Respectful maternity care among laboring women in public hospitals of Benishangul Gumuz Region, Ethiopia: A mixed cross-sectional study with direct observations

SAGE Open Medicine, Volume 10, Year 2022

Interpretation

Objectives: Promoting respectful maternity care is a fundamental strategy for enhancing facility birth, which significantly reduces maternal and newborn mortality and morbidity. Despite these effects, disrespect and abusive childbirth care remain a challenge in Ethiopia. Therefore, this study aimed to determine the prevalence of respectful maternity care and its associated factors among laboring women in public hospitals of Benishangul Gumuz region, Ethiopia. Methods: A facility-based cross-sectional study design was employed, and trained external assessors observed the care provided to 404 laboring women in public hospitals using structured observation checklists. A focus group discussion and two key informant interviews were also conducted. A structured pre-tested questionnaire and a semi-structured guide were used to generate quantitative and qualitative data, respectively. Seven verification criteria were employed, and the mean value and above for each criterion were used to measure respectful maternity care. Results: Of the 404 client–provider interaction observations during childbirth, only 12.6% (n = 51) participants received respectful maternity care. Being from an urban area (adjusted odds ratio = 3.34, 95% confidence interval: 1.39, 8.08), giving childbirth at daytime (adjusted odds ratio = 2.59, 95% confidence interval: 1.26, 5.33), receiving the service from compassionate and respectful care trained provider (adjusted odds ratio = 4.54, 95% confidence interval: 1.63, 12.66), giving childbirth at general hospital (adjusted odds ratio = 3.03, 95% confidence interval: 1.39, 6.65) were positively associated with respectful maternity care. Staff workload, shortage of supply and equipment, partiality in providing timely care, yelling and insulting at clients and birth companions were also barriers to respectful maternity care. Conclusion: The observed respectful maternity care practices were low in the study area. Therefore, the findings of this study suggest that addressing respectful maternity care would require increased compassionate and respectful care trained providers, and sustained efforts to improve access to basic equipment and supply for maternity care with an emphasis on primary hospitals. Tailored interventions aimed at improving respectful maternity care should also target rural residents and nighttime parturients. A facility-based mixed cross-sectional study comprising a quantitative component followed by a qualitative component was conducted from 1 April to 20 May 2019 in Benishangul Gumuz region, Ethiopia. The region is located 634 km from Addis Ababa, Ethiopia’s capital city. Its population is estimated to be 1,127,001, assuming 572,815 men and 554,186 women in 2019. 10 There were 402 health posts, 46 health centers, 3 primary hospitals, 2 general hospitals, 1 regional laboratory center, and 2 blood banks in the region. Annually, an estimated 10,000 women give births to the region. Of these, approximately 6000 deliveries are in public hospitals.10,29 Pregnant women who came for labor and delivery services in public hospitals in the Benishangul Gumuz region were used as the source population. Laboring women and their respective birth attendants throughout the data collection period were used as the study population. The unit of analysis was an observation that represented a unique woman, but not a unique provider since providers usually cared for multiple women during the observation period. Inclusion criteria: All client–provider interactions during childbirth in public hospitals of the Benishangul Gumuz region. Exclusion criteria: Women who visited the hospital after the second stage of labor, were fundamentally sick, and attended by undergraduate students were excluded from the study. Moreover, postpartum mothers and senior maternal and neonatal health care (MNHC) providers were used as study participants for qualitative phase data inquiries. The sample size was determined using the single population proportion formula (n = (Zα/2)2pq/d2) by considering the proportion of RMC in Bahir Dar, Ethiopia 57%, 30 95% confidence interval (CI), 5% marginal error, and adding 5% of non-response rate; the final sample size was determined to be 415. All public hospitals (five hospitals) in the region were included in this study, as each of these hospitals provides essential obstetrics and neonatal care. Based on a previous delivery report, the sample was allocated proportionally to each hospital. A systematic random sampling technique was employed to recruit study participants according to their admission order. A total of 51 obstetric care providers who were on duty during the data collection period were observed while attending the labor delivery process. On average, one obstetric care provider was observed while attending 7–10 unique laboring women. Purposive sampling was used to recruit postpartum women and senior health