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Exploring mistreatment of women during childbirth in a peri-urban setting in Kenya: experiences and perceptions of women and healthcare providers.

ABSTRACT: BACKGROUND:In Kenya, indirectly caused maternal deaths form a significant portion of all maternal deaths within the health system. Many of these deaths are avoidable and occur during delivery and labor. Poor quality health service has been a recurring concern among women in Kenya, with women reporting interactions with healthcare workers that are often demeaning and abusive. This paper explores the experiences and perceptions of both female patients and healthcare workers regarding mistreatment during childbirth. This study aims to provide recommendations on how dignified care can be made the norm, specifically focusing on a peri-urban setting in Kenya. METHODS:The research was accomplished using qualitative research methods with focus group discussions and in depth interviews with women and healthcare workers. The aim was to gain a deeper understanding of the manifestations of mistreatment within the context of a peri-urban setting in Kenya. RESULTS:Female patients reported different forms of mistreatment, such as verbal abuse, physical abuse, neglect, discrimination, abandonment, poor rapport and failure of the health system to uphold professional standards. The healthcare workers described a health system that was weak and fragmented with poor policy support particularly for the new free maternity services policy leading to the mistreatment of women. CONCLUSION:Newly formed County Governments need to provide resources for a functioning health system to ensure an enabling environment for the provision of high quality maternal health services. This process can include feedback loops with maternity clients to ensure woman-centered services. Policy makers need to strengthen oversight for the implementation of the free maternity services Community health volunteers can be trained to provide this information. Professional associations that govern the standards of quality care for healthcare workers need to address the mistreatment through retraining and norms transformation.

SUBMITTER: Oluoch-Aridi J

PROVIDER: S-EPMC6296108 | biostudies-literature | 2018 Dec

REPOSITORIES: biostudies-literature

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Exploring mistreatment of women during childbirth in a peri-urban setting in Kenya: experiences and perceptions of women and healthcare providers.

Oluoch-Aridi Jackline J Smith-Oka Vania V Milan Ellyn E Dowd Robert R

Reproductive health 20181217 1

<h4>Background</h4>In Kenya, indirectly caused maternal deaths form a significant portion of all maternal deaths within the health system. Many of these deaths are avoidable and occur during delivery and labor. Poor quality health service has been a recurring concern among women in Kenya, with women reporting interactions with healthcare workers that are often demeaning and abusive. This paper explores the experiences and perceptions of both female patients and healthcare workers regarding mistr ...[more]

PMID: 30558618

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Project description:BackgroundKenya continues to have a high maternal mortality rate that is showing slow progress in improving. Peri-urban settings in Kenya have been reported to exhibit higher rates of maternal death during labor and childbirth as compared to the general Kenyan population. Although research indicates that women in Kenya have increased access to facility-based birth in recent years, a small percentage still give birth outside of the health facility due to access challenges and poor maternal health service quality. Most studies assessing facility-based births have focused on the sociodemographic determinants of birthing location. Few studies have assessed women's user experiences and perceptions of quality of care during childbirth. Understanding women's experiences can provide different stakeholders with strategies to structure the provision of maternity care to be person-centered and to contribute to improvements in women's satisfaction with health services and maternal health outcomes.MethodsA qualitative study was conducted, whereby 70 women from the peri-urban area of Embakasi in the East side of Nairobi City in Kenya were interviewed. Respondents were aged 18 to 49 years and had delivered in a health facility in the preceding six weeks. We conducted in-depth interviews with women who gave birth at both public and private health facilities. The interviews were recorded, transcribed, and translated for analysis. Braune and Clarke's guidelines for thematic analysis were used to generate themes from the interview data.ResultsFour main themes emerged from the analysis. Women had positive experiences when care was person-centered-i.e. responsive, dignified, supportive, and with respectful communication. They had negative experiences when they were mistreated, which was manifested as non-responsive care (including poor reception and long wait times), non-dignified care (including verbal and physical abuse lack of privacy and confidentiality), lack of respectful communication, and lack of supportive care (including being denied companions, neglect and abandonment, and poor facility environment).ConclusionTo sustain the gains in increased access to facility-based births, there is a need to improve person-centered care to ensure women have positive facility-based childbirth experiences.

