Experiences of and responses to disrespectful maternity care and abuse during childbirth; a qualitative study with women and men in Morogoro Region, Tanzania

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Study Justification:
This study aims to explore the experiences of and responses to disrespectful maternity care and abuse during childbirth in facilities across Morogoro Region, Tanzania. The study is justified by the persistently low rates of facility-based birth in low-resource settings, including Tanzania, and the need to understand the factors contributing to this issue. By investigating the dimensions of and responses to abuse during childbirth, the study seeks to inform policy changes and interventions that can improve maternal health outcomes.
Highlights:
– The study found that many Tanzanian women experienced unfavorable conditions when delivering in facilities, including instances of abuse and neglect.
– Women described various forms of abuse, such as feeling ignored or neglected, facing monetary demands or discriminatory treatment, and experiencing verbal or physical abuse.
– Both women and their male partners responded to abuse in different ways, with women often acquiescing or bypassing certain facilities or providers, while men took more assertive approaches, such as requesting better care, paying bribes, lodging complaints, or even assaulting providers.
– The findings were consistent across respondent groups and districts, highlighting the widespread nature of the issue.
Recommendations:
– Providers, women, and their families must be made aware of women’s rights to respectful care.
– Further research is recommended to investigate the prevalence and dimensions of disrespectful care and abuse, mechanisms for reporting and redressing such events, and interventions that can mitigate neglect or isolation among delivering women.
– Respectful care should be prioritized as a critical component to improve maternal health.
Key Role Players:
– Health facility staff: They play a crucial role in providing respectful care and addressing instances of abuse.
– Community health workers (CHWs): They can act as advocates for women and help identify and report cases of abuse.
– Religious leaders: They can raise awareness and promote respectful care within their communities.
– Village health committees: They can support efforts to improve maternal health and ensure accountability.
Cost Items for Planning Recommendations:
– Training programs for health facility staff and CHWs on respectful care and addressing abuse.
– Awareness campaigns to educate providers, women, and their families about women’s rights to respectful care.
– Strengthening of health facilities to ensure they have the necessary resources and equipment to provide quality care.
– Support for the establishment and functioning of village health committees.
– Monitoring and evaluation systems to track progress and identify areas for improvement.
Please note that the provided information is based on the description and highlights of the study. For more detailed information, it is recommended to refer to the original publication in BMC Pregnancy and Childbirth, Volume 14, No. 1, Year 2014.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a qualitative study with a large sample size of 112 respondents. The study used in-depth interviews and employed the principles of Grounded Theory for analysis. The findings were consistent across respondent groups and districts. However, to improve the evidence, the abstract could provide more specific details about the methodology, such as the selection criteria for respondents and the process of data collection and analysis.

Background: Interventions to reduce maternal mortality have focused on delivery in facilities, yet in many low-resource settings rates of facility-based birth have remained persistently low. In Tanzania, rates of facility delivery have remained static for more than 20 years. With an aim to advance research and inform policy changes, this paper builds on a growing body of work that explores dimensions of and responses to disrespectful maternity care and abuse during childbirth in facilities across Morogoro Region, Tanzania. Methods: This research drew on in-depth interviews with 112 respondents including women who delivered in the preceding 14 months, their male partners, public opinion leaders and community health workers to understand experiences with and responses to abuse during childbirth. All interviews were recorded, transcribed, translated and coded using Atlas.ti. Analysis drew on the principles of Grounded Theory. Results: When initially describing birth experiences, women portrayed encounters with providers in a neutral or satisfactory light. Upon probing, women recounted events or circumstances that are described as abusive in maternal health literature: feeling ignored or neglected; monetary demands or discriminatory treatment; verbal abuse; and in rare instances physical abuse. Findings were consistent across respondent groups and districts. As a response to abuse, women described acquiescence or non-confrontational strategies: resigning oneself to abuse, returning home, or bypassing certain facilities or providers. Male respondents described more assertive approaches: requesting better care, paying a bribe, lodging a complaint and in one case assaulting a provider. Conclusions: Many Tanzanian women included in this study experienced unfavorable conditions when delivering in facilities. Providers, women and their families must be made aware of women’s rights to respectful care. Recommendations for further research include investigations of the prevalence and dimensions of disrespectful care and abuse, on mechanisms for women and their families to effectively report and redress such events and on interventions that could mitigate neglect or isolation among delivering women. Respectful care is a critical component to improve maternal health.

