Compassionate and respectful maternity care during facility based child birth and women’s intent to use maternity service in Bahir Dar, Ethiopia

Child birth is a special moment for parents, families and communities but can also be a time of intense vulnerability for women to be exposed to disrespectful and abusive behavior while at the health facilities. If mothers do not receive what they perceive as compassionate and respectful maternity care during facility based child birth their intention to use facility based maternity services will be reduced [1].

The concept of “safe motherhood” is usually restricted to physical safety, but childbearing is also an important passage from woman to mother, with deep personal and cultural significance for a woman and her family. Because motherhood is specific to women, issues of gender equity and gender violence are also at the core of maternity care [2].

In recent years advocacy for skilled birth attendance has increased and has become the single most important intervention suggested to decrease maternal mortality and morbidity. However, client satisfaction with such care, which is an important element of quality care, which has the potential to influences effectiveness of care, has not been given enough attention [2, 3].

Problems related to maternal provider behaviors and attitudes are a major barrier when compared to any other geographical or financial barriers to utilization of skilled childbirth care [4].

Advancing compassionate and respectful maternity care is critical in order to increase facility based child birth and ensure effective implementation of women’s rights and women-centered approaches in maternal health services. In fact efforts to increase the use of facility based maternity care service in low resources countries are unlikely to achieve desired gains without improving the quality of care and focusing on women’s experience of care [5].

Despite advances in maternal health outcomes, ensuring that women have skilled and respectful care during delivery remains a challenge. In many countries, women are mistreated when delivering in health facilities and unable to make choices or follow practices that allow them to be in control of their own experience [6]. In addition, health systems are underequipped and health workers are not satisfied due to inadequate pay, lack of infrastructure, or insufficient staff and supplies; staff may also not receive guidance, support or supervision facilitating the provision of respectful maternity care [7].

According to the WHO statement on the prevention and elimination of disrespect and abuse of women during facility-based childbirth and the White Ribbon Alliance charter, respectful maternal care refers to “the right of every woman to the highest attainable standard of health, which includes the right to dignified, respectful health care at all health systems around the world of childbearing woman throughout her pregnancy, during labour and delivery, and post natal period” [1, 8]. Maternal morbidity and mortality has continued to be a public health problem globally as evidenced by high maternal morbidity and mortality [9]. Globally in 2015, an estimated 303,000 women have lost their lives due to easily preventable pregnancy and childbirth related complications, 99% of which were in low income countries. In this figure, sub- Saharan Africa alone was accountable for 66% of the deaths [10].

Ethiopia has one of the highest maternal mortality rates globally (MMR) of 412 maternal deaths per 100,000 live births [11].

In countries where more than 80% of births are attended by trained health personnel, the rate of maternal mortality is less than 200 per 100,000 live births. Thus one of the strategies designed to decrease maternal morbidity and mortality was to increase maternity up take with skilled health care providers [9, 12, 13].

The proportion of women who are giving birth at health institutions with trained birth attendants in Ethiopia is not more than 28%. [11] . Multiple studies have examined reasons for failing to use skilled services during delivery. However, there is inadequate research linking the role of disrespect and abuse of women during facility based deliveries and decreased utilization of maternity services. Disrespect and abuse during childbirth, which is a violation of a universal human right that is due to every childbearing woman in every health system, is common throughout the world and can occur at the level of interaction between the woman and provider leading to low intake of maternity service [14‐16].

Despite the problem, little research has been conducted in Ethiopia with regard to the status of disrespect and abuse during facility-based childbirth. Therefore this study aimed at assessing the status of compassionate and respectful maternity care and associated factors in health facility-based childbirth in Bahir Dar town.

This study investigated the prevalence and factors associated with compassionate and respectful maternity care during facility-based childbirth in Bahir Dar town at the facility level. This study revealed that the prevalence of compassionate and respectful maternity care was reported by 57% of women, with abusive maternity care reported by 43%. This proportion is higher than that in a study conducted in Kenya which showed that 20% of women reported any form of disrespect and abuse during child birth [19]. The considerable difference may be due to socio-cultural and socio-economic. It may also be due to differences in staff training and organization of healthcare. However, the proportion women reporting abuse in this study is lower than a study conducted in Enugu in Nigeria where 98% of the women have reported that they have had at least one instance of abuse during the course of childbirth [20]. The differences may also be due to the study period selected and the relatively small sample size in this study. The results of this study also show a higher level of abusive maternity care compared with data collected in Tanzania where the frequency of any abusive or disrespectful treatment during childbirth was 19% [21]. The considerable difference may be due to socio-cultural and socio-economic poupulation difference. In this study 34.5% of respondents reported that a health care provider slapped them during childbirth compared with a similar proportion in Nigerian study which showed that 35.7% of women reported slapping during childbirth at health facilities [19]. In this study negligent care was reported by 30.3% of women which is markedly higher than the study conducted in Tanzania with only 7.9% reporting negligent care [20]. Respondents who gave birth by caesarian section were four times more likely to be disrespected and abused than respondents who had gave birth through vaginal delivery perhaps it is due to staff work load and attitude of health care provider. The results of this study show that the prevalence of disrespect and abuse at 43% is lower than that reported in Addis Ababa, Ethiopia where the comparable figure for facility-based childbirth was 76.8% [17].The discrepancy may be due to services improvement. Similarly, the overall prevalence of compassionate and respectful maternity care was 57% which is notably higher than the 21.4% reported in the study conducted in Addis Ababa [17]. The study also revealed that respondents who were residents of rural areas were six times more likely to experience disrespect and abuse than urban residents. Over all in this study the prevalence of discrimination- free care was experienced by only a third of women, with friendly care reported by a quarter. Income level also made a difference, with respondents in this study having a low family monthly income of < 3000 Ethiopian birr being twice as likely to be disrespected and abused as respondents with a higher family monthly income. This finding is in line with the study conducted in Addis Ababa which showed that respondents with low family monthly income were significantly more likely to report disrespect and abuse [17]. Respondents who have no intention to give birth in a health facilities were six time more likely to report disrespect and abuse than respondents who have the intention to give birth in a health facilities. The finding of this study showed that the prevalence of disrespect and abuse is high. To reduce this high prevalence all stakeholders who were working to reduce maternal and child mortality must be involved to promoting respectful maternity care for all child bearing mothers. In addition to this strengthening responsibility through legal redress, citizen involvement on hospital administration boards, client health care charters, improving the quality of the work environment for providers, training and introduction of care standards is very important to promote compassionate and respectful maternity care.

The results of this study show that the prevalence of disrespect and abuse during childbirth was 43% among the women studied. Abuse of mothers during facility child birth is a health facility failure and a violation of women’s rights as well as an important barrier to women seeking institutional delivery. Independent factors identified that increased disrespect and abuse included low family monthly income, rural residency, complications during delivery, caesarian birth and intention not to use maternity service. Therefore, to reduce disrespect and abuse, attempts to break down barriers between health workers and clients through regular community facility dialogue and strengthening the health system is a vital factor in inviting more women to health facilities and for improving institutional delivery. It is every woman’s right to give birth in a woman centered context with compassionate and respectful care. Provision of woman-centered care in compassionate and a respectful manner needs to be given adequate emphasis to attract more women to health facilities, and to make services more women friendly.