Demographic Features of Participants
The midwives were on average 33 years old, with a range of 31-48 years. They had engaged in professional practice for an average of eight years. Seven participants obtained a bachelor’s degree in midwifery and the remaining a diploma. Only one of the midwives was a Muslim, and the others were Christians. Eleven were currently married. Those with children (n=10) had an average of 2.3 living children (range = 1-3).
Views of the midwives were sought on disrespect and abusive care (D&AC) and the occurrence in their professional practice. Three main themes emerged from the data: (1) description of D&AC, (2) facilitators of D&AC, and (3) prevalence of D&AC. The themes also had sub-themes as presented in table 1.
Table 1: Themes and Subthemes
Description of D&AC
1. Providing inadequate care and overlooking patient-centred care
2. Forms of Abuse (verbal, psychological, and physical)
Facilitators of D&AC
1. Socio-economic inequality
2. Provider perception and victim blaming childbearing women/
3. Health systems related facilitators
Prevalence of D&AC
1. Prevalence of D&AC
Description of Disrespect and Abusive Care
All the midwives were aware of D&AC, and their descriptions of D&AC are categorized as providing inadequate care & violation of patient-centred care, and forms of abuse (verbal, psychological, and physical). Also, their views on the prevalence of D&AC are presented.
Providing inadequate care & violation of patient-centred care
The midwives believed that providing suboptimal maternity care and overlooking childbearing women’s unique experiences during labour constitute D&AC. According to them, suboptimal maternity care is comprised of unconsented care, discriminatory care, and disrespecting childbearing women’s rights of confidentiality and anonymity. The midwives mostly offered practical examples to demonstrate their knowledge of D&AC. This is evident in the quotes below:
Maybe you have two (2) clients on the ward. From their appearance, or from the type of people who come around them, you could tell one is from a wealthy family and the other from a poor background or something, and all attention is on the wealthy person. Meanwhile, the second client also needs your attention. …That is, can the patient afford treatment, care, and all attention are diverted towards that person and you look down on the person who is not able to afford much… erm, not giving the right care or the needed care. I will say that one is abuse…. [Midwife 003].
Some people [health workers] won’t even ask for your concern when they are going to give you an injection, she won’t even ensure privacy, just turn your buttocks this way Madam, and then she injects you…There are instances where a midwife knows the name of the patient, or even if you’ve forgotten, the midwife can call the patient by the bed number, example ‘bed one’, but call the patient by their disease, example AIDS patient or TB patient lying there…Well, these can cause the patient to be so stigmatized beyond being human. Or, someone may be abjectly poor. Some people look at how a person looks like, being poor, whether the patient gets visitors or not, as a criterion when talking to them and these can lead to them being treated badly. It makes some patients feel bad and depressed. [Midwife 004].
Further, the midwives offered their views on what constitutes a violation of patient-centred care. They stated that providers were in violation of patient-centred care when midwives act in ways toward the women who do not meet their expectation for perceived “acceptable” behaviour during labour. Examples of the views of the midwives are presented as follows:
You would say, ‘why are you…screaming? This one [childbearing woman] is not screaming, so why are you doing that? [Midwife 001].
You know, someone may be a nullip, never delivered before, but can endure pain. Others cannot endure much pain. So, you can never compare that ‘Look at your sister lying there quietly, and you are here shouting your voice hoarse’. [Midwife 008].
Forms of Abuse—verbal, physical, and psychological
The midwives were asked to mention and explain behaviours they would generally define as D&AC. Their explanations revealed that they were aware of what constituted verbal, psychological, and physical abuse in maternity care, and some revealed that these behaviours are actually occurring at the facility. The midwives reported that insulting and shouting at childbearing women are examples of verbal abuse. Also, the midwives acknowledged that confining and ignoring childbearing women are forms of D&AC. The midwives noted that physical abuse is comprised of slapping, beating, kicking, and hitting of childbearing women. The following are the expressed views of the midwives.
And with the verbal, that is where midwives falter a lot; when we talk, we don’t think of the impact it has on the patient, but sometimes we talk anyhow to the patient. And sometimes people, some people are more hurt with words. Some people don’t care, but some people are more hurt with words as compared to maybe the physical one. [Midwife 002].
I know of physical abuse, psychological, verbal, erm…Yeah. It starts with the verbal abuse whereby you are talking harshly with the patient or insulting the patient and their relatives. Yes. And with the physical, it can go to the extent of maybe hitting the patient. [Midwife 007].