Project description:BACKGROUND:Effective communication and respect for women's autonomy are critical components of person-centered care. Yet, there is limited evidence in low-resource settings on providers' perceptions of the importance and extent of communication and women's autonomy during childbirth. Similarly, few studies have assessed the potential barriers to effective communication and maintenance of women's autonomy during childbirth. We sought to bridge these gaps. METHODS:Data are from a mixed-methods study in Migori County in Western Kenya with 49 maternity providers (32 clinical and 17 non-clinical). Providers were asked structured questions on various aspects of communication and autonomy followed by open ended questions on why certain practices were performed or not. We conducted descriptive analysis of the quantitative data and thematic analysis of the qualitative data. RESULTS:Despite acknowledging the importance of various aspects of communication and women's autonomy, providers reported incidences of poor communication and lack of respect for women's autonomy: 57% of respondents reported that providers never introduce themselves to women and 38% reported that women are never able to be in the birthing position of their choice. Also, 33% of providers reported that they did not always explain why they are doing exams or procedures and 73% reported that women were not always asked for permission before exams or procedures. The reasons for lack of communication and autonomy fall under three themes with several sub-themes: (1) work environment-perceived lack of time, language barriers, stress and burnout, and facility culture; (2) provider knowledge, intentions, and assumptions-inadequate provider knowledge and skill, forgetfulness and unconscious behaviors, self-protection and comfort, and assumptions about women's knowledge and expectations; and (3) women's ability to demand or command effective communication and respect for their autonomy-women's lack of participation, women's empowerment and provider bias. CONCLUSIONS:Most providers recognize the importance of various aspects of communication and women's autonomy, but they fail to provide it for various reasons. To improve communication and autonomy, we need to address the different factors that negatively affect providers' interactions with women.

Project description:BACKGROUND:The study aims to assess the discordance between self-reported and observed measures of mistreatment of women during childbirth in public health facilities in Uttar Pradesh, India, as well as correlates of these measures and their discordance. METHODS:Cross sectional data were collected through direct observation of deliveries and follow-up interviews with women (n = 875) delivering in 81 public health facilities in Uttar Pradesh. Participants were surveyed on demographics, mistreatment during childbirth, and maternal and newborn complications. Provider characteristics (training, age) were obtained through interviews with providers, and observation data were obtained from checklists completed by trained nurse investigators to document quality of care at delivery. Mistreatment was assessed via self-report and observed measures which included 17 and 6 items respectively. Cohen's kappas assessed concordance between the 6 items common in the self-report and observed measures. Regression models assessed associations between characteristics of women and providers for each outcome. RESULTS:Most participants (77.3%) self-reported mistreatment in at least 1 of the 17-item measure. For the 6 items included in both self-report and observations, 9.1% of women self-reported mistreatment, whereas observers reported 22.4% of women being mistreated. Cohen's kappas indicated mostly fair to moderate concordance. Regression analyses found that multiparous birth (AOR = 1.50, 95% CI = 1.06-2.13), post-partum maternal complications (AOR = 2.0, 95% CI = 1.34-3.06); new-born complications (AOR = 2.6, 95% CI = 1. 96-4.03) and not having an Skilled Birth Attendant (SBA) trained provider (AOR = 1.47, 95% CI = 1.05-2.04) were associated with increased risk for mistreatment as measured by self-report. In contrast, only provider characteristics like older provider (AOR = 1.03, 95% CI = 1.02-1.05) and provider not trained in SBA (AOR = 1.44, 95% CI = 1.02-2.02) were associated with mistreatment as measured through observations. Younger age at marriage (AOR = 0.86, 95% CI = 0.78-0.95) and provider characteristics (older provider AOR = 1.05, 95% CI = 1.01-1.09; provider not trained in SBA AOR = 0.96, 95% CI = 0.92-0.99) were associated with discordance (based on mistreatment reported by observer but not by women). CONCLUSION:Provider mistreatment during childbirth is prevalent in Uttar Pradesh and may be under-reported by women, particularly when they are younger or when providers are older or less trained. The findings warrant programmatic action as well as more research to better understand the context and drivers of both behavior and reporting. TRIAL REGISTRATION:CTRI/2015/09/006219. Registered 28 September 2015.

Project description:IntroductionPeri-urban settings have high maternal mortality and the quality of care received in different types of health facilities is varied. Yet few studies have explored the construct of person-centered maternity care (PCMC) within peri-urban settings. Understanding women's experience of maternity care in peri-urban settings will allow health facility managers and policy makers to improve services in these settings. This study examines factors associated with PCMC in a peri-urban setting in Kenya.Methods and materialsWe analyzed data from a cross-sectional study with 307 women aged 18-49 years who had delivered a baby within the preceding six weeks. Women were recruited from public (n = 118), private (n = 76), and faith based (n = 113) health facilities. We measured PCMC using the 30-item validated PCMC scale which evaluates women's experiences of dignified and respectful care, supportive care, and communication and autonomy. Factors associated with PCMC were evaluated using multilevel models, with women nested within facilities.ResultsThe average PCMC score was 58.2 (SD = 13.66) out of 90. Controlling for other factors, literate women had, on average, about 6-point higher PCMC scores than women who were not literate (β = 5.758, p = 0.006). Women whose first antenatal care (ANC) visit was in the second (β = -5.030, p = 0.006) and third trimester (β = -7.288, p = 0.003) had lower PCMC scores than those whose first ANC were in the first trimester. Women who were assisted by an unskilled attendant or an auxiliary nurse/midwife at birth had lower PCMC than those assisted by a nurse, midwife or clinical officer (β = -8.962, p = 0.016). Women who were interviewed by phone (β = -7.535, p = 0.006) had lower PCMC scores than those interviewed in person.ConclusionsFactors associated with PCMC include literacy, ANC timing and duration, and delivery provider. There is a need to improve PCMC in these settings as part of broader quality improvement activities to improve maternal and neonatal health.