care providers for focus group discussion (FGD) and key informant interview (KII), respectively. A structured and pre-tested interview administered questionnaire which was sorted from previous literature was used to generate quantitative data.23,30,31 For observation of labor and delivery, we used a validated tool adopted and accustomed from the Federal Ministry of Health guidelines and previous studies that were conducted on RMC.11,23,32 For direct observation of deliveries, the medical directors in charge of the selected health facilities were informed about the purpose of the study, and women were informed about the observers’ purpose in observing delivery care. Observations were made after obtaining written consent from survey participants and health care providers. Observational checklists were used to assess provider–client interactions during labor and delivery services. In total, 15 trained external assessors (two midwives and one health officer per facility) who were not working at the selected health facilities were recruited for data collection, and each assessor covered an 8-h shift per day. Assessors observed MNHC providers attending labor and delivery services day and night. The assessors did not intervene in the care provided to the women. In an event where the safety or life of the mother or newborn was in danger or when the client’s status was deteriorating, the assessors were trained to alert a senior clinician to intervene. The observation of women started in the second stage of labor and continued for 2 h post-delivery. The characteristics of health care providers providing delivery care to women were also recorded during the survey. Qualitative data were collected after quantitative data assessment using a semi-structured probing guide questionnaire prepared in English and translated into the local language. Two authors (A.A. and B.A.) who were university lecturers with master’s degrees conducted the FGD and the KIIs. Qualitative data collection was performed using face-to-face interviews with the participants. The FGD was tape-recorded, and notes were taken. The FGD lasted approximately 1:20 h, and each session of KII lasted between 20 and 40 min. Daily, the discussions were analyzed to frame the themes set from the objectives. Data generation, transcription, and analysis were carried out by experts with prior experience in handling qualitative data. To ensure data quality, each data collector went through a 3-day training workshop on the objectives of the study and data collection techniques. Each day, supervisors checked the completeness of the observational data. A pre-test was performed outside of the study area on 5% of the sample size to check the consistency of the tool. Subsequently, correction and modification of the instrument were undertaken accordingly. Efforts were made to minimize the effect of observation on provider behavior, that is, the Hawthorne effect, by assuring providers that data collection was anonymous and that individual performance would not be reported to their supervisors or shared publicly (published reports only refer to aggregate data). Moreover, obstetric care providers were not aware of the topics and items on the checklists, so they could not prepare in any way. RMC: The level of RMC services was measured using seven performance standards (categories of disrespect and abuse) and their respective verification criteria developed by the Maternal and Child Health Integrated Program (MCHIP) as part of their RMC tool kit, 14 which includes (1) free of physical harm or ill-treatment, (2) woman’s right to information and informed consent, (3) women’s right to confidentiality and privacy, (4) women’s dignity or respect, (5) woman’s right to receive equitable care, (6) women’s right to never be left without care, and (7) women’s right to never be detained or confined against their will. A total of 28 verification criteria from the disrespect and abuse assessment checklist were used in the survey. RMC—A score equal to or greater than the mean value of each of the seven criteria.11,23 Non-RMC—A score below the mean value for any of the seven criteria.11,23 After checking completeness, data were entered using Epi Data version 3.1 and then exported to SPSS version 20 for analysis. Descriptive summary measures, such as frequency, percentages, means, and standard deviation, were used to describe the characteristics of the participants. Bivariate analysis was used primarily to determine which variables were associated with the dependent variable. To control for possible confounding factors, variables with a p value of ⩽0.25 in the bivariate analysis were used in the multivariable analysis. Multicollinearity and model fitness were checked using standard error and Hosmer–Lemeshow tests, respectively. The adjusted odds ratio (AOR), with a 95% CI, was used to identify the independent variables associated with RMC. Statistical significance was declared at a p value of ⩽0.05. A thematic analysis was conducted for the qualitative study, and the findings were further used to improve the quantitative phase questionnaires.

