It does matter where you come from: Mothers’ experiences of childbirth in midwife obstetric units, Tshwane, South Africa

Background: Health professionals are striving to improve respectful care for women, but they fall short in the domains of effective communication, respectful and dignified care and emotional support during labour. This study aimed to determine women’s experiences of childbirth with a view to improving respectful clinical care practices in low-risk, midwife-led obstetric units in the Tshwane District Health District, South Africa. Methods: A survey covering all midwife-led units in the district was conducted among 653 new mothers. An anonymous questionnaire was administered to mothers returning for a three-days-to-six-weeks postnatal follow-up visit. Mothers were asked about their experiences regarding communication, labour, clinical care and respectful care during confinement. An ANCOVA was performed to identify the socio-demographic variables that significantly predicted disrespectful care. Six items representing the different areas of experience were used in the analysis. Results: Age, language, educational level and length of residence in the district were significantly associated with disrespectful care (p ≤ 0.01). Overall, the following groups of mothers reported more negative care experiences during labour: women between the ages of 17 and 24 years; women with limited formal education; and women from another province or a neighbouring country. Items which attracted fewer positive responses from participants were the following: 46% of mothers had been welcomed by name on arrival; 47% had been asked to give consent to a physical examination; and 39% had been offered food or water during labour. With regard to items related to respectful care, 54% of mothers indicated that all staff members had spoken courteously to them, 48% said they had been treated with a lot of respect, and 55% were completely satisfied with their treatment. Conclusion: There is a need to improve respectful care through interventions that are integrated into routine care practices in labour wards. To stop the spiral of abusive obstetric care, the care provided should be culturally sensitive and should address equity for the most vulnerable and underserved groups. All levels of the health care system should employ respectful obstetric care practices, matched with support for midwives and improved clinical governance in maternity facilities. A baseline survey was conducted in all 10 MOUs in the Tshwane District from February to April 2016, to explore women’s experiences of childbirth and early postnatal care. A survey method was considered an appropriate methodology for measuring maternal experiences to gauge respectful care, involvement in decision making and clinical care processes [26]. Data were collected by means of an anonymous, self-administered questionnaire with 32 structured and open-ended questions of which seven were socio-demographic items. The survey tool elicited data on the main concepts of respectful care. Sixteen items reflected women’s’ self-report of the clinical care they received and their experience thereof. The nine items on client satisfaction included aspects of communication and satisfaction. Items all required a yes/no/unsure response or a response on a four-point Likert-type survey scale. Many of the questions included in our survey had been used in previous sets of validated maternal experiences surveys and covered domains related to the lack of consented care, communication and feedback processes, pain relief and respectful care aspects [15, 18, 19, 27]. Text boxes included after satisfaction questions allowed participants to supply feedback and descriptions of poor service or abusive behaviour and to report unfulfilled expectations. The questionnaire was also made available in Setswana, the predominant local language, after translation from English to Setswana, followed by back-translation into English and the resolving of interpretation issues. The questionnaire was pilot-tested with 30 mothers to confirm the appropriateness of questions and ease of comprehension. (The questionnaire is attached as Additional file 1). The design of the sample for this survey was based on historical population data on annual deliveries at each MOU (range: 390 to 1502 in 2015). A planned sample of 800 respondents was envisaged, but 653 questionnaires were received back. Factors that impeded data collection included an unexpected drop in the number of deliveries in the district during the first 3 months of 2016 and several external service-delivery strikes that hampered access to the semi-rural areas. Mothers completed questionnaires during the same period at various sites. University students fluent in the local vernaculars were trained as research assistants. They signed a confidentiality clause and assisted mothers with the completion of the questionnaire, only on request, in a private space. A sequential sample was drawn consisting of mothers returning for follow-up visits to primary health care consultation rooms in the three-days-to-six-weeks postnatal period. This gave mothers enough time to reflect on their care. Data were collected at a venue separate from the labour ward to minimise potential interference from MOU staff [28]. All mothers who had read the information leaflet and were willing to participate in the study were screened for eligibility. No mothers eligible for inclusion refused to participate. To qualify for inclusion, a mother had to be older than 17 years, have delivered in one of the 10 Tshwane MOUs and have returned for her postnatal visit during the prescribed period. Mothers younger than 17 years or those who had delivered in a hospital were excluded. Mothers completed the questionnaire voluntarily and anonymously. The completed questionnaires were collected, reviewed and coded. Data were captured in password-protected Excel files. The data were then crosschecked, cleaned and analysed with the aid of SAS version 9.4 [29]. Descriptive statistical measures such as means, frequencies and proportions were calculated and age, level of education, language, province or country of birth and length of residence in the Tshwane District were categorised to facilitate data interpretation. In order to establish the significance or importance of factors and attributes or items in the study that contributed to the acceptability or unacceptability of the treatment of mothers in the MOUs during childbirth, an analysis of variance approach was followed, with the inclusion of a covariate (ANCOVA). Due to the complexity of the analyses (multiple effects/factors), the classical approach of applying non-parametric procedures to ordered data, was not followed, but a transformation of the data as described below. For purposes of comparison, weighted means according to the number of 2015 deliveries based on scores on a Likert-type scale were calculated for categories of socio-demographic variables, namely age of mother, level of education, first language, province or country of birth, and length of residence in Tshwane. Missing values of categorical variables were replaced by hotdeck imputation [30], using simple random sampling with replacement of the units to produce complete data for a multivariate ANCOVA. The number of children a woman had given birth to was used as the covariate. The following six items relating to mothers’ experiences during childbirth were selected as dependents and a series of ANCOVAs were performed: The items were generally transformed from nominal [Yes, Unsure, No] measures to a Likert-type [0, 1, 2] scale. The ties present in the Likert scores were resolved by adding a small random univariate term from the [-0.000005; 0.0000005] interval and the resultant values were then normalised using the BLOM transformation [31]. Means for each item were calculated with scores of dependents as follows: Yes = 0, Unsure = 1, No = 2. The higher the means, the less positive the experience of the mother on an aspect of care; the lower the means, the more positive the experience. Means for a response were calculated for each of the categories of the selected socio-demographic variables, as well as the standard error based on this specific response for all categories of the particular demographic variable under consideration. The category corresponding to the maximum mean and all categories within one standard error of this maximum mean were considered as those contributing to the worst treatment of mothers in MOUs (see Additional file 2). Open-ended responses related to the six items mentioned above were collated and some striking statements were selected to illustrate a particular issue.