Plain English Summary
Background
Domain Number | Domain Description of Disrespect and Abuse | Universal Childbirth Right |
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1 | Physical abuse (e.g., painful or embarrassing procedures without warning or unnecessarily performed) | 1. freedom from harm and ill treatment |
2 | Non-consented care (e.g. lacks provision of information to make an intelligent decision, lack of permission or courtesy for invasive and traumatic procedures) | 2. informed consent and refusal and respect for choices |
3 | Non-confidential care (e.g., lack of covering to provide culturally desired modesty, inappropriate sharing of client’s information, inability to track or secure patient records) | 3. right to privacy and confidentiality |
4 | Non-dignified care (e.g. verbal abuse, psychological abuse) | 4. right to dignity and respect |
5 | Discrimination based on specific attributes (e.g. lack of equitable maternity care regardless of group membership) | 5. equality, freedom from discrimination and equitable care |
6 | Abandonment or denial of highest quality of care available (e.g., Provision of efficient and effective care) | 6. Access to healthcare and the highest attainable level of health |
7 | Detention of mother or baby in facilities (e.g., for lack of payment, lack of universal access to care) | 7. liberty, autonomy, self-determination, and freedom from coercion |
8 | Enhancing quality of physical environment and resources | 6. Access to healthcare and the highest attainable level of health |
9 | Engaging with effective communication | 4. right to dignity and respect and 5. equality, freedom from discrimination and equitable care |
10 | Availability of competent and motivated human resources, inability to provide continuity of care and continuity of carer (e.g., less than optimal staffing, poor fiscal management, poor recruitment and retention of personnel, loss of morale and lack of workforce job satisfaction, poor remuneration for work, poor working conditions and policies, lack of emotional and professional support for staff, lack of staff training) | 6. Access to healthcare and the highest attainable level of health |
11 | Restriction from movement or position changes, disempowering or inequitable behaviours or policies (denying the client a culturally safe space) | 4. right to dignity and respect |
12 | Lack of support for desires and choices (e.g. having a labour support person present at birth, declining a test or procedure, policies at the facility or governmental level that do not support the desire of mother to be accompanied by a desired family member or partner, lack of support for the special psychosocial needs of adolescents or other vulnerable populations) | 2. informed consent and refusal and respect for choices and preferences even when the choice is to reject recommended community standards |
Methods
No. | Author Information | Context and Sampling | Methodology (variables, analysis) | Findings and implications to practice |
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1. | Abuya T et al. [1] | 13 facilities in Kenya (private, public and faith based) with various levels of care (hospital, nursing home, health centers and referral facilities). All with small numbers of deliveries, similar professional expertise, skills, clientele, location and fees. Nurses and midwives practices in all. Bed capacity ranged from 42 to 135 beds. Women 15–45 yr. old. N = 641, 85 (13.2%) ages 15-19yr. | mixed methods, 90% power what authors identify as “Quasi-experimental before-and after implementation” | 1:5 women felt “humiliated” during Labour and Delivery dept. 6 categories of disrespect and abuse reported. Multiparous women 3× more likely to be detained for lack of payment, 5X more likely bribe. Study measured 10% decrease in disrespect and abuse. |
2. | Bohren MA et al. [19] | Mixed methods systematic review of 65 studies, 34 countries. Developed and Developing countries included (included the studies of Kruk et al., Sando et al., and McMahon all of which included sampling in Tanzania in which self-reports were used for gathering data. | PubMed, CINAHL, and Embase databases and grey literature were searched and synthesized thematically using CERQual tool. | Key behaviours were identified in Tanzania as disrespectful (neglectfulness, preoccupation with other tasks, discrimination due to HIV status, lack of privacy, lack of consent for internal cervical exams, detention of mother or baby for lack of payment, unclear fee structures. “Mistreatment” is defined as involving the health care system and facility policies |
