Are underprivileged and less empowered women deprived of respectful maternity care: Inequities in childbirth experiences in public health facilities in Pakistan

Abstract

Background Attainment of healthcare in respectful and dignified manner is a fundamental right for every woman regardless of the individual status. However, social exclusion, poor psychosocial support, and demeaning care during childbirth at health facilities are common worldwide, particularly in low- and middle-income countries. We concurrently examined how women with varying socio-demographic characteristics are treated during childbirth, the effect of women’s empowerment on mistreatment, and health services factors that contribute to mistreatment in secondary-level public health facilities in Pakistan. Methods A cross-sectional survey was conducted during August–November 2016 among 783 women who gave birth in six secondary-care public health facilities across four contiguous districts of southern Sindh. Women were recruited in health facilities and later interviewed at home within 42 days of postpartum using a WHO’s framework-guided 43-item structured questionnaire. Means, standard deviation, and average were used to describe characteristics of the participants. Multivariable linear regression was applied using Stata 15.1. Results Women experiencing at least one violation of their right to care by hospital staff during intrapartum care included: ineffective communication (100%); lack of supportive care (99.7%); loss of autonomy (97.5%); failure of meeting professional clinical standards (84.4%); lack of resources (76.3%); verbal abuse (15.2%); physical abuse (14.8%); and discrimination (3.2%). Risk factors of all three dimensions showed significant association with mistreatment: socio-demographic: primigravida and poorer were more mistreated; health services: lesser-education on birth preparedness and postnatal care leads to higher mistreatment; and in terms of women’s empowerment: women who were emotionally and physically abused by family, and those with lack of social support and lesser involvement in joint household decision making with husbands are more likely to be mistreated as compared to their counterparts. The magnitude of relationship between all significant risk factors and mistreatment, in the form of β coefficients, ranged from 0.2 to 5.5 with p-values less than 0.05. Conclusion There are glaring inequalities in terms of the way women are treated during childbirth in public health facilities. Measures of socio-demographic, health services, and women’s empowerment showed a significant independent association with mistreatment during childbirth. At the health system level, there is a need for urgent solutions for more inclusive care to ensure that all women are treated with compassion and dignity, complemented by psychosocial support for those who are emotionally disturbed and lack social support.

Maternal Disrespect and Abuse by Health Care Providers among postpartum women attending Mizan-Tepi University Teaching Hospital, South West Ethiopia

“…The discrepancy might be due to good commitment of health care professionals against physical abuse. This finding is similar with studies conducted in Pakistan and India on women's experiences of mistreatment during facility based childbirth (22,23) The odds of maternal disrespect and abuse among mothers who gave birth at night shifts were 2.2 times higher than those who delivered at day shifts [AOR=2.21; 95% CI:1.306, 3.772 ].This finding in line with study conducted in Kenya (17). In line with this, qualitative study conducted in Ethiopia revealed disrespectful and abusive care were more common during night shifts(4) .…”

Directly observed and reported respectful maternity care received during childbirth in public health facilities, Ibadan Metropolis, Nigeria

“…Women's level of education was significantly directly proportional to the level of observed RMC scores received in our study. Lack of education was also one of the primary determinants of mistreatment received by women during childbirth according to the WHO-supported study conducted across four countries [21] Higher levels of education and being gainfully employed would expectedly increase women's ability to demand their rights during childbirth and procure essential commodities for their birth [49]. In health facilities where essential birthing requirements are not freely provided to women, or where there are no financial protection schemes for women, non-procurement of these delivery materials has contributed to women's mistreatment during childbirth [30].…”

Inclusive, supportive and dignified maternity care (SDMC)—Development and feasibility assessment of an intervention package for public health systems: A study protocol

“…Mean score mistreatment was considered as key outcomes which is taken from a background study in similar setting that yielded a mean score of 25 (score range 0 to 40). A total of 308 postpartum women will be required to detect a statistical difference of 2.5-units decrease (or 10% reduction) in the mean score of mistreatment (from 25 [ 34 ] to 22.5) with standard deviation of 6 [ 34 ], 90% power, 5% level of significance, 2 design effect, and 10% lost-to-follow-up (LTFU) and/or non-response. We decided to proceed with a sample of 308 as it gives sufficient precision to perform range of additional analysis such as estimation of prevalence of different types of mistreatment and the effect of intervention on each of these types of mistreatment, while will not negatively affecting study timelines.…”