Twenty-eight midwives were interviewed. All of them were aged 25–38 years (mean age 31.3 years) a half of them were married and a half were single. The majority had worked for more than three years (n = 14), ten had worked between one and three years and six had worked for less than one year. The great majority of participants were registered A1 Midwives (n = 24) and four were A0 registered.
Midwives knowledge on respectful maternity care during childbirth
The RMC was launched in 2011 by White Ribbon Alliance and from this time it rooted in the international human right. The RMC community built a document, the human right of childbearing women (RMC Charter), with a common goal to demonstrate the respectful maternity care application as a fundamental human right in maternal health context. It has been used globally as a tool to help healthcare providers how maternity can be performed in accordance to the human right respect. It is in this purpose that it is used in this study to help researchers assessing perceptions and attitudes of midwives in providing RMC in selected settings.
Midwives awareness on respectful maternity care
In general, midwives working in maternity services from Masaka district hospital, Kacyiru district hospital and Muhima district hospital were knowledgeable on the RMC, they confirmed that they have had a course covering RMC during their curriculum, they have internal regulation and an orientation form guiding them about what information they need to share with their clients including their right to information, privacy and confidentiality.
“Yeah, we have learnt those rights in ethical course and we have internal regulations. We all know that clients need to be respected, informed about the procedure and confidentiality. For example, every client has her file; I am not allowed to share information from her file to others as it is her own information. Sharing it with others is prohibited”. (Participant18)
Knowledge on the seven rights of Respectful Maternity Care
The majority of participants understood well seven rights which are the right to be free from harm and ill treatment, the right to information, informed consent and refusal, and respect for a woman’s choices and preferences, including companionship during maternity care, the right to privacy and confidentiality, the right to be treated with dignity and respect, the right to equality, freedom from discrimination, and equitable care, the right to healthcare and to the highest attainable level of health, and the right to liberty, autonomy, self-determination, and freedom from coercion; stated in RMC. They make a self-presentation by introducing themselves to the clients and explain the basic information on the process of labour. Privacy was reported to be assured within existing infrastructure.
“I understand women’s rights as the right to be provided with explanations/information to her health problem, being treated as a human being, playing a role in her healthcare, privacy; so that she can feel satisfied with the service provided.”(Participant28)
In addition, participants perceived that they provide maternal healthcare services in equitable manner without any discrimination. For example, having health insurance or not does not affect the quality of service intended.
“From my experience, we provide healthcare for both insured and non-insured clients without counting on money as we need to save life and money comes later. This is the principal right but in some situations, clients may not receive a full range of healthcare services based on payment issue but I never observe it here, maybe in other hospital settings. We provide healthcare services and when client is unable to pay the social service intervenes.”(Participant2)
Knowledge on different kinds of mistreatment experienced by women during childbirth period
Midwives had different views on existing kinds of women’s mistreatment during childbirth period. They supported that mothers should be free from any harm during childbirth. The majority agreed that mothers need to be respected and they considered mistreatment as unprofessional practice.
“On my understanding, this should sound bad like beating a pregnant woman. She is in pain and this pain is observed even from her appearance. So I think we cannot cause harm to her, like shouting on her, even beating her. This is against the midwives’ practices.”(Participant2)
There are some shared experiences in abusive practices among midwives which can be classified in three forms. The first reported form of abusive practice is verbal by shouting on mothers, but midwives reported that they do not do it deliberately.
“(…..) People do not do it from their willing of shouting on mothers. Meeting with uncooperative mother sometimes creates a bad reaction because if you do not shout on her, the outcome may be bad and you are not able to save the life of the baby, but this is a rare situation.”(Participant25)
The second form of abusive practice is physical abuse by slapping on mothers particularly during second stage of labour and they considered it as a way to stimulate and help them pushing for a positive labour outcome.
“This small room is not comfortable for mothers and midwives. The second stage is a difficult moment for both mother and midwives. You all wish to have a safe baby. You may decide to let the mother doing whatever she wants but you may regret later; you try your best to have a safe baby. It is better to be asked why you slapped on a mother instead of responding to how the baby died. You do not slap on mother because you are against her, but for you need to have a safe baby”.(Participant26)
The third form is psychological, from missing labour support. A narrative report from one midwife provided information on lack of support with mothers in labour based on their health status like having a contagious disease. Midwives in this case do not provide labour support as usual for fearing being in contact with mothers by prohibiting holding them in arms.
“A mother in labour needs support and you need to react for every step positively. You need to be on her side but sometimes, considering the existing number of contagious diseases, a mother may feel contraction and want to be hold in arms or other support like back massage; in this case, some midwives shout on them”. (Participant16)
Attitudes of midwives towards RMC during childbirth
Midwives have different point of view on their attitude on RMC during childbirth. The majority report positive attitude towards RMC. They provide respectful maternity care services by respecting its underlying rights. Participants agree that really midwives support mothers during childbirth by not blaming them when they cry during contractions, but they try to educate them on how they can cope with contractions.
