Respectful maternity care and associated factors among women who delivered at Harar hospitals, eastern Ethiopia: a cross-sectional study

A facility-based cross-sectional study was conducted from April 01 to July 01, 2017, at Harar town hospitals, Eastern Ethiopia. Harar is found 526 km away from Addis Ababa, the capital city of Ethiopia. In view of the 2007 Census projection, the all out populace of the Harari region was 232,000, of which female records 115,230 [29]. Harar town had 19 kebeles (most minimal regulatory unit) separated into six districts. In the town, there were seven hospitals (2 open, 2 private, 1 Nongovernmental (NGO) and 2 different hospitals), 8 health centers and 26 health posts. The antenatal care (ANC), health facility delivery and SBA coverage of the Region reach 75.9, 50.2, and 51.2% respectively [2].

Women who visited the nominated Harar hospitals for labor and delivery throughout the information assortment period were included. Women who were fundamentally sick, and unfit to impart were excluded from the study.

A single population proportion formula was used, to determine the minimum adequate sample for this study, with the following assumptions: P = 0.214 (proportion of women who received respectful and abusive free care in Addis Ababa) [7], 95% degree of certainty, 4% margin of error and 5% contingency. In view of the above suppositions, the final sample size was 425. Four out of seven hospitals were chosen (i.e. Hiwot Fana Specialized University Hospital (HFSUH), Jugal, Yemage and Harar General hospital) purposively dependent on administration arrangement to people in general and arrangement of essential obstetrics and infant care. At that point, the sample was apportioned relatively to every hospital by investigating the number of deliveries in the earlier year. The information was gathered from every other postnatal woman until the anticipated sample was accomplished.

A pretested and organized questionnaire was sorted out from previous literature. The instrument was first arranged in English and converted into nearby dialects (i.e. Amharic and Afaan Oromo) and back to English by free language specialists. The tool incorporates socio-demographic and obstetric characteristics, companion during labor, length of hospital stay, and RMC assessment items. The Maternal and Child Health Integrated Program (MCHIP) developed 23 items in seven categories of D&A as part of the RMC tool kit [30]. However, this tool is not validated in the context of developing countries including Ethiopia. Hence, the level of RMC was assessed using 15 validated items in the Ethiopian context. The tool had four categories with verification items (i.e. friendly care by 7 items, abusive free care using 3 items, timely care using 2 and discrimination-free care using 3 items). The items have a good internal correlation (Cronbach’s alpha (α) of 0.857) and adequate reliability (α = 0.845) [31]. In addition, the tool was pretested on 5% of the sample and alteration was done preceding the beginning of the genuine information assortment.

Four qualified diploma birthing assistance experts who were conversant in local dialects and didn’t work in the investigation settings were enlisted for information assortment. The information assortment was directed in an institution based discharge interview using an organized questionnaire regulated poll. Women who satisfy the consideration criteria and ready to partake were met in a private setting after discharge from the postnatal ward. Supervision was carried out on a daily basis throughout the study period.

Respectful maternity care refers to care organized for and provided to all women in a manner that maintains their dignity, privacy, and confidentiality, ensures freedom from harm and mistreatment and enables informed choice and continuous support during labor and childbirth [32]. RMC, which is a composite variable of four constructs: friendly, abusive free, timely and discrimination-free care was the dependent variable. The level of RMC was assessed using a five-point Likert scale ([1] strongly disagree to [5] strongly agree) questionnaires. The overall cutoff-point for RMC was determined based on previous studies and those participants who encountered D&A for at least one of the 15 items were categorized as “disrespected” [7]. The socio-demographic and obstetric characteristics, companion during labor, and length of hospital stay were the independent variables for this study.

The instrument was pretested on 20 postnatal women at HFSUH one month preceding the actual information assortment. A 2-days preparation covering both hypothetical and commonsense parts of information assortment was held. Close supervision was done consistently all through the investigation time frame. Double data entry was done on 5% of the sample to guarantee the consistency of the entered information.

After checking completeness, the data were entered into EpiData version 3.1 statistical software. Then, the data were exported to SPSS version 22.0 for cleaning and analysis. During analysis, the reactions of ‘strongly agree’ and ‘agree’ were classified as “Yes” (received RMC) and reactions of ‘strongly disagree’, ‘disagree’ and ‘neutral’ as “No” (disrespected and abused) for positive statements. Those contrarily articulated statements were categorized in the turnaround heading as “strongly disagree” and “disagree” categorized as “Yes” and the reaction of “neutral”, “agree” and “strongly agree” categorized as “No”. Descriptive summary measures such as frequency, percentages, mean and standard deviation were used to describe characteristics of the participants. Binary logistic regression was carried out to identify the factors associated with RMC. To control possible confounding factors, variables with a p-value of ≤0.25 in the bivariate analysis were taken to the multivariable analysis. Multicollinearity and model fitness was checked using standard error and Hosmer-Lemeshow test respectively. The adjusted odds ratio (AOR), with 95% confidence intervals (CI), was used to identify the independent variables associated with RMC. Statistical significance was declared at a P-value of < 0.05.

In this study, 425 women were involved, with a response rate of 100%. The mean (±SD) age of the participants was 27 (±6.0) years. Among the participants, 48% were within the age group of 25–34 years, 63.0% were Oromo by ethnicity, 80.9% were muslims, 98.6% were married and 79.3% were housewives. Of the participants, 39.5% were uneducated and 51.3% were from urban settings (Table 1).

More than two-thirds (68%) of women were multipara. Three hundred three (71%) of women had ANC follow-up for the current pregnancy; of them, 58% had four ANC visits and above. Of the participants, 38% came to the hospital through referral and pregnancy was planned for 89% of women. Labor was not attended by a companion for 79% of women and half (49.9%) of the participants were attended by female HCPs. Episiotomy was done for 32% of the participants. Among the participants, 53% were delivered through spontaneous vaginal delivery followed by instrument-assisted delivery (25%). Childbirth ends up without an impediment for 87% of the clients (Table 2). Of the participants, 82.4% were enthusiastic to recommend and visit the facility in the future (Fig. 1).

Overall, only 38.4% (95%; CI: 33.7, 42.0%) of the women received RMC. Among the participants, ~ 45% received discriminative free care (Fig. 2). Of the participants, 17.6% didn’t receive information about pain relief measures and 16.5% complained that HCPs did not show any concern and empathy. One-third (33.2%) of women reported that the HCPs did not respond to their needs. A significant number (14.8%) of women complained that some HCPs shouted at them during childbirth. Nearly, one-fifth (18.6%) were insulted due to the presence of a birth companion and personal attributes (Table 3).

After controlling confounding using multivariable analysis five variables: delivering at a private hospital, having ANC follow-up, planned pregnancy, labor attended by male providers, and normal maternal condition after delivery were significantly associated with RMC. The odds of RMC were 2 times [AOR: 2.3, 95% CI: 1.25, 4.07] higher among women who delivered at private hospitals as compared to women who delivered in public hospitals. The odds of RMC were almost 2 times [AOR: 1.8, 95% CI: 1.10, 3.20] higher among women who had ANC follow-up. Likewise, planned pregnancy increases the odds of RMC by three-fold [AOR: 2.9, 95% CI: 1.19, 6.92]. The odds of RMC were two times [AOR: 1.8, 95% CI: 1.14, 2.77] higher among women attended by male providers as compared to women whose labor attended by female providers. Moreover, the odds of RMC were 2 times [AOR: 2.3, 95% CI: 1.13, 4.83] higher among women whose childbirth process ends up without complications (Table 4).