Plain English summary
Background
Methods
Study design
Settings
Sample and recruitment
Data collection
Ethical considerations
Data analysis
Ethical approval
Results
Respect for women
Positive interactions between midwives and women
Midwife C was talking to the woman while checking her blood pressure. After checking, she told the woman that the measurement “was normal”. During that time, the woman cried because of labor pain. Midwife C discontinued the examination and gently advised the woman on how she could relieve her the pain by imitating the proper breathing technique, namely, “give a short breath like huff, huff”. Then after midwife C completed her questions, she gently told the woman that “the baby would not be delivered very soon”. Midwife C also advised the woman that she had “better walk around rather than lie on the bed, take a cup of tea whenever she wanted, and not to take herbal leaves.” (EP no. 3)
Respect for women’s privacy
Midwife E called a woman over to the admission room. Immediately after the woman entered the room, midwife E closed the door and moved a partition curtain across the door. (EP no. 4)
Provision for safe and timely midwifery care for delivery
Midwife K realized that woman C was yelling while she was still in the antenatal ward. Upon hearing the tone of her loud voice, midwife K decided to bring woman C to the labor ward. Midwife K told woman C to lie down on her back and to open her legs with her knees bent. Midwife K wore gloves and applied antiseptic with her previously prepared swab to woman C’s perineum. Soon after the rupture of the membrane, the fetal head was crowning. Midwife K supported her perineum and the fetus was delivered soon after she provided support to the perineum. (EP no.6)
There was yelling and crying from a woman in the antenatal ward. Midwife F checked her chart and said to the researcher that, “She was fourth gravida, and her cervix was already dilated seven centimeters - she is crying, so I will move her to the labor ward.” Midwife F assessed that “her labor was progressing”. After the woman lay on the delivery bed, midwife F inserted an intravenous line and gave fluids “because she didn’t eat and drink for a long time and she seemed to be tired”. (EP no. 7)
Active engagement in the labor process
Woman ‘A’ who was lying on a bed in the antenatal ward was suffering from labor pains. Her uterine contractions occurred every three minutes. Midwife D instructed woman ‘A’ to move to the labor ward. After reaching the labor ward, she complained of increasing labor pain. Midwife D asked, “Are you feeling [the need] to push?” and woman ‘A’ answered, “Yes”. Midwife D asked her to lie on her back and she performed vaginal examination and said, “eight centimeters dilated”. After 30 minutes, midwife D went back to the delivery room to check the condition and progress of labor of woman “A”. (EP no. 8)
Woman B was calling “Nurse! Nurse!”. Midwife D who was in the nurses’ station stood up and started listening to the voice, and then went from the nurses’ station into the labor ward. Woman B was lying on her right side on the delivery bed. Midwife D found that woman B’s blood was returning and passing through the intravenous line, and the midwife understood why she was called. After she replaced the empty IV bottle with a new bottle, she asked woman B “how are you feeling and how about the labor pains?” (EP no. 9)
Encouragement of the mother-baby relationship
Midwife K instructed the woman who had just delivered to sit on the edge of the delivery bed. When the woman was seated, midwife K asked the woman to hold her baby in her arms and midwife K encouraged her to start breastfeeding using verbal instructions and gestures. Then, the woman was able to start breastfeeding. (EP no. 5)
II. Disrespect of women
Physical abuse
Midwife D was staring at woman C silently and waiting for the fetal head that was crowning. When woman C tried to close her legs and turn over in the bed because of the labor pain, midwife D slapped her on the inner side of her thigh and said in a harsh tone, “open!!” (EP no. 10)
Woman J had been suffering from labor pains. Midwife I went to her to see how the labor was progressing. Midwife I explained to the researcher, “the uterus contractions were not strong enough to progress”, [which was why] she looked around and found a broken glass ampule that had been left on the table. She quickly inserted the broken glass ampule into the vagina of woman J. Then, she tried to break the membrane with the cutting edge of the ampule but was not successful in spite of several attempts. She then gave up, left woman J, and returned to the nurses’ station. (EP no. 11)
Midwife L received the prescription and order from a doctor to administer oxytocin to woman K. The infusion rate and dose escalation, including the dose increment between the time intervals were written on the prescription. However, midwife L started the IV drip without minding the infusion rate or even using a watch to monitor the drip rate. (EP no. 12)
