Disrespect and Abuse During Facility ‐ Based Childbirth in North Showa Zone, Ethiopia

Background: Respectful maternity care is a fundamental human right, and an important component of quality maternity care that every childbearing woman should receive. Disrespect and abuse during childbirth is not only a violation of a women’s rights, it is associated with a reduction in the number of women accessing professional maternity services and increases the risk of maternal mortality. This study investigated women’s experience of disrespect and abuse during facility-based childbirth in Ethiopia. Methods: A cross-sectional study was conducted with 435 randomly selected women who had given birth at public health facility within the previous twelve months in North showa zone of Ethiopia. A structured, researcher administered questionnaire was used with data collected using digital, tablet-based tools. Participants’ experiences were measured using the seven categories and verication criteria of disrespect and abuse identied by White Ribbon Alliance. Multivariable logistic regression was used to identify the association between experience of disrespect and abuse and interpersonal and structural factors at p-value < 0.05 and OR values with 95% con ﬁ dence interval. Results: All participants reported at least one form of disrespect and abuse during childbirth. Types of disrespect and abuse experienced by participants were; physical abuse 435(100%), non-consented care 423(97.2%), non-condential care 288 (66.2%), abandonment/ neglect (34.7%), non-dignied care 126(29%), discriminatory care 99(22.8%) and detention 24(5.5%). Hospital birth [AOR: 3.04, 95% CI: 1.75, 5.27], rural residence [AOR: 1.44, 95% CI: 0.76, 2.71], monthly household income less than 1,644 Birr (USD 57) [AOR: 2.26, 95% CI: 1.20, 4.26], being attended by female providers [AOR: 1.74, 95% CI: 1.06, 2.86] and midwifery nurses [AOR: 2.23, 95% CI: 1.13, 4.39] showed positive association with experience of disrespect


Background
While motherhood is often considered a ful lling positive experience, pregnancy and childbirth related complications are a leading cause of death for women of child bearing age in developing countries (1).
Developing countries contribute 94% of global maternal deaths and more than half of these deaths occur in sub-Saharan Africa (2). Ethiopia's maternal mortality, 401 per 100,000 live births in 2017, is one of the highest globally (3). Birth outside of a health facility without skilled birth attendants is the major reason behind this loss of life (4,5).
Ethiopia aims to reduce its maternal mortality ratio to less than 70 per 100,000 live births by 2030 in order to achieve the United Nations Sustainable Development Goal three (6). Ensuring access to quality obstetric care is essential as it has the potential to reduce up to 75% of preventable deaths (7,8). The proportion of Ethiopian women who report having di culty accessing health care decreased from 96% in 2005, to 70% in 2016 (9). However, only 48% of women gave birth in health facility in 2019. This highlights the need for maternity care to be accessible, competent, appropriately resourced, and, respectful if women are to use it (10).
Respectful maternity care, is a key element of quality of maternity care (10). It is an approach that stresses positive interpersonal interactions between providers and women, throughout maternity care (11). Women's right to respectful and digni ed health care throughout pregnancy and childbirth has become a central focus in intervention strategies that seek to reduce maternal mortality (12); disrespect and abuse (D&A) affects women's trust in care providers and the health system deterring them from seeking and using maternity care (11).
Disrespectful treatment ranges from denial of a woman's right to make informed decisions and being scolded for demanding their rights (13), to denial of anaesthesia while performing and repairing episiotomies (14). The White Ribbon Alliance (WRA) categorise D&A in childbirth into seven categories: physical abuse, non-digni ed care, non-consented care, non-con dential care, abandonment, discrimination, and detention. Each category has more than one veri cation criteria with "Yes" or "No" dichotomized responses. According to WRA, veri cation criteria/ manifestations of D&A often fall into more than one category, so that categories are not intended to be mutually exclusive. Rather categories should be seen to be overlapping along a continuum (15). International human rights frameworks highlight D&A of women during childbirth as a key human rights issue, (16)(17)(18)(19) and a human rights based approach to birthing care has become a primary concern (20).
Research shows growing evidence of disrespectful and abusive care in Ethiopia (21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33). Thus, understanding D&A will help inform changes in the practice and culture of maternity care. However, the experience of D&A and its determinants are not well understood. Thus, the aim of this study is to gain insight into women's experiences of D&A during facility based childbirth in Ethiopia and thereby contribute to quality and safety in maternity care by creating an evidence base to inform education and training, policy and future research.

Study design and setting
This survey was conducted as part of a larger mixed methods study that examined disrespect and abuse of women during facility based childbirth in Ethiopia. A community-based cross-sectional study was conducted from 5 October 2019 to 25 January 2020 in North showa zone of Ethiopia. The zone is located 110km to north of the capital Addis Ababa. Based on the 2007 Census conducted by the Central Statistical Agency of Ethiopia, the Zone has a projected total population of 1.5 million in 2016, of whom 48% were women. North Shewa zone has an area of 10,322.48 square kilometers and population density of 138.66 (34). Three hospitals, 62 health centers, 268 health posts are currently functioning in the zone.

Study population and eligibility
Participants were women who had given birth at public health facilities of North showa zone during the last twelve months preceding the survey, regardless of the birth outcome. Women who gave birth at home, those who were acutely unwell physically or mentally and those with disability which would prevent them talking to a researcher were excluded.