3. | Bowser D et al. [3] | Desktop review of the published and gray literature, individual interviews with nine expert informants and a structured group discussion. Tanzania was one of 19 countries in both the Global South and North studied. | Web-based search yielding 70 peer-reviewed articles with terms: abusive care, disrespectful care, dignified birth, caring behavior, humanization of childbirth, discrimination during childbirth, stigma, detention, neglect, accountability, human rights and childbirth, health workers for change, empowerment, redress, health systems and childbirth, quality of care, barriers to treatment of obstetric emergencies, and women‘s perceptions of maternal care (150+ documents references provided by key informants (journal articles, book, reports). | A model was presented which describes the relationships between contributors or deterrents and disrespect and abuse in childbirth. These include individual, national policies and human rights, governance and leadership, service delivery and providers, financial access, geographic access and cultural birth preferences, and skill level of workers. The authors concluded that there is a connection between the woman’s autonomy and empowerment with disrespect was made. |
4 | Bhutta ZA et al. [4] | Rural district of Southern Pakistan, Feb 2006 to March 2008. | 16- cluster randomised trial. Intervention was the use of trusted Lady Health Workers trained in culturally sensitive prenatal education. | 63% (4428) of the planned group educational sessions were delivered and 2943 neonates (24%) received home visits in their catchment villages. The stillbirth rate was 39.1 per 1000 births compared to the control of 48.7. RR 0,79, 95% CI with p = 0.006. NMR was 43 per 1000 compared to the control of 49.1 (RR = 0.85, CI 0.76–0.96, p = 0.02. Although not stated, the cultural sensitivity and relationship of trust between the mother and LHW was significant. The curriculum was standard, however the exact content, delivery and behaviours were not described. |
5 | Duysburgh E et al. [9] | Rural Burkina Faso, Ghana and Tanzania. Tanzania’s Builsa and Kassena-Nankana districts with populations of > 30,000 and access to emergency services at the facilities sampled. In communities where 95.7% of pregnant women receive care from skilled providers. | Non-randomized intervention study. QUALMAT project Was implemented at provider level to measure the existing gap between ‘knowing what to do’ and ‘doing what you know’. Two kinds of interventions are planned: (i) performance-based incentives to increase health workers’ motivation and (ii) computer-assisted clinical decision support, to improve compliance with clinical guidelines. Exit interviews, health facility surveys and retroactive chart review. | Counselling, health education practice, laboratory investigations, equipment for vacuum assisted birth, maternal and newborn assessment and partograph use were all deficient. Rectifying these deficiencies could easily reduce MMR and NMR. |
6 | Hanson C et al. [14] | Rural Southern Tanzania, 226,000 households. This survey reportedly captures higher mortality rates than the facility-based MMR published by the Ministry of Health Community Development Gender Elderly and Children (MoHCDGEC) | Census data using a georeferenced household survey measuring pregnancy-related mortality ratio (number of pregnancy-related deaths reported by the household head) | 60% of the mothers who lived less than 5 km from the birthing facility reportedly died secondary to poor quality care during their hospital birth with an MMR of 111 direct deaths per 100,000 livebirths. |
7 | Kidanto HL et al. [15] | University teaching hospital in Dar es Salaam Tanzania | Criteria-based audits (CDA) were performed to determine the contributing factors when Apgar scores for newborns were less than 7 at the 5th minute. 389 eclampsia cases audited initially and 88 cases in the re-audited for evidence-based management of eclampsia. | Providing access to the highest quality care available is one of the measurement criteria for respectful maternity care and CBA is considered a feasible method for identifying problems with quality of care. Poor performance improved when re-audited but it was noted that poor documentation and ineffective staff utilization persisted. Inexpensive recommendation could help the facility reach targeted goals. |
8 | Kruk ME et al. [13] | 1203 were sampled out of 1322 eligible women (91% response rate). Rural western Tanzania. Most were married, ethnically 3 ethnically similar groups. Facility births account for only 1/3 of all births. | Population-based discrete choice experiment to determine factors that influence choice of birthplace. Choice A was 1 h away, care cost 500 shillings, with a doctor who neither smiled nor listened carefully and was not always available. Choice B was 3 h away, cost 3000 shillings, the nurse smiled and listened carefully and was always available. Both A and B provided free transport. Choice C meant choosing neither A nor B facility. | There was a high coefficient ratio for predicting which facility would be preferred by the women, however the provider attributes provided were minimal. Other relevant factors such as availability of drugs and equipment, provider type considered after data collection. The author concludes that facility and provider attributes were contributing to the high rates of out of facility births and possibly the use of traditional birth attendants and avoidance of the disrespectful care received at the facilities. |
