Magnitude and associated factors of disrespect and abusive care among laboring mothers at public health facilities in Borena District, South Wollo, Ethiopia

Background Recent studies have indicated that disrespectful/abusive/coercive service by skilled care providers in health facilities that results in actual or perceived poor quality of care is directly and indirectly associated with adverse maternal and newborn outcomes. According to the 2016 Ethiopian Demography and Health Survey, only 26% of births were attended by qualified clinicians, with a maternal mortality rate of 412 per 100,000 live-births. Using seven categories developed by Bowser and Hill (2010), this study looked at disrespect and abuse experienced by women in labor and delivery rooms in health facilities of Borena Ddistrict, South Wollo, Ethiopia. Methods A facility-based cross-sectional study was conducted among 374 immediate postpartum women in Borena District from January 12 to March 12, 2020. Systematic sampling was used to access respondents to participate in a structured, pre-tested face-to-face exit interview. Data were entered into EpiData version 4.6 and exported to SPSS version 25 for analysis. Finally, bivariable and multivariable logistic regression analysis were performed to declare statistically significant factors related to maternal disrespect and abusive care in Borena District at a p-value of < 0.05 and at 95% CI. Result Almost four out of five (79.4%) women experienced at least one type of disrespect and abuse during facility-based childbirth. The most frequently reported type of disrespect and abuse was non-consented care 63.7%. Wealth index [AOR = 3.27; 95% CI: (1.47, 7.25)], type of health facility [AOR = 1.96; 95% CI: (1.01, 3.78)], presence of companion(s) [AOR = 0.05; 95% CI: (0.02, 0.12)], and presence of complications [AOR = 2.65; 95% CI: (1.17, 5.99)] were factors found to be significantly related to women experiencing disrespect and abuse. Conclusion The results showed that wealth index, type of health facility, presence of companion(s), and birth complications were found to be significant factors. Therefore, health personnel need to develop interventions that integrate provider's behavior on companionship and prevention of complications across facilities to reduce the impact of disrespectful and abusive care for laboring women. A facility-based cross-sectional study was conducted in Borena public health facilities from January 12 to March 12, 2020. Borena is one of the 23 districts (woredas) in the South Wollo zone. It is surrounded by other districts, by Leganbo to the east, Gojjam to the west, Wagdi to the south, and Saint to the north. The total land area of Borena is 5560km2 of which 65% is highland area. The total population was 202,832 in 2012 E.C. (Ethiopian Calendar) as projected from the 2007 census. In Borena is the town of Mekane-Selam, which is located 180 km from Dessie (the city of South Wollo); 281 km from Bahir-Dar (the center of the Amhara region) and 581 km from Addis Ababa (the capital city of Ethiopia). There are 39 kebeles (4 urban and 35 rural) and one primary hospital, 7 health centers (one urban and 6 rural), and 36 health posts. A total of 5,283 mothers gave birth in Borena health facilities in the 2011 budget year (Borena Woreda Health Office Annual Report, 2011). All women living in Borena were the source population of the study while all women who gave birth in selected public health facilities of Borena during the data collection period were used as the study population. Those women who were critically ill and referred to others health facilities were excluded from the study. The sample size required for the first specific objective was calculated based on a single population proportions formula with the following assumptions: Prevalence of disrespect and abuse during labor and delivery 67.1% [17], 95% confidence level, 10% non- response, 5% margin of error. Thus, the final sample size found was 374 after adding 10% non-response rate. The sample size for the second specific objective was determined using Epi-info version 7.1 software by considering three variables from previous studies but the final sample sizes determined by this software were less the above sample size determined (374). Therefore, the final sample size used for this study was 374. In Borena there were 8 public health facilities, of which 5 (Mekane-Selam Hospital (187) n1 = 185; Mekane-Selam Health Center (30) n2 = 29; Tewa Health Center (45) n3 = 44; Galemot Health Center (60) n4 = 58; and Dilfrie Health Center (60) n5 = 58) were selected for the study by simple random sampling. From these five public health facilities, the delivery numbers from February and March, 2011 E.C. were taken from the facilities’ registration books and then the calculated sample size was proportionally allocated based on number of deliveries in those two months in each facility. Finally, using systematic random sampling, every 3rd woman who was eligible and available during the data collection period was included in an exit interview at each respective health facility. The dependent variable of this study was disrespect and abuse (yes/no) while the independent variables were socio-demographic related factors including age, residence, marital status, religion, educational background, economic status; obstetric history including ANC follow-up, parity, complications during labor and delivery, time of delivery, mode of delivery; health care providers- and facility type-related factors including sex of health care provider, type of health facilities, type of health professionals; and individual-related factors including HIV status, history of previous institutional delivery, intention to deliver at health facilities, presence of companion, and decision making power on health issues. Disrespect and abuse (D & A) were measured by seven performance standards (types of disrespect and abuse) including physical abuse, non-consented care, non-confidential care, non-dignified care, discriminated care, neglect of care, and detention in the health facility. Accordingly, those women who replied ‘yes’ to at least one form of disrespect and abuse were labeled as being subjected to disrespect and abuse during labor and delivery services. A total of 22 verification criteria of D & A were used to measure the seven performance standards in the composite scale [42]. Women who were not protected from physical harm or ill-treatment [2]. Measured by 5 verification criteria including 1. A health provider physically hit or slapped, pinched or pushed the mother and/or 2. A health provider verbally insulting the mother and/or 3. A health provider restricted the mother from drinking any fluid throughout the labor course unless medically necessitated and/or 4. The birth attendant pushed a mother’s tummy down to deliver the baby (used fundal pressure) and/or 5. The care providers did not allow the mother to assume the position of her choice during the birth. A woman who answered ‘yes’ to at least one criterion was considered to have been physically abused at the time of childbirth. Women’s right to information, informed consent, and choices/preferences were not protected. Measured by 5 standard verification criteria including 1. The care provider did not introduce themselves and greet mother and her support person and/or 2. The provider did not encourage the mother