Keywords

Abusive maternal care; Associated factors; Women; Ethiopia

Abbreviations

ANC: Antenatal Care; AOR: Adjusted Odds Ratio; CI: Confidence Interval; FIGO: Federation of international Gynaecology and obstetrics; SPSS: Statistical Package for the Social Sciences; WHO: World Health Organization

Introduction

On 9 January 2020, the World Health Organization (WHO) officially announced the discovery of a novel coronavirus, SARSCov2 which is recognized as highly pathogenic viral strains responsible for infectious respiratory disease (COVID-19) which affect including the health care system [1].

In the globe, around 303,000 women die annually of these 201,000 deaths were from Sub-Saharan Africa [2]. In Ethiopia, maternal mortality and morbidity levels are among the highest in the world which was 412 per 1, 00,000 live births in 2016 [3].

Even though skilled birth attendance during childbirth and immediate postpartum care can prevent 75% of maternal mortality only 26% of women deliver their baby at health institutions [4].

Abusive care is a comprehensive term that is expressed in the form of physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination based on specific patient attributes, abandonment of care, and detention in facilities [5].

This respectful maternity care is a universal right of every woman which is chartered at different times and compiled by in White ribbon alliance in 2011 [6].

Enhancing institutional delivery coverage is a primary action to tackle maternal mortality, but abusive maternal care during childbirth decreases women’s intention on institutional delivery [5]. Skilled birth attendance during childbirth and immediate postpartum care can prevent 75% of maternal mortality but women are not willing to deliver in the health institutions due to ignorance of their sensitive issues by health professionals and the care given in the health institution is not psychological supportive of what they need [4,7].

Most countries affected by the pandemic were able to slow down the spread of the coronavirus with varying degrees of success, like banning public events and gatherings, workplace closures, stayat- home restrictions, restrictions on domestic and international transport, and shutting some health care services [8].

In South Africa, women are not volunteers to attend their pregnancy follow up at the health institution because midwives were so rude and would only go when in labour [9]. Nigerian women also do not utilize maternal health care at health institutions due to prior uncomfortable health service experiences or the fear of being humiliated by the health care Staff [10].

A study conducted in Kenya revealed that the prevalence of any abusive care facing the women during service utilization was 20% [11] which was 78.6% at governmental health institutions Addis Ababa Ethiopia [12].

Although abusive care during childbirth is not only threatened their rights to life, health, bodily integrity, freedom from discrimination but also deny institutional delivery preference of the women. Therefore, this study aimed to assess the level of abusive maternal care and associated factors during childbirth in North Wollo Hospitals, Northeast Ethiopia.

Methods

Study settings

An institution-based cross-sectional study was conducted in North Wollo governmental hospitals from June 20 to August 30, 2020. Even though there were five governmental hospitals in North Wollo, Ethiopia, two hospitals were taken as a study institution. The study was conducted at Woldia general hospital and Lalibela primary hospital. The study population was women who gave birth in selected hospitals in the study period. Women with postpartum psychiatric problems and women who referred for complication management after they gave birth in the other health institution were excluded.

Sample size determination and sampling procedure

The sample size was determined by using a single population proportion formula with the following assumptions, Proportion of abusive care in Addis Ababa governmental hospital was 81.8% [12], marginal error (4%), and considering 10% for non-response rate. Therefore the final sample size was 394.

Sampling procedure

A stratified systematic random sampling technique was applied. The sample was proportionally allocated to the hospitals based on the patient flow rate of the delivery ward in one month period before the actual data collection period (Figure 1).

Figure 1: Sampling procedure.

Operational definitions

Abusive maternal care: if the score of abusive maternal care assessing questions is greater than the mean score (21.12) the study considered the mother faced abusive care.

Data collection tools and procedure

Data were collected from women who gave birth in respective hospitals immediately at the time of discharge through the exit interview. The questionnaire has three parts, the first sociodemographic characteristics, obstetric history, and abusive maternal care assessing parts (seven performance indicators and thirty-one verification criteria). To assess women’s abusive care during childbirth the questionnaire was adopted from White Ribbon Alliance, Federation of international gynaecology and obstetrics and Maternal and Child Health Integrated Program standards of respectful maternity care tool kit. The organization listed above has prepared using seven performance standards and their respective verification criteria.