Project description:Mistreatment of women during childbirth is a clear breach of women's rights during childbirth. This study aimed to determine the prevalence and associated factors of mistreatment of women during childbirth in the north of West Bank, Palestine. A cross-sectional study was conducted among 269 women within the first 16 weeks of their last vaginal childbirth to understand the childbirth events by using proportionate stratified random sampling. An Arabic valid questionnaire was used as a study instrument. Simple and multiple logistic regression analyses were conducted to determine the factors associated with each type of mistreatment. The mean age of the women was 26.5 (SD 4.77) years. The overall prevalence of mistreatment was 97.8%. There were six types of mistreatment. Nine factors were significantly associated with the occurrence of one or more types of mistreatment. Delivery at a public childbirth facility was associated with all of the six types (aAdjOR: 2.17-16.77; p-values < 0.001-0.013). Women who lived in villages (aAdjOR 2.33; p-value = 0.047), had low education (aAdjOR 5.09; p-value = 0.004), underwent induction of labour (aAdjOR 3.03; p-value = 0.001), had a long duration of labour (aAdjOR 1.10; p-value = 0.011), did not receive pain killers (aAdjOR: 2.18-3.63; p-values = 0.010-0.020), or had an episiotomy or tear (aAdjOR 5.98; p-value < 0.001) were more likely to experience one or more types of mistreatment. With every one-hour increase in the duration of labor, women were 1.099 times more likely to experience a failure to meet the professional standard of care. Women were less likely to experience mistreatment with increasing age. Women with increasing age (aAdjOR: 0.91-0.92; p-values = 0.003-0.014) and parity (aAdjOR 0.72; p-value = 0.010) were less likely to experience mistreatment. Awareness of women's fundamental rights during childbirth, making the childbirth process as normal as possible, and improving the childbirth facilities' conditions, policies, practices and working environment may decrease mistreatment occurrence.

Project description:BACKGROUND:Research suggests that birth companionship, and in particular, continuous support during labor and delivery, can improve women's childbirth experience and birth outcomes. Yet, little is known about the extent to which birth companionship is practiced, as well as women and providers' perceptions of it in low-resource settings. This study aimed to assess the prevalence and determinants of birth companionship, and women and providers' perceptions of it in health facilities in a rural County in Western Kenya. METHODS:We used quantitative and qualitative data from 3 sources: surveys with 877 women, 8 focus group discussions with 58 women, and in-depth interviews with 49 maternity providers in the County. Eligible women were 15 to 49 years old and delivered in the 9 weeks preceding the study. RESULTS:About 88% of women were accompanied by someone from their social network to the health facility during their childbirth, with 29% accompanied by a male partner. Sixty-seven percent were allowed continuous support during labor, but only 29% were allowed continuous support during delivery. Eighteen percent did not desire companionship during labor and 63% did not desire it during delivery. Literate, wealthy, and employed women, as well as women who delivered in health centers and did not experience birth complications, were more likely to be allowed continuous support during labor. Most women desired a companion during labor to attend to their needs. Reasons for not desiring companions included embarrassment and fear of gossip and abuse. Most providers recommended birth companionship, but stated that it is often not possible due to privacy concerns and other reasons mainly related to distrust of companions. Providers perceive companions' roles more in terms of assisting them with non-clinical tasks than providing emotional support to women. CONCLUSION:Although many women desire birth companionship, their desires differ across the labor and delivery continuum, with most desiring companionship during labor but not at the time of delivery. Most, however, don't get continuous support during labor and delivery. Interventions with women, companions, and providers, as well as structural and health system interventions, are needed to promote continuous support during labor and delivery.

