When the baby remains there for a long time, it is going to die so you have to hit her small for the baby to come out": justification of disrespectful and abusive care during childbirth among midwifery students in Ghana

Abstract

Despite global attention, high levels of maternal mortality continue to plague many low- and middle-income settings. One important way to improve the care of women in labour is to increase the proportion of women who deliver in a health facility. However, due to poor quality of care, including being disrespected and abused, women are reluctant to come to facilities for delivery care. The current study sought to examine disrespectful and abusive treatment towards labouring women from the perspective of midwifery students who were within months of graduation. Key Messages •Midwifery students in Ghana’s public midwifery schools report witnessing and participating in many forms of disrespect and abuse during deliveries as part of their education. While they are clear as to why respectful care is important and necessary, they are able to justify and explain reasons for disrespectful and abusive care. This poor treatment of labouring women was explicitly and tacitly supported by these students’ teachers and preceptors. •All study materials and methods were reviewed and approved by the Ghana Health Service Ethical Review Committee, the Kwame Nkrumah University of Science and Technology Committee on Publication and Human Ethics, and the University of Michigan Institutional Review Board. •This research was made possible through a grant from the African Studies Center, University of Michigan. For this study, we conducted focus groups with final year midwifery students at 15 public midwifery training colleges in all 10 of Ghana’s regions. Focus group discussions were recorded and transcribed. A multi-disciplinary team of researchers from the US and Ghana analysed the qualitative data. While students were able to talk at length as to why respectful care is important, they were also able to recount times when they both witnessed and participated in disrespectful and abusive treatment of labouring women. The themes which emerged from these data are: 1) rationalization of disrespectful and abusive care; 2) the culture of blame and; 3) no alternative to disrespect and abuse. Although midwifery students in Ghana’s public midwifery schools highlight the importance of providing high-quality, patient-centred respectful care, they also report many forms of disrespect and abuse during childbirth. Without better quality care, including making care more humane, the use of facility-based maternity services in Ghana is likely not to improve. This study provides an important starting point for educators, researchers, and policy makers to re-think how the next generation of healthcare providers needs to be prepared to provide high-quality, respectful care to women during labour and delivery in low-resource settings.

Women’s perspectives of mistreatment during childbirth at health facilities in Ghana: findings from a qualitative study

“…Our findings are similar to the few previous studies in Ghana, which reported women experiencing physical abuse, scolding, shouting and abandonment during childbirth, as well as health facilities that are unresponsive to their needs, or unable to provide the necessary emotional and physical support during childbirth. [12][13][14]19,20 Failure to push, young age and inability to bring all items required for the birthing process were reported in our study as potential triggers for mistreatment, also echoing previous studies in Ghana. 13,14,20 Mistreatment during facility-based childbirth is increasingly recognised as a widespread problem.…”

“…A study among student midwives across Ghana also confirmed occurrences of mistreatment during childbirth. 14 Similarly, a study by Moyer et al 13 in rural northern Ghana noted that mistreatment during facility-based childbirth was pervasive, and could serve as a disincentive for attending health facilities in the future. These studies did not specifically assess views of acceptability of mistreatment during childbirth, or the perceived factors influencing mistreatment.…”

“…11 Mistreatment of women during facility-based childbirth in Ghana has been documented, albeit in few studies. [12][13][14] D'Ambruoso et al presented women's accounts of their interaction with birth attendants during facility-based childbirth in semi-urban suburbs of Accra. 12 Their findings showed that women were deeply concerned about health provider attitudes and refused to attend health facilities where they were not treated kindly.…”

Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis

“…In addition, most health workers that provide maternity care are female and may have experienced several forms of disempowerment in the workplace, and are therefore not able to advocate within the health system for better treatment of the women they care for. As a result, poor health worker-mother interaction may be normalised as part of the 'culture' of the health system in some settings, and both health workers and mothers may come to accept this as the norm (Bohren 2017, Rominski 2017, Sadler 2016). The perspective of Leape and colleagues on the nature and causes of disrespectful behaviour by physicians supports this hypothesis (Leape 2012).…”

Getting the ‘Comfortable’ to listen: a mixed methods study of refusal of recommended maternity care

“…While there is clear alignment between the domains of disrespect and abuse and the right to decline recommended maternity care, the research in this area has not focused on the intersection of these two issues. The majority of research on respectful maternity care has also been conducted in low-resource settings, mainly in Africa (see Asefa & Bekele, 2015;Bradley et al, 2016;Kruk et al, 2014;Kujawski et al, 2015;McMahon et al, 2014;Moyer et al, 2016;Rominski et al, 2016). Because disrespect and abuse are likely to manifest differently in low and high resource settings (Molina et al, 2016), the literature on disrespect and abuse in maternity care is not reviewed here in detail.…”