AI Digest

Study Justification:

– Promoting respectful maternity care is crucial for improving facility birth rates and reducing maternal and newborn mortality and morbidity.
– Disrespect and abusive childbirth care are persistent challenges in Ethiopia.
– This study aimed to determine the prevalence of respectful maternity care and identify associated factors among laboring women in public hospitals in the Benishangul Gumuz region of Ethiopia.

Highlights:

– Only 12.6% of the observed client-provider interactions during childbirth demonstrated respectful maternity care.
– Factors positively associated with respectful maternity care included being from an urban area, giving birth during the daytime, receiving care from compassionate and respectful providers, and giving birth at a general hospital.
– Barriers to respectful maternity care included staff workload, shortage of supplies and equipment, partiality in providing timely care, and disrespectful behavior towards clients and birth companions.
– Tailored interventions should target rural residents and nighttime parturients to improve respectful maternity care.

Recommendations:

– Increase the number of compassionate and respectful care trained providers to improve the quality of maternity care.
– Sustain efforts to improve access to basic equipment and supplies for maternity care, with a focus on primary hospitals.
– Implement interventions specifically designed to improve respectful maternity care for rural residents and nighttime parturients.

Key Role Players:

– Trained external assessors
– Obstetric care providers
– Medical directors of selected health facilities
– Postpartum women
– Senior maternal and neonatal health care providers
– Experts with experience in handling qualitative data

Cost Items for Planning Recommendations:

– Training workshops for data collectors and supervisors
– Transportation and accommodation for assessors and data collectors
– Tools and equipment for data collection
– Translation services for questionnaires and guides
– Analysis of qualitative data
– Printing and dissemination of study findings
Please note that the above cost items are examples and may not reflect the actual costs associated with implementing the recommendations.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a mixed cross-sectional study design with direct observations, which provides a moderate level of evidence. The study employed a facility-based approach and included a quantitative component followed by a qualitative component. Trained external assessors observed the care provided to 404 laboring women in public hospitals using structured observation checklists. The study also conducted a focus group discussion and key informant interviews. The sample size was determined using a single population proportion formula, and all public hospitals in the region were included. The study used validated tools and employed measures to ensure data quality. The findings indicate that only 12.6% of participants received respectful maternity care. The study identified factors associated with respectful maternity care and barriers to its provision. The conclusion suggests the need for increased compassionate and respectful care trained providers, improved access to basic equipment and supplies, and tailored interventions targeting rural residents and nighttime parturients. To improve the strength of the evidence, future studies could consider using a longitudinal design to assess changes over time and include a larger and more diverse sample to enhance generalizability.