Study variables
The dependent variables of this research were speci c categories of D&A (physical abuse, non-digni ed care, non-consented care, non-con dential care, abandonment, discrimination, and detention) women experience during facility based childbirth. The independent variables of this research were sociodemographic variables (age, residence, marital, education, occupation and monthly household income), obstetric history and experience of maternity care utilisation (walking distance of health facility from home, total number of live births, number of birth in health facility, antenatal care (ANC) checkups, ANC and childbirth in same facility, type of health facility visited for birth (health center vs hospital), method of birth and number of baby in most recent childbirth, profession and sex of provider who attended the birth).
Sample size determination and sampling procedures A single population proportion formula was used to calculate the sample size with assumptions of 78.6% proportion of disrespect and abuse (21), 4% precision, 95% level of con dence and a 10% non-response rate, the nal sample size was 443. A list, including contact details, of women who gave birth in public health facility is maintained by local health extension workers (HEWs). Using this list as a sampling frame 443 eligible women were selected by computer generated random numbers in Excel spreadsheet (Microsoft Corporation, 2013). Selection and initial contact was made in person by HEWs and women were invited to choose time and place of interview. HEWs are all female, have a one year formal preservice training and provide basic health promotion services in health posts. They are not directly connected to the birthing facilities.

Data collection tool and procedures
Data were collected using digital, tablet-based tools, Open Data Kit (ODK) Collect. A validated questionnaire was programed and uploaded to tablets for the survey (21,35). The questionnaire consisted of three parts. The rst part contained seven questions and was used to assess the sociodemographic characteristics of participants. The second part contains 10 questions focusing on the participants' obstetric history and experience of maternity care utilisation, and the third part includes the seven categories of disrespect and abuse (physical abuse, non-digni ed care, abandonment, nonconsented care, non-con dential care, discrimination and detention) including the 48 veri cation criteria used to measure experience of D&A. The questionnaire was designed in English and translated to the local language, Amharic, and then back to English by a third person to check for internal consistency. The Amharic version of the questionnaire was piloted and used to collect data face to face. Participants were surveyed in their homes or another preferred location and were accompanied by person of their choice during the interview.

Measurement
The D&A were categorised in to seven groups and prevalence was calculated for each speci c category. Each category has more than one veri cation criteria with "Yes" or "No" dichotomised responses. A respondent was considered to have been disrespected and/or abused for the speci c category if she reported "Yes" in at least one of the veri cation criteria in that category (21).

Data quality assurance
Digital, tablet-based data collection improves quality of the data as it allows predetermined options only. Local health extension workers with prior experience of tablet-based survey implementation conducted the survey following two days of intensive training. The health extension workers also practiced collecting data using the tablets in order to familiarize themselves with the tool prior to data collection. The enumerators, HEWs, were all females to make sharing ideas easier, as the topic is sensitive. The principal investigator has closely supervised the data collection process.

Data processing and analysis
The data were exported to SPSS Window version 21. Descriptive statistics were used to describe the study population in relation to relevant variables. To identify predictors of each D&A categories bivariate logistic regressions with each potential covariate was conducted and variables that have p-value of <0.2 were included in the nal multivariable binary logistic regression models. Then, four multivariable logistic regression models (one model for each category of D&A, except for physical abuse, non-consented care and detention), with a 95% con dence interval were tted. Physical abuse and non-consented care were reported by too many participants whereas the number of women who reported detention were too small. As a result, these three categories were excluded as we could not perform further statistical analyses.
Adjusted odds ratios and their 95% con dence intervals were computed and statistical signi cance was declared at p-value of <0.05.

Results
Out of the invited 443 women, 435 agreed to participate in the study yielding a response rate of 98.1%.
The mean age of respondents was 28.65 (SD = ± 5.38) ranging from 18 to 46 years. Over two thirds, 304 (69.9%), of respondents were urban dwellers. Most 378(86.9%) of participants were married and 100 (23%) have attended tertiary level of education, and only 77 (17.7%) of the participants reported monthly household income > = 1,644 birr.  women received negative comments regarding their age. In addition, 24(5.5%) of respondents said they were detained in the facility against their will, of which, 17 (3.9%) were detained due to inability to pay hospital bills while 13 (3.0%) were instructed to clean up their own blood or other uid after birth.

Discussion
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 veri cation 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.
When interventions become necessary, service providers should provide the mother su cient 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 nding is higher than ndings of previous research across all contexts (25,31,42). Best practice is that providers respect the privacy and con dentiality 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 con dentiality. Studies from other parts of the country have similarly revealed a high level of non-con dential 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-digni ed care. Previous studies have documented similar result elsewhere in Ethiopia (21,23,31,33). Non-digni ed 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 nding 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 signi cant 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)(32)(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 identi ed as a signi cant barrier to quality care. Unlike nancially 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 insu cient sta ng may impede the provision of respectful maternity care in hospitals (49). Previous studies have identi ed that working in under-equipped and overwrought health systems affects provider enthusiasm and is often labelled as signi cant 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 ndings 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).

Conclusion
The level of disrespect and abuse reported by participants is high. Structural and interpersonal factors were identi ed to have positive association with women's experience of disrespect and abuse. Expanding the size and skill mix of professionals in the preferred facilities (hospitals), and sensitizing care providers and health managers regarding the magnitude and consequences of D&A are responses that could possibly mitigate D&A during childbirth. Categories of disrespect and abuse reported by women (N=435)