and her companion to ask questions and/or 3. The provider did not respond to the mother’s question with politeness and/or 4. The provider did not explain what was being done and what to expect throughout labor and during examinations; and/or 5. a health care provider did not obtain consent or permission before any procedure. If a woman answered ‘yes’ to at least one of the criteria, she was considered as having been abused by non-consented care at the time of childbirth. A woman’s confidentiality and privacy was not protected, measured by 3 criteria including 1. The provider did not use drapes or covering to protect the mother’s privacy during any procedure and/or 2. Health providers discussed a mother’s private health information in a manner that others might hear and/or 3. Other persons apart from the care providers were allowed in the room while the mother was giving birth who were able to observe a mother while she was naked on the bed. If A woman answered ’yes’ to at least one of the above criteria, she was considered to have been abused by non-confidential care at the time of childbirth. A woman w not treated with dignity and respect, measured by 3 criteria. 1. A health provider shouted at or scolded the mother and/or 2. The care provider blamed the mother for getting pregnant or for shouting/crying due to the pain of delivery and/or 3. The care providers did not allow the mother’s companion to enter the delivery room. If a woman answered ’yes’ to at least one of the criteria, she was considered as being abused by non-dignified care at the time of childbirth. A woman received not equitable care, not free from discrimination. Measured by 2 criteria. If 1. A health care provider discriminated by ethnicity, religion, age, and being rural and/or 2. A health care provider discriminated by HIV-positive status. If a woman answered ’yes’ to at least one of the criteria, she was considered to have been abused in discriminatory care at the time of childbirth. A woman did not get timely care or was left alone without care, measured by 3 criteria. 1. A health provider ignored a mother’s call for help and/or 2. A mother was alone when she gave birth in the health institution because the care providers were not around her and/or 3. A mother encountered a life-threatening condition for which she had shouted for help but could not get anyone to reach her in time. A woman who answered ’yes’ to at least one of the criteria was considered to have been abused by abandonment/neglect of care at the time of childbirth. A woman was detained or confined against her will, measured by 1 criterion 1. Health care providers detained a mother in the health facility because of payment issues when she had posed damage to the property of the health institution. A woman who answered ’yes’ to this criterion was considered to have been abused by detention at the time of childbirth. The wealth index is a composite measure of a household’s cumulative living standard. The wealth index is calculated using easy-to-collect data on a household’s ownership of selected assets, such as televisions, radio, materials used for housing construction; and types of water access and sanitation facilities; pets and others. The outcome variable was measured using seven performance standards (types of D & A) and their corresponding verification criteria established by the Maternal and Child Health Integrated Program (MCHIP) [42]. A total of 22 verification criteria for disrespect and abuse were used. For independent variables, questionnaires were adapted after reviewing various literature [16, 17, 43–49]. Generally, the tools consists of three sections; the first section was used to assess socio-demographic characteristics of the mother, the second section was used to assess obstetric and individual-related factors of participants and the third section was used to assess categories of disrespect of women during labor and delivery. The data were collected by trained collectors using a pretested, structured questionnaire in a face-to-face exit interview from the postnatal care unit. The questionnaire was translated to the local language (Amharic) by language experts before the actual data collection period. Six diploma-holding midwives and three BSC nurses were trained as data collectors and supervisors respectively. The data collectors were assigned to health facilities where they collected the data on each respective participant according to the orientation they had been given on data collection procedures; supervisors and investigators checked the processes and questionnaire responses for consistency and completeness. Before starting the actual data collection processes, to assure the data quality, high emphasis was given to designing data collection instruments during and after data collection. Questionnaires were developed in English, translated to Amharic, then translated back into English to ensure consistency. Six female diploma-holding midwives were selected to collect the data, and three BSC nurses were recruited as supervisors from non-study area health facilities. One day of training was given to data collectors and supervisors on the aim of the study, the content of the questionnaire, how to ensure confidentiality and privacy and the techniques of the interview. Then, the questionnaires were pre-tested on 5% (19) of the total sample size in the Billi Health Center from outside of study area. After pre-testing, no further adjustments to the data collection tools were made because there were no findings to do so. During data collection process all of the questionnaires were checked for completeness and accuracy onsite. The collected data were compiled, checked for any inconsistency and missed value, coded, and entered into Epi-data version 4.6 software and exported into SPSS version 25 for data management and analysis. The data were cleaned for missing values through running frequencies and crosstabs. The findings of this study were described using frequencies, percentages, tables, and graphs. Variables with p-value less than 0.25 in bivariable logistic regression were fitted to multivariable logistic regression model. The Hosmer and Lemeshow test was used to check the final model fitness (p-value was > 0.05). Adjusted odds ratio with 95% confidence interval was computed to assess the degree of association between the outcome and independent variables. Finally, variables with a p-value less than 0.05 in the multivariable logistic regression were considered to have a statistically significant association with the outcome variable. Ethical clearance was obtained from Wollo University, College of Health Sciences, and School of Public Health Ethical Review Committee (ERC). A etter of permission to conduct the study was obtained from the administrative office of Borena District Health Office. A letter of permission was also obtained from South Wollo Zonal Health Department and given to the district and health facilities. Written informed consent was obtained from all participants before data collection. They were informed that participating in the study was voluntary and their right to withdraw from the study at any moment during the interview was assured. No personal identifiers were used on data collection forms. The recorded data were not accessed by any third person except the principal investigator, and was kept confidentially and anonymously.