In Tanzania, the maternal mortality ratio is 454 deaths for 100,000 live births. One in 38 women have a lifetime risk of death due to maternal causes [27] and for every 1,000 births, 4–5 women die from pregnancy-related causes [28]. Nationwide, 50.2% of births are facility-based and 50.6% of all births are in the presence of a skilled attendant [28]. Since the early 1990s, the national rate of facility-based birth has remained below 52.6% [28, 29]. In rural areas, less than half of births are facility-based (41.9%) and 42.3% of all rural births are in the presence of a skilled attendant [28]. This study was based in 16 villages across 4 districts of Morogoro Region, in eastern Tanzania. Compared to national averages, slightly more women in the region deliver in a facility (58%) and more births are attended by a skilled provider (60.6%) [28]. Throughout the country’s Eastern Zone, which encompasses the region, hospitals and health centers are ill equipped to provide basic or comprehensive emergency obstetric care (EmOC). Basic EmOC is available in 11% of facilities and comprehensive EmOC is available in 10% of facilities [30]. In terms of personnel, facilities in Morogoro Region are understaffed, which reflects national trends. The Region’s density of doctors (0.2), assistant medical officers (0.3) and clinical officers (2.1) per 10,000 people attests to severe human resource limitations [30]. Less than half of all facilities in the Zone (47%) have at least 2 qualified providers assigned to a facility to support basic emergency services 24-hours [30]. Supportive management practices, which are critical for supporting quality care, are also limited. While many facilities in the Eastern Zone receive an external supervisory visit (79%), 34% of facilities provide routine staff training and only 25% of facilities provide “supportive management practices” (an external supervisory visit, routine training and personal supervision) [30]. This qualitative, cross-sectional study employed in-depth interviews (IDIs) with women, their male partners, community health workers (CHWs) and community leaders. At eight health centers across four districts, health center staff were asked to identify one village with difficult access to the health center, yet within the center’s catchment area. The data collection team then presented the study to leaders in both the village encompassing the health center and the village described as having difficult access. In Tanzania, the long-standing policy has been for every village to have a village health committee, which appoints two CHWs. Leaders interviewed included religious leaders, as well as members of an elected village board and/or village health committee who identified CHWs. Leaders and CHWs were interviewed irrespective of gender, age, education level, or length of service. Leaders as well as CHWs helped identify women in the village who had delivered in the preceding 14 months. In addition, data collectors canvassed the village and invited eligible mothers and fathers to participate. For a breakdown of respondent groups by distance to facility and district, see Table 1. Respondent groups by distance to facility and district *Women who delivered a child within the preceding 14 months. **Includes any male partner regardless of legal marriage status. Women and their partners were eligible if they had delivered a baby within the preceding 14 months regardless of reports on quality of care, or experiences of disrespectful care. An emphasis was placed on identifying women who had non-complicated, normal deliveries. Women who reported severe vaginal bleeding, eclampsia, obstructed labor, retention of placenta, severe anemia or whose births required vacuum or forceps extraction, or cesarean section were not included with the rationale that such births alter not only careseeking behaviors (often necessitating referrals) but also entail a vastly different subjective sense of the birth experience. For discussion on how a birth experience alters later assessment of quality of care (described as “fulfillment theory”), see Bramadat [31]. All women providing consent were interviewed, until 2–4 women had been interviewed for that site. Five Tanzanian research assistants fluent in Swahili with graduate-level training in education, public health, and social sciences were trained for five days to collect the data using instruments, which were pre-tested and revised before starting interviews. Training topics included maternal and newborn health, interview techniques, research ethics and qualitative methods. IDIs were recorded and conducted one-on-one, in a private place of the respondent’s choosing following verbal consent. IDIs focused on experiences related to care seeking during a most-recent pregnancy and birth. At the outset of data collection, the research team did not intend to explicitly investigate experiences of abuse, but rather to explore careseeking for birth in facilities. The abuse theme emerged in the earliest interviews, however, and was probed more explicitly as data collection progressed. A supervisor conducted daily debriefing sessions with data collectors to discuss and triangulate key findings, refine lines of inquiry, and identify saturation of themes. A main product of these debriefings were memos, first generated as a version of meeting notes from debriefings and later amplified by the data collection supervisor to incorporate reflexive notes, contextual information and emerging understandings that could be shared and commented upon by the wider research team. Data collection lasted approximately two months during July and August 2011. In-country debriefings with national stakeholders following the close of data collection corroborated and refined the framework for thematic analysis. All interviews were recorded and transcribed into Swahili. An initial phase of open, inductive coding on a selection of rich, diverse and representative transcripts was conducted based in part on Grounded Theory [32]. This resulted in the creation of a codebook that was validated by co-authors. A co-author fluent in Swahili and English applied these broad codes to remaining transcripts using ATLAS.ti [33]. Coded data were then translated from Swahili to English and a second phase of detailed coding was undertaken by a social scientist. During the analysis process, a subset of co-authors discussed codes and themes, and drew comparisons across respondent groups and regions, and by distance to facility. This aided in triangulation of findings and provided texture and nuance to descriptions. Drawing on the principles of Grounded Theory, a literature review followed the completion of coding [32]. The study received ethical approval from the Muhimbili University of Health and Allied Sciences and Johns Hopkins School of Public Health Institutional Review Boards. Names used in this paper are pseudonyms to protect the privacy of interviewees.

Based on the research described in the publication, here are recommendations to develop innovations to improve access to maternal health:

1. Increase awareness and education: Develop community education programs, antenatal care sessions, and public awareness campaigns to inform providers, women, and their families about women’s rights to respectful care during childbirth. This will empower women to demand respectful care and hold providers accountable.

