Midwives’ and patients’ perspectives on disrespect and abuse during labor and delivery care in Ethiopia: A qualitative study

Background: It is increasingly recognized that disrespect and abuse of women during labor and delivery is a violation of a woman’s rights and a deterrent to the use of life-saving, facility-based labor and delivery services. In Ethiopia, rates of skilled birth attendance are still only 28% despite a recent dramatic national scale up in the numbers of trained providers and facilities. Concerns have been raised that womens’ perceptions of poor quality of care and fear of mistreatment might contribute to this low utilization. This study examines the experiences of disrespect and abuse in maternal care from the perspectives of both providers and patients. Methods: We conducted 45 in-depth interviews at four health facilities in Debre Markos, Ethiopia with midwives, midwifery students, and women who had given birth within the past year. Students and providers also took a brief quantitative survey on patients’ rights during labor and delivery and responded to clinical scenarios regarding the provision of stigmatized reproductive health services. Results: We find that both health care providers and patients report frequent physical and verbal abuse as well as non-consented care during labor and delivery. Providers report that most abuse is unintended and results from weaknesses in the health system or from medical necessity. We uncovered no evidence of more systematic types of abuse involving detention of patients, bribery, abandonment or ongoing discrimination against particular ethnic groups. Although health care providers showed good basic knowledge of confidentiality, privacy, and consent, training on the principles of responsive and respectful care, and on counseling, is largely absent. Providers indicated that they would welcome related practical instruction. Patient responses suggest that women are aware that their rights are being violated and avoid facilities with reputations for poor care. Conclusions: Our results suggest that training on respectful care, offered in the professional ethics modules of the national midwifery curriculum, should be strengthened to include greater focus on counseling skills and rapport-building. Our findings also indicate that addressing structural issues around provider workload should complement all interventions to improve midwives’ interpersonal interactions with women if Ethiopia is to increase provision of respectful, patient-centered maternity care. The overall goal of this cross-sectional, qualitative study was to examine the nature of disrespect and abuse in midwifery care during labor and delivery in the Debre Markos area. The specific research aims were to: This project took place in Debre Markos, a city in Amhara region, located 5 h northwest of Ethiopia’s capital. A joint team of researchers from Debre Markos University’s (DMU) Department of Public Health, Touro University California’s Public Health program and the Bixby Center for Population, Health, and Sustainability, at the University of California, Berkeley, conducted this research. Data collection took place on the DMU campus in the School of Midwifery, at Debre Markos three main public health centers (the Hidase, Gozeman, and Debre Markos Health Centers), and at the Debre Markos Referral Hospital in February and March, 2015. The study examined two populations: women who had recently given birth and midwifery professionals (both students who were providing care and practicing midwives). A convenience sample of 23 women over the age of 20 who had given birth attended by a midwife within the past year, was recruited from health facilities to take part in an open-ended interview. Three women who had given birth at home were recruited by Health Extension Workers and interviewed. The study also conducted in-depth interviews with fifteen randomly selected (93% response rate) third-year bachelor’s degree midwifery students from DMU and four purposively sampled practicing midwives from the study health facilities. Patients were recruited as they left the postnatal or well-baby clinics at Debre Markos health centers or the Debre Markos referral hospital on a first-come first-served basis. Both the provider and patient samples were stratified by the gender of the midwife provider. Midwifery students were drawn from gender-separated, numbered class lists and were randomly selected using SPSS’s random number generator. Recruiters selected two males and two female practicing midwives from the study health centers and screened patients during recruitment to ensure that at least one-third of the patients had had male midwives at their last delivery. Interview guides and surveys (Additional file 1) were developed in English, reviewed with colleagues in the DMU Department of Public Health, and then translated into Amharic by a professional translator of reproductive health materials. The instruments were pre-tested for length and comprehensibility with a sample of five women at the Debre Markos Health Center and five midwifery students at the DMU School of Midwifery. A project investigator debriefed interviewers and the project coordinators after pre-testing and confirmed the faithfulness of