Disrespect and Abuse During Facility-Based Childbirth in Ethiopia: A Mixed-Methods Study

Abstract

Disrespect and abuse of women during facility-based childbirth is a violation of human rights and an indicator of poor quality of care. Disrespect and abuse have been identified as deterrents for women attending facility-based childbirth in developing nations; however, this barrier is poorly understood in the Ethiopian context. Thus, this project aimed to investigate the prevalence of disrespect and abuse, and women’s and care providers’ perspectives on disrespect and abuse, during facility-based childbirth in Ethiopia. This thesis comprises four iterative and interconnected studies. In study 1, a community-based cross-sectional survey was conducted to quantify the frequency and categories of disrespect and abuse. Women who had given birth at a public health facility within the previous twelve months were recruited via health extension workers. All 435 participants reported at least one form of disrespect and abuse during childbirth. The types of disrespect and abuse were physical abuse, non-consented care, non-confidential care, abandonment/neglect, non-dignified care, discriminatory care and detention. Hospital birth, rural residence, monthly household income less than 1,644 Birr (USD 57) and being attended by female providers and midwives were positively associated with experiences of disrespect and abuse. In study 2, qualitative in-depth interviews and focus group discussions were employed to collect data. The participants were 50 women who had given birth at a public health facility within the previous twelve months. The participants were invited to reflect on the acceptability of hypothetical scenarios about mistreatment during childbirth, rather than being asked to disclose personal experiences of mistreatment. While the women rejected disrespectful and abusive acts during childbirth generally, they considered some acts acceptable or necessary under certain circumstances. Four themes were identified: (1) disrespect and abuse is not acceptable, (2) disrespectful and abusive actions are only acceptable if intended to save lives, (3) disrespectful and abusive actions are an accepted part of everyday practice to prevent complications and adverse outcomes, and (4) disrespectful and abusive actions are necessary to discipline disobedient women. In study 3, a testimony of a 28-year-old mother of two children, narrated in her own words, was used with her permission to form a case study. Five themes emerged from her narrative: denial of care; non-consented care; non-dignified care; taking a sick baby home without medical assistance; and loss of trust in care providers. In study 4, qualitative in-depth interviews were used to collect data from 15 care providers (midwives, nurses, general practitioners and obstetricians) from selected health facilities with direct involvement in the care of women during pregnancy and labour. The care providers revealed that women are being subjected to disrespect and abusive treatment during childbirth. While the care providers generally considered disrespectful and abusive acts during childbirth unacceptable, they tended to consider some acts acceptable and a few necessary under certain circumstances. Four themes were identified: 1) disrespect and abuse breaches professional standards, 2) disrespectful and abusive actions are justified at times to save the mother and her baby, 3) disrespect and abuse is used as a tool to assert power, and 4) disrespect and abuse arise from health system deficiencies. Conclusion: According to the accounts of the participants, the application of respectful care in everyday maternity practice in Ethiopia is insufficient. The findings highlight the urgent need for policy and practice interventions to address the issue, such as empowering women through education to reinforce their right to respectful care. It reflects the need for health professionals to be educated and trained on the importance of providing respectful care and how such care can be incorporated into daily practice. The underlying gender-related issues suggest the importance of interventions at a broader socio-political and community level, such as educating all adults about their right to respectful care and empowering them to report disrespectful practices.