The seven performance standards are physical abuse, nonconsented care, non-confidential care, non-dignified care (including verbal abuse), discrimination based on specific attributes, abandonment or denial of care, and detention in facilities [13]. Six female data collectors who are not working in the respective hospitals were recruited to collect the data.

Data quality assurance

The questionnaire was prepared in English first then it was translated to the Amharic language by language professionals and translated back to English to maintain consistency. A pretest was conducted at Woldia health center before two weeks of actual data collection period in 5% of the sample size. The data collector was given training and supervision were done daily to check the completeness of the questionnaire and to evaluate daily activities.

Data processing and analyses

The data were checked for completeness after data collection and entered into Epi Data version 3.1 and analysed by using SPSS version 23. Descriptive statistics were used to present the data. The question has a binary response (yes/no). "Yes" scored as "1" and "No" is scored as "0". Bivariate and multivariable logistic regression analysis was carried out. Model fitness was assured.

Results

Socio-demographic characteristics

A total of 382 respondents were interviewed with a non-response rate of 3% (12 discontinued the survey). The majority of study participants were in the age range of 20-34 years (Table 1).

Table 1: Socio-demographic characteristics of childbearing women in Northeast Ethiopia, 2020(n=382).

Obstetric characteristics

Regarding the previous history of institutional delivery, only 50% of them were delivered at the health institution 200 (52%) of women attending ANC in their previous pregnancy (Table 2).

Table 2: Obstetric characteristics of childbearing women in Northeast Ethiopia, 2020(n=382).

Level of abusive maternal care among childbearing women

The assessment of abusive maternal care was addressed through the white ribbon alliance declaration rights of childbearing women. This white ribbon alliance declaration has seven performance indicators. Generally, all most all mothers (99.2%) were suffered from at least one abusive care from thirty-one verification criteria. By using mean as cut off point the level of abusive care among childbearing women was 47.1%.

About 97.3% of women were suffered from at least one physical abuse component. A woman abused from physical force (slapping, aggressiveness, and beating) was 90.8%. Respect for women receiving care according to culture 90.1% was not treated accordingly. The prevalence of non-consented care was 98.6% (that means they receive a minimum of one no consented care from the components). From all participants, 65.2%were greeted by the health care provider, and only 27.7% were introduced by the health care provider. Of the total study participants, 96.6% of women receive non-confidential care. Of the total 86.1% of the client’s information was protected from being transferred to others. Only 49.5% were gain drape to cover the lower part of the abdomen during diagnosis by the health care provider.

The overall prevalence of non-dignified care was 99% (that means they receive a minimum of one non-dignified care). From the total participants, only 18% of women were encouraged to practice cultural activities like (praying, reading spiritual books, and holly pictures). Of the total women, 98.7% of women were discriminated during childbirth. Among the total 96.6% of health care providers were communicating to the women in a language that she understands. An additional 84.6% of health care providers didn't show any disrespect to what she responds. The prevalence of abandonment of care during childbirth was 97.4%. Almost all mothers receive essential basic care for women. Around 80% of women were well informed by a health care provider to call when they want and 86.4% of women were not left alone in the delivery room. The overall prevalence of detained care during childbirth in hospitals was 4.5%. More than 97% were not detaining against their will and due to a lack of payment (Table 3).

Table 3: Level abusive maternal care childbearing women Northeast Ethiopia, 2020 (n=382).

Factors associated with abusive care

In multivariable logistic regression analyses women who attend their childbirth at a general hospital, women who have antenatal care, and the number of birth attendants were significant association with abusive maternal care.

Women who attended their childbirth at general hospital 87% (AOR=0.13, 95% CI: 0.06, 0.26) decreases the odds of abusive maternal care as compared to the primary hospital. Women who had no antenatal care 2.08 times (AOR=2.08, 95% CI: 1.27, 3.39) higher the odds of abusive maternal care as compared to have ANC follow up.

Women attended by one health care provider (AOR=0.29, 95% CI: 0.1, 0.84) decreases the likelihood of abusive maternal care by 71% as compared to a woman attended by more than three health care providers. Receiving abusive maternal care among women attended by two health care providers lowered by 44% as compared to a woman attended by more than three health care providers (AOR=0.56, 95% CI: 0.35,0.92) (Table 4).

Table 4: Multivariable regression table factor associated with abusive care during childbirth Northeast Ethiopia, 2020(n=382) Hosmer Lemeshow: P-value=0.742 1 =reference category Backward LR method was applied.