Socioeconomic inequality facilitators
The findings indicated that socioeconomic inequalities facilitate D&AC. It emerged that the following marginalized groups were at high risk for D&AC: the non-compliant, mentally ill, HIV/AIDs+, teenagers, poor, and the general labour ward childbearing women. Childbearing women in the general labour ward were often disrespected and abused compared to their counterparts in the special ward. Special ward childbearing women pay for their services, whereas childbearing women admitted into the general labour ward most often use national health insurance to access maternity care. Regarding the neglect of or refusal to provide care to a childbearing woman who was HIV+, this midwife shared the following experience:
It is because the mother is infected with HIV that is the reason why my colleagues didn’t want to treat her... [Midwife 008].
Another midwife reported that a mentally ill postnatal woman was neglected by a midwife colleague:
That one had to deal with a mentally ill patient. We had to force to clean her and fix the baby to breast…Force to clean [her because] she wouldn’t clean herself and I think she had CS done… And because she had the [mental illness] condition, like the attention wasn’t given so sort of she was rejected and now she was [left alone] there. [Midwife 003].
Some midwives noted that poor postnatal women were often detained in a room, and they were only released after clearing their debts. These are their reports:
We have a sideward like this that all the discharges who were not able to pay, whether you were a hundred or fifty [childbearing women], you will all be [detained] in this room. [Midwife 007].
Oh, we have security at the post, I don’t think they will allow you when you have cannula, or when you have the white cap. They won’t allow them to go out. They monitor them, like when they are going to the washroom, they will just abscond. [Midwife 009].
Regarding the disparity in treatments of the special ward and general ward childbearing women, this midwife had the following to say:
You know when it comes to the special ward, most of the clients are difficult but those of us working here, you have to have patience…we exercise a lot of patience for these patients, for if you do not exercise restraint, some of them can cause trouble for you…those of us at the special ward do not encounter such problems [D&AC] because that is what we habitually do, but once one of us is transferred to the main ward and she starts exhibiting such care [respectful maternal care], the other staff will be talking behind your back, ‘it won’t take long for her to abandon her nice attitude. She is only doing this because she came from the special ward. Every turn, she says to clients, please, please, please. Every statement begins with a ‘please.’ Just wait, the nice attitude will vanish in a minute’…Yeah. The staff will be talking about you. So, if you don’t know what you are about, eventually, you will copy their attitude towards patients. [Midwife 008].
Some midwives noted that teenage childbearing women were often mistreated compared to adults. Their experiences were reported as follows:
Oh, (chuckling) the students were here so this one [midwife] will say something, and the other [midwife] will chip in “you, such a young girl, you are morally spoilt and got yourself pregnant. Now, [when we ask you to] lie down and let us deliver the baby, you won’t. So, what do you expect us to do to you right now? [Midwife 011].
Thirteen, fourteen, fifteen [years old girl], you are supposed to be in school, so what happened? And when they come and they start complaining ‘it’s painful, it’s this, it’s this’, if you had waited for a little you would have known that this is all. Didn’t you know that labour was painful, and you went to do this at this age? So, caring for an older person and the younger one, the respect that is given to the older client is different from the younger one. [Midwife 012].
Provider Perception and Blaming of Childbearing Women
Some midwives expect that childbearing women will come to the hospital neatly dressed and with the necessary delivery kit, be calm, lay on the bed, and comply with staff’s instructions. Also, some midwives believed that childbearing women are difficult to deal with and some intentionally act in provocative ways. From the views of the midwives, it is evident that such beliefs about childbearing women have compelled the midwives to act in unprofessional ways that disrespected and abused childbearing women.
As human as we are, we are very difficult. So, sometimes, in making a decision and achieving your aim, you would have to force something on the patient. So, sometimes for the betterment of all, we do [apply] force on patients. [Midwife 003].
If it comes to the attention that you are just a petty trader in the market, to put it mildly, some of these petty traders are not exceptionally neat, not their fault but a lot are unkempt. So, when they are coming to labour, instead of taking a bath, shave, do the necessary little stuff that makes a woman presentable, she just picks a bag and presents herself to the ward. Sometimes, you open that bag and it is full of bed bugs. So, if you don’t hold yourself in check, you will get angry [and act unprofessionally]. [Midwife 008].