Midwife I brought the needle holder, needle, and thread from the other room, and started to stitch the woman’s perineum tear resulting from a delivery without using any anesthesia. The woman screamed to complain about pain, but midwife I continued to stitch while ignoring the woman’s screams. (EP no. 13)
Psychological abuse
Woman D was vomiting. Midwife B found that there were contaminants mixed in the contents of the vomitus and realized that woman D took some traditional herbal medicine believed to strengthen uterine contraction and promote smooth labor. Midwife D scolded her in harsh tones for taking the herbal medicine, “How many times were you told not to take the local herb?” Other midwives also joined in by berating woman D and began exclaiming: “Why did you take it?” “Who gave it to you?” “Your baby will die if you take it!” (EP no. 14)
Woman E was lying on her back in the delivery bed and yelling. Midwife M went to her because she heard her screaming. Midwife M stood and rose to her full height at her bedside and lambasted her saying, “Push enough! Push more strongly!” Woman E was writhing and crying. Midwife M threatened her, “Don’t cry, or your baby will die!” (EP no. 15)
While woman F was walking from the antenatal ward to the labor ward under agonizing labor pains, midwife D was just silently standing in the labor ward with her hands on her hips just watching woman F walking. Woman F stopped many times to hold herself up during the labor pains, but midwife D never went near her or say anything to her. Midwife D instead concentrated on preparing the bed and slowly donned gloves while chatting with other staff. (EP no. 16)
Woman G delivered a stillbirth baby. Midwife I, who came in just before the baby was coming out, pulled the baby out and just put the baby between the legs of woman G. After midwife I recognized that the baby was not breathing, she just gave the back of the baby some taps as an attempt to resuscitate, but she quickly slowed down and stopped her attempts after seeing that the baby did not respond. Midwife I casually told women G, “your baby is dead”, and then she wrapped and took the baby to the sanitary room without even allowing the mother to hold her baby. Woman G just stared at the ceiling and looked vacantly into space. After midwife I returned, she let woman G stand up but said nothing to her. (EP no. 17)
Non-confidential care
Woman A was lying on the bed in the antenatal ward agonizing from labor pains and was yelling for help. When midwife A realized that woman A was yelling, midwife A shouted at woman A in the labor ward saying “Who is yelling?” Midwife A then noticed woman A who was bearing the brunt of the pain and she shouted at woman A again in front of all the other women asking “What is your name?”, “How old are you?”, “How many times have you given birth?” (EP no. 18)
Non-consented care
Midwife K was standing in front of woman B who was lying on a delivery bed. Midwife K just suddenly instructed her to remove the sheet covering her lower half and to spread her legs widely without any explanation. Next, midwife K began to silently clean woman B’s perineum. After cleaning, she picked up the clamps and quickly inserted the tip into woman B’s vagina to break the membrane. Woman B flinched but said nothing. (EP no. 19)
Abandonment of care
Woman H was screaming loudly in the labor ward and calling the midwives saying “Ahhhhhhhhh!! Nurse!! Nurse!!”. Midwife N was sitting and chatting with other staff at the nurses’ station, which is not far from the labor ward. (Since the labor ward opens into the nurses’ station, they can hear the women’s voices even at the nurses’ station.) After a while, midwife N peeked at woman H and said, “Don’t sit like that! Just lay on the bed, but don’t do anything!” Afterward, woman H continued yelling and calling the midwives. Her yelling gradually became loud, but midwife N was taking a nap face down on the desk at the nurses’ station. Eventually, the woman screamed, “please!! please!! coming out! The baby is coming out!” but still midwife N ignored her cry. Finally, a student nurse who was passing by conducted her delivery. (EP no. 20)
III. Unprioritized and disorganized nursing and midwifery management
Lack of accountability
More than 30 women were in the crowded antenatal ward. The midwives had been sitting at the nurses’ station overviewing all the beds, but no midwives were checking on the women. At some point, a woman’s cry was heard and she was standing with her legs planted far apart. The other midwives prompted midwife J to go check on the woman and she slowly went to the woman. Upon arriving, the fetal head was already crowning and coming out. While midwife J was putting on her gloves, the baby came out and fell onto the floor. The baby died shortly afterward. (EP no. 21)