Discussion

The level of abusive care in this study was 47.1% (95% CI 42.1- 52.6). This finding is similar to a systemic review done on the mistreatment of women during childbirth in health facilities globally [14]. The finding of this study is lower than the study done in Addis Ababa which might be due to the study was implemented from the health care providers unlike this study [15].

Among the study participants, about 97.4% of women were suffered from at least one physically abuse(physical force or abrasive behaviour, not treated according to her culture, abandoning of body movement during labour, denied to drink and to eat food during labour, didn't get pain relief activity and unnecessary separation between child and mother) which is higher than research conducted in Addis Ababa with a prevalence of physical abuse 2.3% [16] and 35.7% in Kenya [17]. This difference may result from socio-demographic variations among study participants.

Another study conducted in six countries of Africa (Ethiopia, Kenya, Zanzibar, Rwanda, Madagascar, and Tanzania) through observation technique to assess abusive maternity care; the observer report applying episiotomy for all prime-gravida women were a routine practice in Ethiopia health facility which harm women's physically but this is not a common problem in the current study [18].

Regarding non-consented care, 98.6% have received a minimum of one no consented care this is supported by other researchers [19,20]. This figure is much greater than the study conducted in Tanzania [21]. From the components 41.3% of women were denied position preference during childbirth; this figure is much higher than a study conducted in Addis Ababa with a proportion of 29% [22]. The variation might be the current study apply exit interview the latter one conducted through direct observation; collecting data by direct observation gives more reliable data.

From all study participants 96.6%, 99%, 98.7%, 99.4% of women receive non-confidential, discriminated, and abandonment care respectively. This is also mentioned in other studies conducted elsewhere [22-25,20,17]. Confidentiality is mandatory and if it is not corrected early, it leads to a crisis in health care delivery.

From the total participants, only 18% of women were encouraged to practice cultural activities like (praying, reading spiritual books and holly picture), which shows there is a restriction on women to express their feelings in the health institution this may result in spiritual stress, loneliness and complicate the outcome of labour. This is strongly evidenced by the obstetric care navigation approach: disrespectful care was highly experienced when cultural and contextual differences between indigenous patients and non-indigenous providers present [26].

The overall prevalence of detained care during childbirth in hospitals was 4.5%, this is lower than a study conducted in Nigeria [17], In other study conducted in Addis Ababa reported that women's are free of detention care [20]. This is due to the declaration of giving payment free service in the maternity ward by the Ethiopian government health policy.

Women who attend their childbirth at general hospitals decrease the occurrence of abusive maternal care as compared to a primary hospital which may be due to the standard difference among hospitals and the number of health professionals with many speciality may available in the general hospitals than primary hospitals.

Women who had no ANC follow up previously increase the occurrence of abusive maternal care as compared to those who had previous ANC follow-ups. Mothers who have ANC follow up may develop friendly relationship with the health care providers which make their delivery time easy and respectful.

Women attended her delivery by one or two health care providers’ decreases the likelihood of abusive maternal care as compared to a woman attended by more than three health care providers. The possible reason may be as the number of birth attendants increases the client's privacy, information, confidentiality will have no guarantee, and this increases the occurrence of abusive maternal care during childbirth.

Social desirability bias is one of the limitations of this study since women may report more acceptable response. The questionnaire also does not address misleading medical procedures (aseptic technique, medical error, maleficence). This study did not establish cause and effect relationship between independent and outcome variable due to the limitation of cross-sectional study design.

Conclusion

The level of abusive maternal care in the health institutions was high as compared to different international declarations which affect women’s willingness to attend their childbirth in the health facility which is directly related with the impact of CVID- 19. Women who attend their childbirth at general hospitals, having antenatal care visits, and the number of birth attendants were significantly associated with abusive maternal care. The interventions better to focus on increasing pregnant women’s ANC follow up. Health institutions also better increase the number of skilled birth attendants to address women’s concerns during childbirth.

Declarations

Ethical considerations

Ethical clearance was obtained from Woldia University ethical clearance committee. A formal letter was given to the selected health institutions from the school of public health. Moreover, informed verbal consent was obtained from each respondent since our study participants are not literate and they informed their right to withdraw from the study at any time. Confidentiality and privacy of participants were secured by omitting any identifier.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interest

The authors declare that they have no competing interests.

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