Disrespect and abuse during facility-based childbirth is a global problem with varying degrees of severity and differing drivers in different contexts (36). It is often a greater problem in developing countries where inadequate number of care providers serve large proportion of clients (37). There is growing evidence in Ethiopia that women are experiencing disrespect and abuse in birthing facilities (38, 39). Thus, this study sought to quantify the frequency and categories of D&A and identify factors associated with reporting D&A among women in north showa zone of Ethiopia.
Respectful maternity care is a universal right of every childbearing women, however this study reveals that disrespect and abuse are common in health facilities. Every women who participated in this study has experienced at least one form of disrespect and abuse, and this rate is higher than for any other study. This disparity is attributed to the comprehensiveness of the current research which used 48 verification criteria for the seven categories of disrespect and abuse, whereas other studies used only 25 or less (21, 23–25, 27, 31, 33),which may have led to under reporting of disrespectful and abusive care. However, two studies from Arbaminch, Ethiopia and Enugu, Nigeria have reported almost similar rate 98.9% (32) and 98% (40) of D&A.
Physical abuse is the most prevailing category with 100% prevalence. From these, 413 (94.9%) women were not allowed to give birth in their preferred birthing position and for 381(87.6%) women an episiotomy was given or sutured without anesthesia. Whereas 34 (7.8%) and 12 (2.8%) participants were Pinched/kicked/slapped and hit with an instrument respectively. Other research from Ethiopia reported level of physical abuse that ranged from 2–75.2% (21, 23–25, 28, 30, 31, 33).
When interventions become necessary, service providers should provide the mother sufficient information in a language she can comprehend so that she can knowingly refuse or consent to the intervention (41). However, this study found that 97.2% of participating women reported non-consented care. This finding is higher than findings of previous research across all contexts (25, 31, 42). Best practice is that providers respect the privacy and confidentiality of every childbearing women during counseling, physical examinations, and clinical procedures, as well as in the handling of patients’ medical records and other personal information. However, two thirds of women who participated in this study had experienced a breach in confidentiality. Studies from other parts of the country have similarly revealed a high level of non-confidential care; common examples include the lack of privacy curtains and women not being appropriately covered during intimate examinations and/or labor and birth (21, 23, 31).
Every woman is a person of value and is worthy of respect. All words, actions, and non-verbal communication of providers must honor the dignity of each woman. Unfortunately, in this study, 29% of women reported non-dignified care. Previous studies have documented similar result elsewhere in Ethiopia (21, 23, 31, 33). Non-dignified care and insults may drive women away from healthcare facilities towards less trained providers who treat them with dignity and respect (40). Service providers must acknowledge that women have the right to be treated with respect and consideration. In this study, a number of women reported negative comments regarding their HIV seropositive status, age and literacy were 11.7%, 8.5% and 5.1% respectively.
Attentive care is the right of each client and a woman should never feel abandoned during labour or immediately after birth. However, our study demonstrates that 40% of participating women felt ignored/abandoned and 12.9% of women reported healthcare providers were not present when the baby was born. This finding is in line with a study conducted in the southwest of Ethiopia (31). Furthermore, women should be able to have a birth companion of their choice. However, more than half of the women in this study reported that this was disallowed. The mere presence of a birth companion can ensure respectful care (43) whereas restricting the presence of a birth companion is reported to be a significant barrier to humanized birth care (25, 44, 45). This suggests that health care providers know the way they behave in the absence of a companion is inappropriate and treat a client differently when a companion of the client is present (46).
Freedom from detention is the right of each childbearing woman and a woman or her baby should never be forcibly kept in a facility. Detention is the least reported category by participants, and this is similar to rates reported in other studies from Ethiopia (21, 23, 25, 29, 31–33) possibly because, maternity services are free of charge in Ethiopia and detention due to unaffordable service bills are rare. The economic status of women has been identified as a significant barrier to quality care. Unlike financially secure families, poor women are more likely to experience disrespectful birthing care (47). Similarly, women of low economic status were more likely to experience D&A in the current research. This indicates the prevailing social attitudes towards people from lower socioeconomic backgrounds. Studies from different contexts have also revealed likewise (25, 48).
Women who gave birth at hospitals reported higher level of D&A compared to those who gave birth at health centers. Hospitals generally belong to the secondary and tertiary levels in Ethiopian three-tier health care system. They serve as referral sites for health centers, which are primary level. Many women prefer hospitals over health centers as they are higher-level and are expected to give better quality of care (26). Increased client volume and insufficient staffing may impede the provision of respectful maternity care in hospitals (49). Previous studies have identified that working in under-equipped and overwrought health systems affects provider enthusiasm and is often labelled as significant contributor to D&A in facilities (50). Local studies have similarly reported higher incidence of D&A among women who gave birth at hospitals (21, 24, 25, 30, 32).
Women who were attended by midwives/nurses were more likely to experience disrespect and abuse compared to those who were attended by doctors. A study from Nigeria revealed that midwives found more of the presented scenarios of mistreatment to be acceptable practices, compared to doctors (13). Middle and lower level care providers, midwives/nurses, work the entire shift whereas higher level (doctors) are mostly called to the labor ward to handle complications or cesarean delivery. Attending to the highly eventful and sensitive process of labor and delivery for long hours in poor working conditions may lead to providers burnout (51) and increase their likelihood of inappropriate treatment of mothers. Negative attitudes of providers towards women is attributed in part to being overworked (52). Evidence shows that if lower level providers are the victims of D&A by managers or higher level providers, then it is more likely that they will use D&A as a tool to ascertain power (53).
Female care providers are presumed to treat women better. Unexpectedly, women who were attended by female providers had a greater likelihood of experiencing D&A in this study. Similar findings have been indicated in a study from Mozambique where higher odds of D&A were reported among women attended by female care providers (54). On the other hand, rural residence was associated with increased likelihood of experiencing D&A. Similarly, in study from Mozambique, the occurrence of disrespect and abuse was much higher in the district hospitals compared to the central hospital (54).