack of communication and autonomy fall under three themes with several sub-themes: (1) work environment—perceived lack of time, language barriers, stress and burnout, and facility culture; (2) provider knowledge, intentions, and assumptions—inadequate provider knowledge and skill, forgetfulness and unconscious behaviors, self-protection and comfort, and assumptions about women’s knowledge and expectations; and (3) women’s ability to demand or command effective communication and respect for their autonomy—women’s lack of participation, women’s empowerment and provider bias.

Conclusions

Most providers recognize the importance of various aspects of communication and women’s autonomy, but they fail to provide it for various reasons. To improve communication and autonomy, we need to address the different factors that negatively affect providers’ interactions with women.

Conceptual model for pluralistic healthcare behaviour: results from a qualitative study in southwestern Uganda

INTRODUCTION

Medical pluralism, or concurrent utilisation of multiple therapeutic modalities, is common in various international contexts, and has been characterised as a factor contributing to poor health outcomes in low-resource settings. Traditional healers are ubiquitous providers in most regions, including the study site of southwestern Uganda. Where both informal and formal healthcare services are both available, patients do not engage with both options equally. It is not well understood why patients choose to engage with one healthcare modality over the other. The goal of this study was to explain therapeutic itineraries and create a conceptual framework of pluralistic health behaviour.

METHODS

In-depth interviews were conducted from September 2017 to February 2018 with patients seeking care at traditional healers (n=30) and at an outpatient medicine clinic (n=30) in Mbarara, Uganda; the study is nested within a longitudinal project examining HIV testing engagement among traditional healer-using communities. Inclusion criteria included age ≥18 years, and ability to provide informed consent. Participants were recruited from practices representing the range of healer specialties. Following an inductive approach, interview transcripts were reviewed and coded to identify conceptual categories explaining healthcare utilisation.

RESULTS

We identified three broad categories relevant to healthcare utilisation: (1) traditional healers treat patients with 'care'; (2) biomedicine uses 'modern' technologies and (3) peer 'testimony' influences healthcare engagement. These categories describe variables at the healthcare provider, healthcare system and peer levels that interrelate to motivate individual engagement in pluralistic health resources.

CONCLUSIONS

Patients perceive clear advantages and disadvantages to biomedical and traditional care in medically pluralistic settings. We identified factors at the healthcare provider, healthcare system and peer levels which influence patients' therapeutic itineraries. Our findings provide a basis to improve health outcomes in medically pluralistic settings, and underscore the importance of recognising traditional healers as important stakeholders in community health.

Healthcare providers' perspectives of disrespect and abuse in maternity care facilities in Nigeria: a qualitative study

Objectives

To explore healthcare providers’ perspectives of disrespect and abuse in maternity care and the impact on women’s health and well-being.

Methods

Qualitative interpretive approach using in-depth semi-structured interviews with sixteen healthcare providers in two public health facilities in Nigeria. Interviews were audio-recorded, transcribed, and analysed thematically.

Results

Healthcare providers’ accounts revealed awareness of what respectful maternity care encompassed in accordance with the existing guidelines. They considered disrespectful and abusive practices perpetrated or witnessed as violation of human rights, while highlighting women’s expectations of care as the basis for subjectivity of experiences. They perceived some practices as well-intended to ensure safety of mother and baby. Views reflected underlying gender-related notions and societal perceptions of women being considered weaker than men. There was recognition about adverse effects of disrespect and abuse including its impact on women, babies, and providers’ job satisfaction.

Conclusions

Healthcare providers need training on how to incorporate elements of respectful maternity care into practice including skills for rapport building and counselling. Women and family members should be educated about right to respectful care empowering them to report disrespectful practices.

Predictors, causes, and trends of neonatal mortality at Nekemte Referral Hospital, east Wollega Zone, western Ethiopia (2010-2014). Retrospective cohort study

Background

Neonatal mortality is a significant contributor to infant mortality. Causes and predictors of neonatal death are known to vary in different settings and across different contexts. This study aimed to assess predictors, causes, and trends of neonatal mortality amongst neonates admitted to Nekemte Referral Hospital neonatal unit between 2010–2014.

Methods

Retrospective data was collected for 2090 live born neonates admitted to the neonatal intensive care unit of Nekemte Referral Hospital by reviewing records between 2010 to 2014. Variables were collected from the neonatal registration book and patient card on the predictors, causes, and trends of neonatal death using a standard checklist developed by the World Health Organization (WHO). Data was analyzed using Epi info version 3.5.1, and SPSS version 25 for windows. The level of significance was set at P<0.05 with the corresponding confidence intervals at 95%. A logistic regression model was used for analysis and to control for confounders. Microsoft Excel 2007 was used to construct the trend analysis.

