Characteristics of mothers surveyed
A total of 515 recently delivered women responded to the survey across the 11 health facilities. Six of the questionnaires were excluded due to incompletion. All of the remaining 509 respondents were included in the analyses. Residence of these respondents was predominantly urban (95.1 %). The average age was 27.4 years with a standard deviation of 4.8, minimum 16 years and maximum 46 years. The women’s parity ranged from zero to six; 51 % had a spontaneous vaginal delivery; 12.3 % had a cesarean section; and 36.7 % had an episiotomy.
In-depth interviews conducted with postpartum women showed that some forms of abuse and disrespect were prevalent in the study area. The in-depth interview participants reported some form of physical abuse. A 20-year-old mother reported that, while she was having pain during labor, she touched a young female health worker and the health worker threw the mother’s hand away. Incidents such as this shocked the women and caused them to lose trust in the health workers. Women also reported that non-consented care has occurred so frequently that mothers do not expect to be asked for their consent for all procedures. A 23-year-old mother reported that, after she was referred from a health center and had waited for some time at a teaching hospital, students came one after the other, asked her to open her legs, and inserted their fingers into her vagina without explaining the reason. In-depth interview participants also reported non-dignified care. Examples of this type of care included health workers shouting at women for not attending antenatal care services and for making noises during their labor pains. A 20-year-old woman reported discrimination during hospital referrals. She was referred to hospitals where she was not able to get services and was later referred to another hospital. Delays caused by these referrals were painful for her, and she felt the health workers should have prioritized her. The 20-year-old woman reported abandonment during her stay at a health center, but detentions in facilities were not reported because the government provided delivery services free of charge.
Factor analysis
Suitability of data for factor analysis was confirmed by KMO and Bartlett’s test of sphericity. The KMO value for RMC scale was 0.903, indicating that there are components in the correlation matrix to uncover. Bartlett’s test of sphericity, which was χ
2 (666) = 9229, p < 0.0001, indicated that correlation between the items was sufficiently large for PCA. The two tests indicated that use of PCA was appropriate.
The scree plot suggested four components explaining 50.3 % of the variation in the initial 37-item scale solution and 67.8 % of the final 15-item scale. Parallel analysis, using Monte-Carlo PA software-generated random data, also confirmed four components. Multidimensionality of the RMC construct was confirmed by the diagnostic tests.
Oblique rotation (direct oblimin with Kaiser normalization) in a series of iterative processes produced four components with eight, three, three, and two items on the four components, respectively.
Table
1 below show items deleted for different reasons.
Table 1
Items deleted during analysis for different reasons, 2014
Q202 Some health providers showed me an intimidating gesture (R) | Low communalities |
Q206 I was left alone after delivery for a long time (R) |
Q203 The counseling sessions were held in a private area |
Q234 The health workers provided coaching on breathing and relaxation |
Q204 The health workers talked to me and my companions politely |
Q201 The health provider greeted me and my companions before service delivery |
Q209 The health worker didn’t mention anything that he/she was performing (R) |
Q231 The health workers showed active involvement during contraction |
Q236 I felt like the health workers tried to move things along for their own convenience (R) |
Q221 The health worker encouraged me to open my legs during labor |
Q210 I was detained in the facility because I didn’t have enough money to pay for the service I was given (R) | Low factor loading |
Q213 The couches were separated by privacy screens during examination |
Q215 Some health workers do not treat all patients equally (R) | High cross loading on two or more factors |
Q217 My consent was requested for all procedures performed |
Q226 The health provider helped me to try different delivery positions |
Q229 During delivery, the health worker draped or covered me to protect my privacy |
Q230 The health workers used a reassuring touch |
Q220 My companions were allowed to enter the delivery room during delivery |
Q212 I was told that I can refuse a procedure if I don’t like it |
Q223 All health workers treat patients equally |
Q214 The health workers shouted at me for different reasons during contraction (R) | Decrease cross-correlation |
Q235 I felt there was inappropriate touching of genitals/thighs during the exam (R) |
During the extraction process, 10 items were deleted for low communalities, eight items were eliminated for high cross loading on two or more factors, two items were eliminated due to low factor loading, and two items were deleted because they contributed to a decrease in cross correlation of other items.