9 | Kujawski S et al. | Tanga Region, Tanzania, 8 facilities in Korogwe and Muheza Districts, both government and non-governmental owned hospitals. | Cross sectional study, structured survey measuring satisfaction. Univariate statistics. | 1388 women participated in the survey (67% response rate). Detailed description of the sample (39% primiparous, 20.87% with secondary education or higher, households, 25.42% with access to electricity and 85.21% had access to a mobile phone. There was a correlation between respectful care, perceived quality of care, intention to deliver at that facility again in future were all related to perceptions of satisfaction. RMC was not clearly defined in the study. |
10 | McMahon SA et al. | Mongoro Region, Tanzania. The concept of “safe motherhood” was expanded to include not only mortality and morbidity but also human rights. | 112 Individual interviews of mothers, male partners within 14 months of birth, public opinion leaders and community health workers. | Proving questions revealed significant reports of disrespect and abuse for which acquiescence and passivity were adopted as coping strategies. Males paid bribes, made formal complaints or resorted to aggression in response to the disrespect, abuse and neglect. |
11 | Miller S et al. | Domincan Republic, 14 facilities, | Facility assessment (chart review, interviews, observations compared to international RMC and clinical norms, facility statistics reviewed and compared with national statistics). | Maternal mortality was contributed to by provider attitudes, poor clinical skills, neglect of patients with the two tiered fee structure in the healthcare system (private and public), poor staffing, lack of emergency skills training. |
12 | Mselle LT et al. | Sample from Comprehensive Community Based Rehabilitation in Temeke district hospital in Dar es Salaam, and Mpwapwa district in Dodoma region of Tanzania. This hospital manages 26, 568 births annually and one of two specialty hospitals for fistula surgery. Patients come from both Mpawapwa district and Temeke district. | Semi-structured interviews with 16 mothers diagnosed with obstetric fistula, 5 nurse-midwives and focus group discussions with husbands and community members | Women described mothers labouring and birthing without attendance, lack of support, lack of equipment and service, physical and verbal abuse. Providers reported lack of supportive supervision, staffing and supplies. Nurse-midwives experienced lack of motivation, disempowerment and moral distress. This is one of the few studies to describe the self-reports and work-life experiences of Tanzanian midwives. |
13 | Penfold S et al. | The study was part of INSIST in six districts of Lindi and Mtwara regions, Tanzania, (population 1,000,000 in 2007) | Mixed method study (cross-sectional survey of all health facilities in the study districts, and qualitative focus group discussions and interviews with health managers) | 200 facilities were sampled. Staff reported lack of essential medications, equipment shortages, and glove shortages. They coped by adapting or improvising clinical care. Logistics problems were not explored to determine the causes of the poor drug and equipment supplies. |
14 | Ratcliffe HL et al. | Large referral hospital in Dar es Salaam, Tanzania with a catchment of 1.4 million people. | Exploratory study. 2000 women were interviewed immediately after birth, 77 of which were also interviewed 4–6 week postpartum. Staff was also monitored following RMC interventions in the facility. Patients evaluated and community interviews conducted after participating in RMC initiatives such as Open Birth Days (similar to an open house) | Average age oft the women was 29.7 yr. 10% were HIV positive, 17.5% nulliparous. 82.6% married with primary education or greater. 15% reported experiencing any category of disrespect and abuse. The staff were given RMC training which providers. The facility held Open Birth Days, which patients found helpful in improving their knowledge and expectations for birth. |
15 | Rosen HE et al. | Tanzania was one of 5 countries studied (others included Kenya, Madagascar, Rwanda). In Tanzania, 52 facilities, 12 hospital, and 40 centers were sampled. | Structured, standardized clinical observations, cross sectional surveys from 2009 to 2012 as part of the Maternal and Child Health Integrated Program to assess quality of care using a checklist. | 2164 labour and birth observations occurred in 1458 patients at hospitals, dispensaries and health centres. 320 of the clients were from Tanzania. Providers (doctors, nurse-midwives, students) obtained informed consent and refusal 62% of the time. Dignity was demonstrated with a friendly greeting 94.6% of the time. Encouragement to have a labour support person only occurred 39.5% of the time. Explanation of procedures occurred 72.1% of the time. Asking if the client had questions only 26.8% of the time. Respect for the woman’s choices was often not observed. Permitted to ambulate only 54.8% of the time. Draping before delivery occurred only 46.1% and visual privacy occurred only 35% of the time in a shared room. However, 93.2% of the time the provider provided friendly support during labour. Although small in sample size, the findings support other larger studies. |