Results

There were 183 deaths in the cohort equivalent to 8.8% of deaths among total admitted neonates during the study period. Early neonatal deaths accounted for 8% and late neonatal deaths accounted for 0.71% of deaths among total admitted neonates. Main predictors identified for an increased risk of neonatal mortality were; neonates from rural residents [AOR 1.35, (95% CI, 1.35–1.87)], birth order of greater than five [AOR 5.10, (95% CI, 1.15–22.63)], home delivery [AOR 3.41, (95% CI, 2.24–5.19)], very low birth weight [AOR 6.75, (95% CI, 3.63–12.54)] and low birth weight [AOR 2.81, (95% CI, 1.95–4.05)] and inability to cry at birth [AOR 2.21, (95% CI, 1.51–3.22)]. The trend analysis showed a sharp fall for the neonatal mortality over the last five years with a mean reduction of 16%.

Conclusions

Data from the Nekemte Referral Hospital Neonatal Intensive Care Unit analysis revealed majority of the deaths were occurred during early neonatal period. The main predictors of neonatal mortality identified from this study needs strengthening an appropriate public health intervention through addressing antenatal care, curbing home delivery.

The association between disrespect and abuse of women during childbirth and postpartum depression: Findings from the 2015 Pelotas birth cohort study

BACKGROUND

This study examined the association between disrespect and abuse of women during facility-based childbirth and postpartum depression (PD) occurrence.

METHODS

We used data from the 2015 Pelotas (Brazil) Birth Cohort, a population-based cohort of all live births in the city. We assessed 3065 mothers at pregnancy and 3-months after birth. Self-reported disrespect and abuse experiences included physical abuse, verbal abuse, denial of care, and undesired procedures. We estimate the occurrence of each disrespect and abuse type, one or more types and disrespect and abuse score. The Edinburgh Postnatal Depression Scale (EPDS) was used to assess PD. EPDS scores ≥13 and ≥15 indicated at least moderate PD and marked/severe. Odds ratios (OR) were calculated by logistic regression.

RESULTS

The prevalence of at least moderate PD and marked/severe PD was 9.4% and 5.7%, respectively. 18% of the women experienced at least one type of disrespect and abuse. Verbal abuse increased the odds of having at least moderate PD (OR = 1.58; 95%CI 1.06-2.33) and marked/severe PD (OR = 1.69; 95%CI 1.06-2.70) and the effect among women who did not experience antenatal depressive symptoms was greater in comparison to those who did (OR = 2.51; 95%CI 1.26-5.04 and OR = 4.27; 95%CI 1.80-10.12). Physical abuse increased the odds of having marked/severe PD (OR = 2.28; 95%CI 1.26-4.12). Having experienced three or more mistreatment types increased the odds of at least moderate PD (OR = 2.90; 95%CI 1.30 - 35.74) and marked/severe PD (OR=3.86; 95%CI 1.58-9.42).

LIMITATIONS

Disrespect and abuse experiences during childbirth were self-reported.

CONCLUSIONS

Disrespect and abuse during childbirth increased the odds of PD three months after birth. Strategies to promote high quality and respectful maternal health care are needed to prevent mother-child adverse outcomes.

Disrespectful and abusive behavior during childbirth and maternity care in Ethiopia: a systematic review and meta-analysis

Objective

Disrespectful and abusive behavior during childbirth and maternity care is violation of fundamental right of women and unborn child. There is scarce of data on disrespectful and abusive behavior during childbirth and maternity care in Ethiopia. The aim of this study was to determine disrespectful and abusive behavior during childbirth and maternity care in Ethiopia.

Results

Seven studies were included in this meta-analysis of disrespectful and abusive behavior during childbirth and maternity care. The pooled prevalence of disrespect and abuse care during childbirth and maternity care was 49.4% (95% CI 30.9–68.1). Whereas physical abuse was 13.6% (95% CI 5.2–31.2), non-confidential care was 14.1% (95% CI 7.3–25.4), abandonment care was 16.4% (95% CI 14.7–18.2), and detention was 3.2% (95% CI 0.9–11.5). This study showed that disrespectful and abusive behavior during child birth and maternity care is high. Whereas, abandonment care is high. This study indicates that health care providers shall not leave women during childbirth and maternity care and listen women, federal minister of health and regional health bureau also identifying root of cause disrespect and abuse and to alleviate mistreatment during childbirth and maternity care.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4118-2) contains supplementary material, which is available to authorized users.