Table
2 below shows the pattern matrix, which is the correlation between each item and uncorrelated components extracted after an iterative process of oblique rotation.
Table 2
Pattern matrix RMC scale, 2014
Q232 I felt that health workers cared for me with a kind approach | 0.811 | | | | 0.724 | Friendly care |
Q211 The health workers treated me in a friendly manner | 0.792 | | | | 0.669 |
Q233 The health workers talked positively about pain and relief | 0.789 | | | | 0.604 |
Q237 The health worker showed his/her concern and empathy | 0.777 | | | | 0.677 |
Q227 All health workers treated me with respect as an individual | 0.731 | | | | 0.632 |
Q205 The health workers spoke to me in a language that I could understand | 0.724 | | | | 0.598 |
Q207 The health provider called me by my name | 0.703 | | | | 0.599 |
Q224 The health worker responded to my needs whether or not I asked | | 0.826 | | | 0.725 | Abuse-free care |
Q208 The health provider slapped me during delivery for different reasons (R) | | 0.820 | | | 0.765 |
Q238 The health workers shouted at me because I haven’t done what I was told to do (R) | | 0.781 | | | 0.725 |
Q216 I was kept waiting for a long time before receiving service (R) | | | 0.897 | | 0.743 | Timely care |
Q225 I was allowed to practice cultural rituals in the facility | | | 0.710 | | 0.587 |
Q219 Service provision was delayed due to the health facilities’ internal problem (R) | | | 0.684 | | 0.666 |
Q222 Some of the health workers did not treat me well because of some personal attribute (R) | | | | 0.840 | 0.76 | Discrimination-free care |
Q218 Some health workers insulted me and my companions due to my personal attributes (R) | | | | 0.820 | 0.718 |
The four components of the 15-item scale extracted by PCA were labeled as friendly care, abuse-free care, discrimination-free care, and timely care considering the core idea explained by the predominant items in terms of factor loading in each subscale [
19].
The 15-item RMC scale’s mean score for the developmental group was 57.83 with standard deviation of 8.46. The mean and standard deviation for each component were 28.54, 5.18 for friendly care; 10.87, 2.98 for abuse-free care; 9.90, 2.78 for timely care; and 8.52, 1.59 for discrimination-free care.
Analysis of inter item consistency showed good internal correlation with Cronbach’s alpha of 0.857 for standardized items for the full 15-item scale: 0.889 for friendly care, 0.75 for abuse-free care, 0.71 for timely care, and 0.666 for discrimination-free care.
Content validity of the RMC scale was assured through a methodological rigor that included review of related literature, in-depth interviews with postpartum women, and expert review.
Concurrent validity was assessed by correlating RMC scale with global satisfaction criterion items (Q339–satisfied with overall service and Q340–recommend facility to others). Pearson product moment correlation of summated RMC scale score with Q339 and Q340 showed a correlation coefficient of 0.711, p < 0.001, and 0.881, p < 0.001, respectively.
Construct-related validity was confirmed by examining the components correlation matrix for the rotated final components. This indicated a minimal correlation among components as shown in Table
3 below. Small Pearson correlation coefficients between components were observed.
Table 3
Component correlation matrix RMC scale, 2014
Friendly care | 1.0 | 0.113 | 0.356 | 0.250 |
Abuse-free care | 0.113 | 1.0 | 0.019 | 0.065 |
Timely care | 0.356 | 0.019 | 1.0 | −0.009 |
Discrimination-free care | 0.250 | 0.065 | −0.009 | 1.0 |
Principal component analysis on a random split sample (320 out of the 509 samples) of the developmental sample confirmed factor stability; all four factors were retained with minimal change in factor loading. The scale accounted for 68.8 % of the variation as compared to 67.8 % in the full scale.