2. Strengthen healthcare facilities: Equip facilities in low-resource settings with the necessary equipment, supplies, and trained healthcare personnel to provide basic and comprehensive emergency obstetric care. Implement supportive management practices to improve the quality of care provided.

3. Improve human resources for healthcare: Address the severe shortage of healthcare personnel in low-resource settings by increasing the number of doctors, assistant medical officers, clinical officers, and other healthcare professionals. Implement recruitment and retention strategies, training programs, and incentives for healthcare workers to serve in rural areas.

4. Establish mechanisms for reporting and redressing abuse: Create complaint mechanisms within healthcare facilities to allow women and their families to report instances of disrespectful care and abuse during childbirth. Train healthcare providers on respectful care and ensure that complaints are taken seriously and addressed promptly.

5. Conduct further research: Conduct research to understand the prevalence and dimensions of disrespectful care and abuse during childbirth. This will help inform targeted interventions and policies to address this issue. Additionally, research should explore interventions that can mitigate neglect or isolation among delivering women.

By implementing these recommendations, access to maternal health can be improved, and women can receive the respectful and quality care they deserve during childbirth.
AI Innovations Description
Based on the research described in the publication, here is a recommendation that can be used to develop an innovation to improve access to maternal health:

1. Increase awareness and education: Providers, women, and their families must be made aware of women’s rights to respectful care during childbirth. This can be achieved through community education programs, antenatal care sessions, and public awareness campaigns. By increasing awareness, women will be empowered to demand respectful care and hold providers accountable for their actions.

2. Strengthen healthcare facilities: Facilities in low-resource settings, such as those in Morogoro Region, Tanzania, need to be equipped to provide basic and comprehensive emergency obstetric care. This includes ensuring that facilities have the necessary equipment, supplies, and trained healthcare personnel to handle obstetric emergencies. Additionally, supportive management practices should be implemented to improve the quality of care provided.

3. Improve human resources for healthcare: There is a severe shortage of healthcare personnel in Morogoro Region and other similar settings. Efforts should be made to increase the number of doctors, assistant medical officers, clinical officers, and other healthcare professionals in these areas. This can be achieved through recruitment and retention strategies, training programs, and incentives for healthcare workers to serve in rural areas.

4. Establish mechanisms for reporting and redressing abuse: Women and their families need effective mechanisms to report and seek redress for instances of disrespectful care and abuse during childbirth. This can be done by establishing complaint mechanisms within healthcare facilities, training healthcare providers on respectful care, and ensuring that complaints are taken seriously and addressed promptly.

5. Conduct further research: More research is needed to understand the prevalence and dimensions of disrespectful care and abuse during childbirth. This will help inform targeted interventions and policies to address this issue. Additionally, research should be conducted to explore interventions that can mitigate neglect or isolation among delivering women.

By implementing these recommendations, access to maternal health can be improved, and women can receive the respectful and quality care they deserve during childbirth.
AI Innovations Methodology
To simulate the impact of the main recommendations on improving access to maternal health, a mixed-methods approach can be used. Here is a suggested methodology:

1. Quantitative data collection: Conduct a survey to gather quantitative data on the current state of access to maternal health in the target area (Morogoro Region, Tanzania). This can include information on facility-based births, skilled attendance at birth, availability of basic and comprehensive emergency obstetric care, and healthcare personnel density. The survey can be administered to a representative sample of women who have delivered in the preceding 14 months, their male partners, and healthcare providers in the region.

2. Qualitative data collection: Conduct in-depth interviews with a subset of survey respondents to gather qualitative data on their experiences with disrespectful care and abuse during childbirth. This can provide insights into the prevalence and dimensions of the issue, as well as the responses and coping strategies employed by women and their families.

3. Analysis: Analyze the quantitative data to assess the current status of access to maternal health in the region. This can involve calculating indicators such as facility-based birth rates, skilled attendance rates, and availability of emergency obstetric care. Compare the findings to the national averages and trends to understand the specific challenges faced in the region.

4. Analyze the qualitative data to identify common themes and patterns related to disrespectful care and abuse during childbirth. This can involve coding the transcripts and using thematic analysis techniques to identify key issues and experiences.

5. Simulate the impact: Use the findings from the analysis to simulate the potential impact of implementing the main recommendations on improving access to maternal health. This can involve creating scenarios where the recommendations are fully implemented and assessing the potential changes in facility-based birth rates, skilled attendance rates, and availability of emergency obstetric care. This can also include exploring the potential impact on women’s experiences with respectful care during childbirth.

6. Recommendations: Based on the simulation results, provide recommendations for policy changes and interventions that can be implemented to improve access to maternal health in the region. These recommendations should be informed by the findings from the research and take into account the specific context and challenges in Morogoro Region, Tanzania.

By following this methodology, researchers can gain a comprehensive understanding of the current state of access to maternal health and the potential impact of implementing the main recommendations. This can inform evidence-based decision-making and help guide interventions to improve access to maternal health in the region.

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