Some midwives believed that the misbehaviour of childbearing women during labour was a cause for their becoming victims of D&AC. The midwives recounted that childbearing women in labour hardly follow their instructions, and this act of disrespect sometimes compel them to act out D&AC.
The staff can sometimes look at the way someone [childbearing woman] will present herself and use that as a yardstick to respect her or not. But this can also create issues. But some of these patients are troublesome too, and that in turn cause some of the midwives to misbehave. [Midwife 008].
[The childbearing woman will be screaming] ‘My baby is coming!’ and you go, and you know, we are not supposed to do VE [Vagina Examination] repeatedly, sometimes we just allow you to part your legs and we see if there is any sign of the second stage. But you would go, she will call you, and there is nothing there. So even imagine, just imagine, you can’t just be going. When she calls you, you will not go because you know that as for this patient, with every contraction, she will call you. So, we just sit there …maybe [the childbearing woman is] around 4cm then she will be repeatedly calling you, you will be going and there is nothing there, when she calls, you just feel relaxed because you know that as for this woman that’s what she (does), every pain she will call. [Midwife 009].
Although these actions are non-evidence-based, some midwives believed that shouting, threatening, restraining, and hitting childbearing women during the active phase of labour can prevent neonatal and maternal death. This belief suggests that D&AC is internalized and normalized by these midwives.
In the second stage when the baby is crowning and the mother is expected to give it way, due to the pain, she may not even know what she is doing and might be closing her legs up and thus hurting the baby. In such a situation, you may involuntarily hit her on the thighs and shout ‘open up!’ (Laughing at the recollections) …As for that one, we frequently do that. Sometimes it happens. It is not always the case though. Here, we have a belt that we use to strap the legs to the bedposts, so you can’t close your legs. In the absence of such devices and an expectant mother closes her legs, you can be distressed because she would be physically hurting the baby and a midwife may involuntarily hit the thighs and shout at her to open the legs wide. [Midwife 004].
[At the] labour ward for instance, if a person [the childbearing woman] is in the second stage, and you tend to say let me leave the patient to do whatever she wants to do until the baby comes, then you are not helping the woman and the baby as well because the baby may come out being asphyxiated. When they get to the second stage, they tend to be somehow tired, not being able to push. But if maybe you use some little force, the woman will tend to push and then you will have the baby and the mother is OK but if you leave the woman like that, she will just relax and then you may end up having an asphyxiated baby. So, in situations like that, we tend to be harsh on them for them to push. [Midwife 008].
Health Systems Related Facilitators
The health systems related facilitators cut across human resource management, policy guidelines, and the architectural structure of the hospital. The midwives mentioned that job distress resulting from unrealistic staff-to-childbearing women ratio, lithotomy-only-birthing position guidelines, incompatibility of the hospital rooms to accommodate alternative birthing positions, and hospital policy on poor childbearing women are drivers of D&AC.
Regarding job distress, the midwives’ responses suggest that pressure from work sometimes put them in situations to act in an unprofessional manner. Some of them noted that the current staff-to-childbearing women ratio of 4 midwives to 30 childbearing women put unbearable pressure on them [midwives].
We have on this ward, this night, thirty-three patients to four midwives, some [childbearing women] are in labour, some are eclamptic, some are having respiratory distress, and then you have the pressure, you feel the pressure, so sometimes you would react in a way which you are not supposed to, because of that pressure that is mounting on you, you might act in a weird way which you are not supposed to…sometimes, too, you would not mind the patient [ignore the childbearing woman]. [Midwife 001].
The midwives too, we are few. Because sometimes on night duty, we have a lot of patients, and once somebody is delivering, even after the procedure itself, the documentation is another thing. And you also have to do it in as much as you have to look at the others who are in the first stage. And we are few. At most, we are four (4), four or five (5) and you can’t give the care you are supposed to give, you are tired. Not that you can’t even, but you are tired. You do a delivery, do suture, documentation, go to the next person, so we, sometimes all the four people are occupied in the four second stage beds and patients are left there alone, they are shouting; they can’t see any midwife so they will be shouting because they think we have left them alone. [Midwife 013].
It was clear that childbearing women’s birthing position was limited to the orthodox lithotomy position. According to the midwives, childbearing women preferred the squatting birthing position. However, the midwives had countless reasons for not acquiescing to childbearing women’s preference, which included the inconvenience of assisting childbearing women’s in a squatting position, hospital protocol, and the unhygienic conditions of the floor in the ward.