“Yes of course”. We provide respectful maternity care. Let us take an example; I cannot examine a mother in presence of others due to the respect on her privacy. Indeed, I need to provide all needed services in general. Sometimes there are mothers who cry when they are feeling contractions; in this case you do not blame them but we educate them on how she should cope with contractions” (Participant23)
In other hand, some participants report having observed some negative attitude among midwives while providing respectful maternity healthcare services and the most reported is shouting on mothers. Mothers are sometimes health cared in uncomfortable condition which is considered like unprofessional practice.
“Sometimes you can shout on the mother, or you do not provide the essential healthcare needed or performing suturing without anaesthesia and pain relief drugs and she may be in uncomfortable place, I think this also is not good for her”. (Participant11)
Challenges in providing Respectful Maternity Care
The provision of respectful maternity care across three district hospitals presents some challenges: the software medical system, material, information, timely healthcare, privacy and infrastructure, client culture and religion, transfer process and other challenges.
Medical system software and material
some of the users of Community based health insurance (CBHI) report that the process of check-up and registration into the system before receiving health care may cause a delay in intervention for some cases which need emergency and affects midwives who may be requested to advocate for mothers and go to explain the emergency case to the CBHI agent in order to provide the needed healthcare.
“This time, the system process requires for each insurer to be checked into system before receiving service as it is in conjunction with client identity card information. Here we always have a problem of internet; so that time, they cannot provide material or medicine to the client which delays the process as you are obliged to go yourself advocating for him/her while you have other many responsibility and this is time consuming”.(Participant22)
In addition, the lack of labour monitoring material like CTG was reported in most of the participant and this result in late detection of foetal distress leads to increase in neonatal death rate.
“The main challenge in monitoring is the lack of cardiotocography (CTG). In our district hospital we do not have any. So the consequence you come and check on the foetal heart beat and you find baby dead inside from a mother who have been admitted with a live baby. This is what we call Intra-uterine foetal demise (IUFD)”. (Participant21)
Right to information
Some participants think that clients receive information correctly. However, most of participants reported the shortage of midwives and high number of clients as a fact to lack of providing all needed information to women.
“The first challenge is that clients are too many considering to the number of midwives, beds and rooms. It means, when you have many clients, you provide short information, you do not enter in detailed and you cannot get another time to come back with a high number of activities. At this time, the client cannot get the chance for asking questions.”(Participant28)
Most participants report that, due to overloaded work, they don’t receive timely healthcare. The most activity affected is regular foetal monitoring.
“I cannot say that clients receive healthcare timely at 100%. Depending on the high number of clients admitted. For example, hearing foetal heart rate among the mothers in room every 30minutes cannot be realized because you make a cycle and you reach on the last too late”. (Participant6)
An existing strategy used for triage with different colour based on the severity of mother’s condition is used whereby red symbolize an emergency case, the yellow colour symbolize the urgent case and green colour symbolize no-severe case but this can lead to a delay in health healthcare provision.
“Depending on this high number, the clients should come at hospital early morning and receive healthcare late. The one scored in green or yellow, you do not start with her as she is not considered as an emergency case, but progressively her issue becomes severe and falls in red colour while if she has been admitted timely her condition should not be severe as it is”. (Participant6)
Privacy and infrastructure
Participants report that they are aware of the importance of privacy and try their best to respect privacy with existing infrastructure. However, privacy was reported to be affected by short space in maternity ward and gynaecological beds. The pregnant women are closed to each other and are obliged to share rooms and beds. This interferes with midwives’ ability to provide private information to the mothers.
“There are many challenges. Let us talk about infrastructure and hospital capacity. When we receive many clients two mothers share the same bed which interferes with the privacy of the client, at that time the only thing to do as healthcare provider is to maximize the benefit from each one”.(Participant18)
an overview on some cases that are more likely to be transferred from District hospital to Referral Hospital reported include peritonitis, post-partum haemorrhage, severe pre-term labour, having more than two previous uterine scar and severe pre-eclampsia. There are some requirements for transfer such as caution fee for those without the health insurance and availability of ambulance.
Most participants report not having any challenges during external transfer process but there are few of them that revealed challenge like the lack of place in maternity ward which leads to refusal of transferred case with fact that there is no available place.
“The first, do you think that transfer the client is easy? Our challenge for transfer to referral hospital is another issue. There some cases which are refused and others are rejected from the criteria of admission like caution fee more likely to people without insurance which create a long discussion with delay.”(Participant19)
Generally, the information gathered from our participants suggests that, the system of maternity health care service delivery is good, due to presence of key material and infrastructure; however, workload was persistently mentioned as major challenge.