Globally, a woman dies every two minutes during childbirth (WHO, 2018). Eliminating preventable maternal deaths is a key element of the United Nations Sustainable Development Goals (2016-2030) strategy (UNDP, 2017). Most maternal deaths are preventable with skilled care at the time of delivery. A major factor which inhibits facility-based skilled care is disrespectful and abusive treatment by healthcare providers (Warren et al., 2013). Disrespectful and abusive treatment can result in long-lasting damage, emotional trauma and is an important barrier to utilization of maternity care services (Bowser & Hill, 2010, Warren et al., 2013). Disrespectful and abusive (D&A) treatment during maternity care is not only a quality of care issue, it is a health system failure and a violation of women’s rights (Bohren et al., 2015).
Bowser and Hill’s landscape analysis, which explored the evidence on disrespect and abuse (D&A), categorized seven major categories of the various forms disrespect and abuse (Bowser & Hill, 2010). These categories overlap and occur along a continuum from subtle disrespect and humiliation to overt violence. They include physical abuse, non-consented clinical care, non-confidential care, non-dignified care (including verbal abuse), discrimination based on specific patient attributes, abandonment or denial of care, and detention in facilities. Most of these categories are related to poor treatment by providers however, health care system deficiencies are also impediments to respectful care and contribute to experiences of disrespect (Freedman et al., 2014). Understanding facilitators and barriers to respectful maternity care and drivers of D&A is critical to informing key targets for intervention.
This study’s aim is to examine factors associated with disrespect and abuse in Kenya where the maternal mortality rate is 510/100,000 live births and only 47.7% of the women receive skilled care at the time of delivery (WHO, 2016). It is estimated that the prevalence of D&A in Kenya is 20% (Abuya et al, 2015).
The Contributors to and Impact of Disrespect and Abuse in Childbirth on Skilled Care Utilization (Bowser & Hill, 2010) conceptual framework was used to inform and guide the choice of variables, analysis and interpretation of study results. The framework describes how poor treatment or conditions caused by system deficiencies are considered disrespectful and how these factors impact the use of maternity care services.
To our knowledge this is the only study to quantitatively examine how women’s perceptions regarding need for improvement in interpersonal and system factors, impact overall feelings about D&A, the absence of respectful maternity care.
Methods:
Data for this present analysis were drawn from a cross-sectional study in which semi-structured interviews were conducted with 247 women who had delivered within the past year. Data was collected from July 2012 – August 2012 in a collaborative effort between the University of Maryland, Baltimore and the University of Nairobi, schools of nursing. Interviews were conducted using a questionnaire adapted from the WHO Safe Motherhood Survey (WHO, 2001). No individually identifiable data were collected from the women participants or about the maternity care facilities. The study examined facilitators and barriers to skilled maternity care utilization. Several questions were asked to understand women’s experiences during childbirth; including how they were treated by the healthcare providers and specific questions about the health facility. Demographic information was also collected. All survey participants were also asked an open-ended question about what improvements they would recommend for the facility where they last delivered.
Results:
The majority (83.8%) of the women were married, mean age 24.6 (SD=4.8), and most (87%) had at least a middle school education. However, over 60% were not employed. Deliveries took place at both public (58%) and private (42%) facilities. Almost a quarter (22.3%) of the women reported being in less than good health at the time of delivery. Fifteen percent of the women had complications during childbirth.
Most (78.9 %) of the women reported being treated with respect, however 20% did not feel respected. Over a quarter (25.5%) of the women said they were not spoken to kindly, 20% did not feel like providers treated them in a caring manner, and 38% were not allowed to ask questions. Required medications were not available where 20% of the women delivered and 30% delivered in facilities that did not provide sufficient privacy. Almost half (49.8%) of the sample identified system factors for improvement and 11.3% recommended interpersonal improvements. More than a third (33%) of the women were not given instructions to follow up for post-partum care. Almost a quarter (23.9%) of the women indicated that they would not return to the facility where they delivered for future maternity care services.
To analyze responses to the open-ended question about needed improvements, thematic analysis was conducted. The Contributors to and Impact of Disrespect and Abuse in Childbirth on Skilled Care Utilization (Bowser & Hill, 2010) conceptual framework guided coding of the responses and theme development. Two main themes emerged: interpersonal (patient-provider interactions) and health system factors (material & availability of human resources). The themes were quantified as either a recommendation for improvements in interpersonal encounters and health system factors for improvement. These new dichotomous variables were used in logistic regression modeling to assess associations with the outcome of being treated with respect.
Bivariate analyses were conducted to identify variables associated with the outcome of respect. Variables with a significant relationship (p<0.20) with the dependent variable were included in the multivariate modeling. Significant variables included: being treated in a caring manner, being allowed to ask questions, being instructed to return for follow up care, facility type, availability of required medications and suggestions for improvements in interpersonal and system factors.
In multivariate logistic regression analysis, the adjusted odds of D&A in maternity care was higher for women who suggested interpersonal improvements (OR = 28.6, P<0.001) than for women not making this recommendation. The adjusted odds of experiencing disrespectful treatment for women delivering in a private facility were lower (OR = 0.045, P=0.009) than for women who delivered in a public facility. Women who reported being treated in a caring manner were less likely (OR = 0.078, P=0.021) report D&A.
Conclusion:
There is a global effort to eliminate D&A and promote respectful maternity care. Interpersonal and system factors impact how women feel about maternity care. Wide ranging system improvements are needed. Our findings suggest that, though most women are aware of the need for system improvements these factors have less of an impact on how they feel about the care they receive and whether they feel disrespected, or not. Though more system factors were identified, interpersonal factors more significantly contributed to not feeling respected. The odds ratio for disrespectful treatment indicates that when holding all other variables constant, a woman is 28.6 times more likely to report feeling like she was treated disrespectfully if interpersonal (provider behavior) factors need improvement than if system improvements were suggested. This is good news, as interventions to improve interpersonal encounters can be initiated sooner and less expensively than costly infrastructural improvements. Efforts to improve respectful care needs to examine context specific root causes. In many developing countries like Kenya where material and human resources are low, significant investments are needed to support both. Continued university collaborations offer an opportunity for co-learning that will be both locally and globally beneficial in eliminating D&A and improving maternity.