16 | Sando D et al. | Large urban regional referral hospital in Dar es Salaam, Tanzania. The Labour unit is often crowded with patients and understaffed. There is significant stigma in Tanzania attached to HIV positive status. | Mixed methods (interviews of 2000 postpartum women, direct observation 208 births, 50 structured questionnaires and 18 in-depth interviews | 12.2% of the HIV positive participants and 15% of the HIV negative participants reported disrespect and abuse during childbirth (p = 0.37). These came in the form of abusive statements and non-consented care. None of the participants reported violations of confidentiality in terms of the HIV status. Staff reported shortages of gloves, cotton wool and overcrowding to be constant challenges but appeared to be engaging in the norms and standards to prevent mother to child transmission of HIV. Despite the size of the hospital and the staff shortages, HIV positive mothers were receiving adequate health education. |
Conceptualization of respectful care
Type of RMC Research Question | Quantitative | Theoretical Framework |
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Methodology | ||
Do health education interventions improve facility utilization? | Quasi experimental before-and-after | Community-based participatory framework |
Does disrespect and abuse correlate with facility utilization? | Correlational | Not usually stated |
What is the incidence and prevalence of disrespectful care and abuse? What types of abuse occur? What are the perinatal outcomes/indicators in the facilities where disrespect and abuse occur? | National health surveys Institutional surveys National household surveys Demographic health surveys Facility statistics Population surveys/epidemiological surveys | RMC Medical models Public health models |
Describe the elements of disrespect and abuse | Case control studies Prospective closed cohort | Critical human rights, reproductive rights |
Do RMC-related community interventions improve perinatal outcomes? (deploying Lady Health or Community Health Workers) | Clustered RCT | Medical model WHO and MDG focus |
Does strengthening one or more domains of RMC affect perinatal outcomes? | Correlational Retrospective descriptive Self-administered surveys | Medical model Public health models |
Qualitative | ||
What do providers and families identify as important to quality, satisfying maternity care and desirable healthcare work environment? | Exploratory | Critical Human Rights, reproductive rights |
Compare client’s lived experience of respectful versus disrespectful care | Phenomenological hermeneutics with semi-structured interviews | Human rights Childbirth Rights Critical Social Theory |
Describe the work-life experience of the healthcare workers when disrespect and abuse are occurring. Describe the lived experience of vulnerable groups when disrespect, abuse or RMC occurs. | Focus groups | Resilience theory |
What are the barriers to provision of RMC and what are the recommendations of midwives for improving care quality? | Individual and focus group interviews | RMC Feminist version of post-structural interactionism |
Mixed Methods | ||
What types of abuse occur? Which providers perpetrate abuse? (MD, RN, RM, resident, staff MD, student midwife) What are their number of years of professional training, years of practice, amount of RMC training? | Institutional/rapid Assessment (including 2-person expert observations, surveys, focus groups, semi-structured individual interviews of staff and patients, facility check-lists based upon national professional standards and WHO standards, facility statistics MMR, IMR) | RMC Human rights Childbirth rights |
The work-life of the midwife
Leadership and change
Social or Clinical Innovations Recommended | Organization who has Recommended These Interventions |
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Open maternity days or open houses | Population Council |
Provider debriefing and psychosocial support | Population Council |
Redevelop partograph | WRA adaptation as an RMC eval tool, UNFPA recommended modifications, Jhpiego e-partograph (https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-018-1760-y) |
Mediation program | Population Council |
Respectful Maternity Care training workshop | WRA Population Council TAMA/CAM/Jhpiego partnership |
Health Facility Management Board or Multidisciplinary Stakeholders group (politicians, business, legal council, writers, journalists) | Population Council Midwives in TAMA RMC Workshops |
Elders meetings and community engagement strategies (teas) | Midwives in TAMA RMC Workshops |
Emergency Skills Workshops infused with RMC PBL | Midwives in TAMA RMC Workshops |
Mediators appointed from laws school students, retired lawyers, social workers | Midwives in TAMA RMC Workshops |
Anteroom outside of delivery room where families may verbally provide ongoing support to birthing/laboring mother | CEPBU Community Health Centres, Burundi http://fr.allafrica.com/stories/200703020713.html |
Educate more mother/family friendly allies and champion in the professional community | NGO “Save the Mothers” founded an interdisciplinary Master of Public Health Leadership in Uganda. https://www.savethemothers.org/what-we-do/degree-program/ |