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.
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