Women's Experience of Facility-Based Childbirth Care and Receipt of an Early Postnatal Check for Herself and Her Newborn in Northwestern Tanzania

Negative experiences of care may act as a deterrent to current and/or future utilization of facility-based health services. To examine the situation in Tanzania, we conducted a sub-analysis of a cross-sectional household survey conducted in April 2016 in the Mara and Kagera regions of Tanzania. The sample included 732 women aged 15–49 years who had given birth in a health facility during the previous two years. Log binomial regression models were used to investigate the association between women’s experiences of care during childbirth and the receipt of early postnatal checks before discharge. Overall, 73.1% of women reported disrespect and abuse, 60.1% were offered a birth companion, 29.1% had a choice of birth position, and 85.5% rated facility cleanliness as good. About half of mothers (46.3%) and newborns (51.4%) received early postnatal checks before discharge. Early postnatal checks for both mothers and newborns were associated with no disrespect and abuse (RR: 1.23 and 1.14, respectively) and facility cleanliness (RR: 1.29 and 1.54, respectively). Early postnatal checks for mothers were also associated with choice of birth position (RR: 1.18). The results suggest that a missed opportunity in providing an early postnatal check is an indication of poor quality of the continuum of care for mothers and newborns. Improved quality of care at one stage can predict better care in subsequent stages.

Methodological development of tools to measure how women are treated during facility-based childbirth in four countries: labor observation and community survey

Background

Efforts to improve maternal health are increasingly focused on improving the quality of care provided to women at health facilities, including the promotion of respectful care and eliminating mistreatment of women during childbirth. A WHO-led multi-country research project aims to develop and validate two tools (labor observation and community survey) to measure how women are treated during facility-based childbirth. This paper describes the development process for these measurement tools, and how they were implemented in a multi-country study (Ghana, Guinea, Myanmar and Nigeria).

Methods

An iterative mixed-methods approach was used to develop two measurement tools. Methodological development was conducted in four steps: (1) initial tool development; (2) validity testing, item adjustment and piloting of paper-based tools; (3) conversion to digital, tablet-based tools; and (4) data collection and analysis. These steps included systematic reviews, primary qualitative research, mapping of existing tools, item consolidation, peer review by key stakeholders and piloting.

Results

The development, structure, administration format, and implementation of the labor observation and community survey tools are described. For the labor observations, a total of 2016 women participated: 408 in Nigeria, 682 in Guinea, and 926 in Ghana. For the community survey, a total of 2672 women participated: 561 in Nigeria, 644 in Guinea, 836 in Ghana, and 631 in Myanmar. Of the 2016 women who participated in the labor observations, 1536 women (76.2%) also participated in the community survey and have linked data: 779 in Ghana, 425 in Guinea, and 332 in Nigeria.

Conclusions

An important step to improve the quality of maternity care is to understand the magnitude and burden of mistreatment across contexts. Researchers and healthcare providers in maternal health are encouraged to use and implement these tools, to inform the development of more women-centered, respectful maternity healthcare services. By measuring the prevalence of mistreatment of women during childbirth, we will be able to design and implement programs and policies to transform maternity services.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0603-x) contains supplementary material, which is available to authorized users.

Identifying disrespect and abuse in organisational culture: a study of two hospitals in Mumbai, India

This paper draws on findings from a qualitative study of two government hospitals in Mumbai, India, which aimed to provide a better understanding of the institutional drivers of disrespect and abuse (D&A) in childbirth. The paper describes the structural context, in which government hospital providers can exercise considerable power over patients, yet may be themselves vulnerable to violence and external influence. Decisions that affect care are made by a bureaucracy, which does not perceive problems with the same intensity as providers who are directly attending to patients. Within this context, while contrasting organisational cultures had evolved at the two hospitals, both were characterised by social/professional inequality and hierarchical functioning, and marginalising women. This context generates invisible pressures on subordinate staff, and creates interpersonal conflicts and ambiguity in the division of roles and responsibilities that manifest in individual actions of D&A. Services are organised around the internal logic of the institution, rather than being centred on women. This results in conditions that violate women's privacy, and disregards their choice and consent. The structural environment of resource constraints, poor management and bureaucratic decision-making leads to precarious situations, endangering women’s safety. With the institution's functioning based on hierarchies and authority, rather than adherence to universal standards or established protocols, irrational, harmful practices endorsed by senior staff are institutionalised and reproduced. A deeper focus on organisational culture, embedded in the discourse of D&A, would help to evolve effective strategies to address D&A as systemic problems.