Abstract

A facility-based mixed cross-sectional study comprising a quantitative component followed by a qualitative component was conducted from 1 April to 20 May 2019 in Benishangul Gumuz region, Ethiopia. The region is located 634 km from Addis Ababa, Ethiopia’s capital city. Its population is estimated to be 1,127,001, assuming 572,815 men and 554,186 women in 2019. 10 There were 402 health posts, 46 health centers, 3 primary hospitals, 2 general hospitals, 1 regional laboratory center, and 2 blood banks in the region. Annually, an estimated 10,000 women give births to the region. Of these, approximately 6000 deliveries are in public hospitals.10,29 Pregnant women who came for labor and delivery services in public hospitals in the Benishangul Gumuz region were used as the source population. Laboring women and their respective birth attendants throughout the data collection period were used as the study population. The unit of analysis was an observation that represented a unique woman, but not a unique provider since providers usually cared for multiple women during the observation period. Inclusion criteria: All client–provider interactions during childbirth in public hospitals of the Benishangul Gumuz region. Exclusion criteria: Women who visited the hospital after the second stage of labor, were fundamentally sick, and attended by undergraduate students were excluded from the study. Moreover, postpartum mothers and senior maternal and neonatal health care (MNHC) providers were used as study participants for qualitative phase data inquiries. The sample size was determined using the single population proportion formula (n = (Zα/2)2pq/d2) by considering the proportion of RMC in Bahir Dar, Ethiopia 57%, 30 95% confidence interval (CI), 5% marginal error, and adding 5% of non-response rate; the final sample size was determined to be 415. All public hospitals (five hospitals) in the region were included in this study, as each of these hospitals provides essential obstetrics and neonatal care. Based on a previous delivery report, the sample was allocated proportionally to each hospital. A systematic random sampling technique was employed to recruit study participants according to their admission order. A total of 51 obstetric care providers who were on duty during the data collection period were observed while attending the labor delivery process. On average, one obstetric care provider was observed while attending 7–10 unique laboring women. Purposive sampling was used to recruit postpartum women and senior health care providers for focus group discussion (FGD) and key informant interview (KII), respectively. A structured and pre-tested interview administered questionnaire which was sorted from previous literature was used to generate quantitative data.23,30,31 For observation of labor and delivery, we used a validated tool adopted and accustomed from the Federal Ministry of Health guidelines and previous studies that were conducted on RMC.11,23,32 For direct observation of deliveries, the medical directors in charge of the selected health facilities were informed about the purpose of the study, and women were informed about the observers’ purpose in observing delivery care. Observations were made after obtaining written consent from survey participants and health care providers. Observational checklists were used to assess provider–client interactions during labor and delivery services. In total, 15 trained external assessors (two midwives and one health officer per facility) who were not working at the selected health facilities were recruited for data collection, and each assessor covered an 8-h shift per day. Assessors observed MNHC providers attending labor and delivery services day and night. The assessors did not intervene in the care provided to the women. In an event where the safety or life of the mother or newborn was in danger or when the client’s status was deteriorating, the assessors were trained to alert a senior clinician to intervene. The observation of women started in the second stage of labor and continued for 2 h post-delivery. The characteristics of health care providers providing delivery care to women were also recorded during the survey. Qualitative data were collected after quantitative data assessment using a semi-structured probing guide questionnaire prepared in English and translated into the local language. Two authors (A.A. and B.A.) who were university lecturers with master’s degrees conducted the FGD and the KIIs. Qualitative data collection was performed using face-to-face interviews with the participants. The FGD was tape-recorded, and notes were taken. The FGD lasted approximately 1:20 h, and each session of KII lasted between 20 and 40 min. Daily, the discussions were analyzed to frame the themes set from the objectives. Data generation, transcription, and analysis were carried out by experts with prior experience in handling qualitative data. To ensure data quality, each data collector went through a 3-day training workshop on the objectives of the study and data collection techniques. Each day, supervisors checked the completeness of the observational data. A pre-test was performed outside of the study area on 5% of the sample size to check the consistency of the tool. Subsequently, correction and modification of the instrument were undertaken accordingly. Efforts were made to minimize the effect of observation on provider behavior, that is, the Hawthorne effect, by assuring providers that data collection was anonymous and that individual performance would not be reported to their supervisors or shared publicly (published reports only refer to aggregate data). Moreover, obstetric care providers were not aware of the topics and items on the checklists, so they could not prepare in any way. RMC: The level of RMC services was measured using seven performance standards (categories of disrespect and abuse) and their respective verification criteria developed by the Maternal and Child Health Integrated Program (MCHIP) as part of their RMC tool kit, 14 which includes (1) free of physical harm or ill-treatment, (2) woman’s right to information and informed consent, (3) women’s right to confidentiality and privacy, (4) women’s dignity or respect, (5) woman’s right to receive equitable care, (6) women’s right to never be left without care, and (7) women’s right to never be detained or confined against their will. A total of 28 verification criteria from the disrespect and abuse assessment checklist were used in the survey. RMC—A score equal to or greater than the mean value of each of the seven criteria.11,23 Non-RMC—A score below the mean value for any of the seven criteria.11,23 After checking completeness, data were entered using Epi Data version 3.1 and then exported to SPSS version 20 for analysis. Descriptive summary measures, such as frequency, percentages, means, and standard deviation, were used to describe the characteristics of the participants. Bivariate analysis was used primarily to determine which variables were associated with the dependent variable. To control for possible confounding factors, variables with a p value of ⩽0.25 in the bivariate analysis were used in the multivariable analysis. Multicollinearity and model fitness were checked using standard error and Hosmer–Lemeshow tests, respectively. The adjusted odds ratio (AOR), with a 95% CI, was used to identify the independent variables associated with RMC. Statistical significance was declared at a p value of ⩽0.05. A thematic analysis was conducted for the qualitative study, and the findings were further used to improve the quantitative phase questionnaires.

Materials

N/A

Innovations

Based on the provided description, here are some potential innovations that can be used to improve access to maternal health:

1. Training programs for healthcare providers: Implementing comprehensive training programs that focus on compassionate and respectful care can help improve the quality of maternity care provided by healthcare providers. This can include training on communication skills, empathy, and cultural sensitivity.

2. Strengthening healthcare infrastructure: Investing in the improvement of healthcare facilities, particularly in rural areas, can help increase access to maternal health services. This can involve upgrading equipment and supplies, ensuring adequate staffing levels, and improving the overall infrastructure of healthcare facilities.