A staff member working at the antenatal ward brought a woman to the labor ward and left her there without informing the labor ward midwives. Midwife I who was at the labor ward nurse station heard the woman yelling and she went to see her. She looked all over for the woman and finally found her lying on the delivery bed. She quickly examined her cervical dilation without checking her chart and directly conducted the delivery without sufficient background information. (EP no. 23)
Unethical clinical practices
After conducting one delivery, midwife D went back to the nurses’ station to complete the woman’s chart. She started to graph a point on the partograph even though nothing was written during the labor and delivery. Despite the fact that she had never checked the fetal heartbeat, woman’s vital signs, uterine contractions, or cervical dilatations, she falsified the information and the graph as well as faked the postnatal check-up, which was prior to the actual event. (EP no. 24)
Discussion
Positive interaction and assuring women’s rights
Bowser & Hill (2010) | Bohren et al. (2015) | White Ribbon Alliance (2011) | Present study | |
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Respect for women | Disrespect for women | |||
Physical abuse | Physical abuse - Use of force - Physical restraint | Freedom from harm and ill treatment | Physical abuse - Physical force including slapping, beating, pushing the abdomen in a non-emergency case; episiotomy without anesthesia; and harmful, unsanitary, and an unprofessional medical procedure | |
Sexual abuse | ||||
Non-consented care | Failure to meet professional standards ① - Lack of informed consent and confidentiality | Right to information, informed consent and refusal, and respect for choices and preferences, including the right to companionship of choice wherever possible | Positive interaction among midwives and women - Giving consideration to women’s emotions, greeting, implementing good communication skills, explaining what they were going to do, providing the results, and giving their own assessment and advice | Non-consented care - Performing medical treatment or physical examination without any explanation or consent from the women |
Non-confidential care | Failure to meet professional standards ② - Physical examinations and procedures | Confidentiality, privacy | Respect for women’s privacy - Considering and protecting woman’s privacy from other women | Non-confidential care - Invading women’s physical and psychological privacy without any partition and asking women their private or personal information in front of others |
Non-dignified care (including verbal abuse) | Verbal abuse - Harsh language - Threats and blaming | Dignity, respect | Positive interaction among midwives and women - Giving consideration to women’s emotions, greeting, implementing good communication skills, explaining what they were going to do, providing the results, and giving their own assessment and advice | Psychological abuse - Actions with violent words or harsh tones such as scolding, threatening, berating, and blaming, and emotional neglect by not genuinely sympathizing or considering the women’s situation |
Abandonment or denial of care | Failure to meet professional standards ③ - Neglect and abandonment | Right to timely healthcare and to the highest attainable level of health | Provide safe and timely midwifery care for delivery - Periodic monitoring of the laboring process, performing appropriate care for delivery with precise timing by judging women’s laboring process Actively engage in women’s laboring process - Correcting both subjective and objective data to grasp and assess the progress of labor by going to the women’s side to predict what would be expected for the women’s childbirth | Abandonment of care - Ignoring, neglecting, and abandoning women during childbirth even if the women were yelling or screaming for help |
Discrimination based on specific attributes | Stigma and discrimination - Discrimination based on sociodemographic characteristics - Discrimination based on medical conditions | Equality, freedom from discrimination, equitable care | ||
Detention in facilities | ||||
Liberty, autonomy, self-determination, and freedom from coercion | ||||
Encourage mother-baby relationship - Encouraging the relationship between the mother and the baby after giving birth by having skin-to-skin mother-baby care and breastfeeding | ||||
Poor rapport between women and providers - Ineffective communication - Lack of supportive care - Loss of autonomy | Psychological abuse - Actions with violent words or harsh tones such as scolding, threatening, berating, and blaming, and emotional neglect by not genuinely sympathizing or considering the women’s situation | |||
Unprioritized and disorganized nursing and midwifery management | ||||
Health system conditions and constraints - Lack of resources - Lack of policies - Facility culture | Lack of accountability - One of the factors contributing to disrespect for women not systematically assigned to a group of women; the midwives’ practice was impromptu Unethical clinical practices - There were no rule-based recordings or ethical charting |