the survey and transcript translation. All interview guides contained questions on respondent demographics and socio-economic characteristics. To address our first research aim, patients were asked about the quality and content of their care during pregnancy and labor and delivery, the quality of their interactions with healthcare providers, their satisfaction with the care they received, and about their knowledge of the quality of other women’s experiences during labor and delivery. They were also asked directly about common forms of mistreatment that might not be perceived as abuse, such as the denial of food and drink during labor, refusal of accompaniment, and not being able to give birth in their desired position. In order to gather provider perspectives on disrespect and abuse of patients (research aim two), we asked midwives and midwifery students about their experiences of provider-patient interactions, and their observation and/or awareness of patient mistreatment. Our third research aim was to examine provider’s understanding of patients’ rights in order to see whether gaps in their knowledge could contribute to patient disrespect and abuse. Midwifery students and midwives were, therefore, also asked questions on the coverage of patients’ rights in midwifery training. In addition, they also responded to a short self-administered survey on their knowledge of patients’ rights. To enable us to contrast midwives’ understanding of patients’ rights with the degree to which they might observe these rights in practice, we questioned them about their knowledge and comfort with service provision in two clinical scenarios where official policy, correct medical practice, and respectful medical care likely conflict with prevailing cultural beliefs, leading to poor quality of care. One scenario gauged their willingness to provide contraception to an unmarried adolescent, the other, their comfort with providing abortion care services. Although the Ethiopian government has actively promoted access to contraception and has liberalized its laws on abortion [48], Ethiopia remains culturally conservative with 67% of the population regarding abortion as “never justifiable” [49] and premarital intercourse for women relatively rare and culturally discouraged [50]. To address our fourth research aim, both patients and providers were asked about the reasons they thought abuse occurred and their recommendations for improving the quality of labour and delivery care. The study used four masters-level interviewers, recruited from the DMU Department of Public Health who had carried out survey- or interview-based data collection previously. We chose interviewers who were outside the departments that train health professionals (midwives, pharmacists, physicians) in order to reduce age and power differentials with study participants, as well the chances of interviewees knowing interviewers. The interviewers participated in a three-day workshop covering the motivation for the study, a refresher on research ethics, project data collection and management procedures, an overview of qualitative methods, and practice using interviewing techniques. Patient interviews took place at coffee stands near to the health facility or in private rooms in the health facility, depending on availability and the patients’s choice. For the three patients who gave birth at home, interviews were conducted in their homes. Student interviews took place in private rooms on the Debre Markos campus. All interviews were conducted in Amharic, audio-recorded, and then simultaneously translated and transcribed into English by a single professional translator conversant with the reproductive health field. The project coordinator held weekly debriefing sessions with interviewers to discuss experiences and surprises encountered during the interviews and to refine the interview guide. In addition, project investigators reviewed interview debrief memos and interview transcripts as they were translated, and provided ongoing feedback and suggestions for making the interviews more open and consistent. We developed a codebook (Additional file 2) with a priori codes guided by the framework of Bowser and Hill, the categories of disrespect and abuse and rights defined in the Charter of Respectful Maternity Care [1, 14], and review of the disrespect and abuse literature. We performed deductive and inductive thematic content analysis of interview transcripts: using a priori codes for initial rounds of analysis and adding new codes to reflect themes emerging from the data. Coding was conducted separately for the two population groups. One investigator was responsible for coding responses of midwives and students, another for patient responses. After completing coding for providers and patients, coders shared results and noted common themes and divergences both within and between the samples. This approach, keeping the samples separate, may have limited the tendency for coders to expect, and therefore find, codes in their sample based on the responses found in the other study groups. It did, however, prevent us from conducting tests of inter-rater reliability. The coding and analysis was conducted using the HyperResearch version 3.73 qualitative data analysis software.