3. Community engagement and education: Conducting community outreach programs to raise awareness about the importance of maternal health and the available services can help increase utilization of maternal health services. This can include educational campaigns, community meetings, and partnerships with local organizations.

4. Telemedicine and mobile health technologies: Utilizing telemedicine and mobile health technologies can help overcome geographical barriers and improve access to maternal health services, especially in remote areas. This can include teleconsultations, mobile apps for prenatal care, and remote monitoring of pregnant women.

5. Integration of maternal health services: Integrating maternal health services with other healthcare services, such as family planning and HIV/AIDS prevention and treatment, can help improve access and continuity of care for women. This can involve co-locating services, coordinating referrals, and providing comprehensive care packages.

6. Empowering women and promoting patient-centered care: Promoting women’s empowerment and involving them in decision-making processes regarding their own healthcare can help improve access to maternal health services. This can include providing information and education to women, promoting shared decision-making, and respecting women’s autonomy and preferences.

These innovations can help address the barriers identified in the study and improve access to respectful maternity care in the Benishangul Gumuz region of Ethiopia.

AI Innovations Description

Based on the study’s findings, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Increase the number of compassionate and respectful care trained providers: The study found that receiving care from compassionate and respectful care trained providers was positively associated with respectful maternity care. Therefore, it is recommended to train more healthcare providers in compassionate and respectful care practices to ensure that all laboring women receive respectful maternity care.

Innovation: Develop a comprehensive training program for healthcare providers that focuses on compassionate and respectful care practices during childbirth. This program can include workshops, simulations, and ongoing mentorship to ensure that providers have the necessary skills and knowledge to provide respectful maternity care.

2. Improve access to basic equipment and supplies: The study identified a shortage of supply and equipment as a barrier to respectful maternity care. To address this issue, it is important to ensure that public hospitals have an adequate supply of essential equipment and supplies for maternity care.

Innovation: Develop a system for monitoring and managing the supply of equipment and essential supplies in public hospitals. This can include regular inventory checks, procurement plans, and partnerships with suppliers to ensure a consistent and reliable supply of equipment and supplies.

3. Tailored interventions for rural residents and nighttime parturients: The study found that rural residents and women giving birth at nighttime were less likely to receive respectful maternity care. To address this disparity, it is important to develop interventions that specifically target these populations.

Innovation: Implement community-based education and awareness programs in rural areas to promote the importance of respectful maternity care. Additionally, establish a system for providing 24-hour access to respectful maternity care services, including trained providers and necessary equipment, in public hospitals.

By implementing these recommendations and innovations, access to respectful maternity care can be improved, leading to better maternal and newborn health outcomes.

AI Innovations Methodology

Based on the provided study, here are some potential recommendations to improve access to maternal health:

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that measure access to maternal health, such as the percentage of women receiving respectful maternity care, the availability of basic equipment and supplies in public hospitals, and the satisfaction level of rural residents and nighttime parturients with maternity care services.

2. Collect baseline data: Gather data on the current status of the indicators before implementing the recommendations. This can involve surveys, interviews, and observations similar to the methodology used in the study.

3. Implement the recommendations: Put the recommendations into action by increasing the number of compassionate and respectful care trained providers, improving access to basic equipment and supplies, and implementing targeted interventions for rural residents and nighttime parturients.

4. Monitor and measure progress: Continuously monitor the implementation of the recommendations and collect data on the indicators. This can involve regular surveys, interviews, and observations to assess the impact of the recommendations on improving access to maternal health.

5. Analyze the data: Analyze the collected data to determine the changes in the indicators after implementing the recommendations. Compare the post-implementation data with the baseline data to assess the impact of the recommendations on improving access to maternal health.

6. Evaluate and adjust: Evaluate the effectiveness of the recommendations based on the analysis of the data. If necessary, make adjustments to the recommendations to further improve access to maternal health.

By following this methodology, it is possible to simulate the impact of the recommendations on improving access to maternal health and make informed decisions on how to enhance maternal health services.

Authors & Co-Authors

Statistics:

Citations: 4

Authors: 10

Identifiers:

DOI: 10.1177/20503121221076995

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Workforce

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cross Sectional Study, Grounded Theory

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Male & Female