She told me the baby is coming, so I told her to lie on the floor because if she stands, the baby can hit the floor. So, I told her to lie on the floor. But this lady didn’t do it but rather, how do I do it, but rather, I don’t even know how to say it, she squatted or something and in Ghana here, or in this hospital, the patient, you are supposed to lie on your back. So, she was squatting. I told her to lie on the back. And she was like ‘no, this is what I want’. And I told her ‘you can’t do this to deliver, please, lie on your back’. So, I held her hand and I turned her to lie on her back, but this woman refused to open the thigh for me to even do the delivery. [Midwife 010].
One midwife indicated that she delivered in a squatting position contrary to the norm. Having experienced the ease associated with squatting during delivery, she attempted advocating for it as an alternative position, but her attempt was rejected by colleagues. When she was asked whether she was satisfied with her midwifery role, she hinted that she would be satisfied if childbearing women were permitted to deliver by squatting, and she reported the labour ward was the problem because it wasn’t designed with squatting in mind. Her experiences are presented as follows:
I am not really satisfied, especially with the birthing position. It would have been easier if patients had the option of squatting [during delivery] …the delivery couch has been shaped in a certain way that you have to lie down, on your back, and it is not easy… One time, I was talking with my colleagues about it [the squatting position], and one doctor [reproachfully] responded that ‘even delivery couch, you are not getting it, and you want to deliver in that position?’ [Midwife 002].
One midwife noted that though they wished they could provide good care to childbearing women, they were unable to due to certain hospital protocols on providing care for poor childbearing women.
In a way, we want to help, …because of, let’s say, the hospital protocol and other things, maybe what you want to do to help a client, you intend to do things according to protocol. So if a client is unable to pay the bills and the hospital protocol is asking you to maybe let the person lie on the floor, put a mattress on the floor and let the person lie down, you have no option than to do what you’ve been asked to do. [Midwife 008].
Another midwife noted that the delivery bed was occupied at the time another woman had need of it, which made it difficult for her to attend to many childbearing women in the second stage at the same time. This, she noted, prevented her from providing the needed care for one childbearing woman. This is what she said:
I nursed a patient. When she was fully dilated and then she was calling, I was attending to someone, so I was like, ‘I am coming,’ and then when I went, the baby was out. So, I just had to assist her, cut the cord and then deliver the placenta. Then she had a tear… so, the patient said, ‘when I called you, you paid no heed, when I called you, you ignored me’…It was really hurting, [so I said] I am sorry. Here [this hospital], we have only one couch. So we manage them and we monitor them at the first stage of labour on the ward and then when they are full, we bring them here [to the couch]…We have only one delivery bed…she didn’t know because the ward extends to that far end [showing the width of the ward], so sometimes you are at the last cubicle and someone is calling from the first cubicle. [Midwife 001].
Prevalence of D&AC
The midwives noted that D&AC is a prevailing phenomenon at their facility. The midwives indicated that they either were a first-hand witness of colleagues acting out D&AC or they personally have been the perpetrators. Neglecting, shouting, restraining, and hitting childbearing women were forms of abuses meted out to childbearing women in labour. In some instances, midwives have interpreted a woman’s pain or distress as aggressive behaviours. It is worth mentioning that the midwives have very positive, life-saving intentions even when exhibiting these abusive behaviours. The following responses of midwives elucidate the foregoing point:
I have done [hit] it on several occasions but when I finish and the baby come(s) out, (Laughing), [I say] Madam, I am sorry for hitting you, I wouldn’t have hit you but you would have killed your baby]. [Midwife 002].
…I hit in-between the thighs ‘open up!’, aha, that’s the only time I hit a patient, and it is not hitting, deliberately hitting a patient…Sometimes, you would have to tie those who are aggressive, yes, you would have to tie them to the bed. [Midwife 003].
Oh, it happens all the time. The hitting, it is an everyday occurrence…even you [the interviewer], they [midwives] will insult you when you come here. Who are you? [Midwife 008].
Other participants indicated that they were disrespected and abused by their fellow midwives when they were in labour at the facility.
During my labour, the midwife insulted me, my junior. [Midwife 002].
Even I myself, when I went into labour, I was beaten. They hit my thighs multiple times. [Midwife 008].