Project description:BackgroundImproving the quality of maternal health care is critical to reduce mortality and improve women's experiences. Mistreatment during childbirth in health facilities can be an important barrier for women when considering facility-based childbirth. Therefore, this study attempted to explore the acceptability of mistreatment during childbirth in Myanmar according to women and healthcare providers, and to understand how gender power relations influence mistreatment during childbirth.MethodsA qualitative study was conducted in two townships in Bago Region in September 2015, among women of reproductive age (18-49 years), healthcare providers and facility administrators. Semi-structured discussion guides were used to explore community norms, and experiences and perceptions regarding mistreatment. Coding was conducted using athematic analysis approach and Atlas.ti. Results were interpreted using a gender analysis approach to explore how power dynamics, hierarchies, and gender inequalities influence how women are treated during childbirth.ResultsWomen and providers were mostly unaccepting of different types of mistreatment. However, some provided justification for slapping and shouting at women as encouragement during labour. Different access to resources, such as financial resources, information about pregnancy and childbirth, and support from family members during labor might impact how women are treated. Furthermore, social norms around pregnancy and childbirth and relationships between healthcare providers and women shape women's experiences. Both informal and formal rules govern different aspects of a woman's childbirth care, such as when she is allowed to see her family, whether she is considered "obedient", and what type of behaviors she is expected to have when interacting with providers.ConclusionsThis is the first use of gender analysis to explore how gender dynamics and power relations contribute to women's experiences of mistreatment during childbirth. Both providers and women expected women to understand and "obey" the rules of the health facility and instructions from providers in order to have better experiences. In this way, deviation from following the rules and instructions puts the providers in a place where perpetrating acts of mistreatment were justifiable under certain conditions. Understanding how gender norms and power structures how women are treated during childbirth is critical to improve women's experiences.

Project description:BackgroundDespite growing recognition of neglectful, abusive, and disrespectful treatment of women during childbirth in health facilities, there is no consensus at a global level on how these occurrences are defined and measured. This mixed-methods systematic review aims to synthesize qualitative and quantitative evidence on the mistreatment of women during childbirth in health facilities to inform the development of an evidence-based typology of the phenomenon.Methods and findingsWe searched PubMed, CINAHL, and Embase databases and grey literature using a predetermined search strategy to identify qualitative, quantitative, and mixed-methods studies on the mistreatment of women during childbirth across all geographical and income-level settings. We used a thematic synthesis approach to synthesize the qualitative evidence and assessed the confidence in the qualitative review findings using the CERQual approach. In total, 65 studies were included from 34 countries. Qualitative findings were organized under seven domains: (1) physical abuse, (2) sexual abuse, (3) verbal abuse, (4) stigma and discrimination, (5) failure to meet professional standards of care, (6) poor rapport between women and providers, and (7) health system conditions and constraints. Due to high heterogeneity of the quantitative data, we were unable to conduct a meta-analysis; instead, we present descriptions of study characteristics, outcome measures, and results. Additional themes identified in the quantitative studies are integrated into the typology.ConclusionsThis systematic review presents a comprehensive, evidence-based typology of the mistreatment of women during childbirth in health facilities, and demonstrates that mistreatment can occur at the level of interaction between the woman and provider, as well as through systemic failures at the health facility and health system levels. We propose this typology be adopted to describe the phenomenon and be used to develop measurement tools and inform future research, programs, and interventions.

Project description:IntroductionTrust of women and families toward health institutions has led to increased use of their services for childbirth. Whilst unpleasant experience of care during childbirth will halt this achievement and have adverse consequences. We examined the experience of women regarding the care received during childbirth in health institutions in Nepal.MethodA prospective cohort study conducted in 11 hospitals in Nepal for a period of 18 months. Using a semi-structured questionnaire based on the typology of mistreatment during childbirth, information on childbirth experience was gathered from women (n = 62,926) at the time of discharge. Using those variables, principal component analysis was conducted to create a single mistreatment index. Bivariate and multivariate linear regression analyses were conducted to assess the association of the mistreatment index with sociodemographic, obstetric and newborn characteristics.ResultA total of 62,926 women were consented and enrolled in the study. Of those women, 84.3% had no opportunity to discuss any concerns, 80.4% were not adequately informed before providing care, and 1.5% of them were refused for care due to inability to pay. According to multivariate regression analysis, women 35 years or older (β, - 0.3587; p-value, 0.000) or 30-34 years old (β,- 0.38013; p-value, 0.000) were less likely to be mistreated compared to women aged 18 years or younger. Women from a relatively disadvantaged (Dalit) ethnic group were more likely to be mistreated (β, 0.29596; p-value, 0.000) compared to a relatively advantaged (Chettri) ethnic group. Newborns who were born preterm (β, - 0.05988; p-value, 0.000) were less likely to be mistreated than those born at term.ConclusionThe study reports high rate of some categories of mistreatment of women during childbirth. Women from disadvantaged ethnic group, young women, and term newborns are at higher risk of mistreatment. Strengthening health system and improving health workers' readiness and response will be key in experience respectful care during childbirth.

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Exploring mistreatment of women during childbirth in a peri-urban setting in Kenya: experiences and perceptions of women and healthcare providers.

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Exploring mistreatment of women during childbirth in a peri-urban setting in Kenya: experiences and perceptions of women and healthcare providers.

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