Indian Journal of Public Health

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 65  |  Issue : 1  |  Page : 11--15

Assessment of respectful maternity care during childbirth: Experiences among mothers in Manipur


Bishwalata Rajkumari1, Ningthoukhonjam Shugeta Devi2, Joenna Ningombam3, Dayananda Ingudam3,  
1 Associate Professor, Department of Community Medicine, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India
2 Tutor, Department of Community Medicine, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India
3 Postgraduate Trainee, Department of Community Medicine, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India

Correspondence Address:
Bishwalata Rajkumari
Department of Community Medicine, Jawaharlal Nehru Institute of Medical Sciences, Imphal - 795 005, Manipur
India

Abstract

Background: The relationship between the lack of quality care and adverse maternal outcomes is being highlighted globally. Respectful maternity care includes respect for women autonomy, dignity, feelings, privacy, choices and freedom from ill treatment, coercion, and consideration for personal preferences including option for companionship during the maternity care. Objectives: This study planned to determine the prevalence and types of disrespect and abuse among mothers during childbirth and its associated factors. Methods: This was a cross-sectional study conducted among 231 women having children <2 years, who had undergone institutional deliveries and accessing immunization clinics during October to December 2018 using a semi-structured questionnaire adapted from the Person-Centered Maternity Care Scale, a validated instrument which gives a holistic measure of women's experiences during childbirth wherein the questions were grouped under seven domains. Results: The mean (standard deviation) age of the respondents was 28.9 ± 5.8 years. The prevalence of any form of abuse present was 96.5% with the highest found in “Facility and Environment” Domain (77.5%). Women delivering in public tertiary care facility were significantly more likely to face more abuse in the domains of “Dignity and Respect,” “Support and Care,” “Facility and Environment,” “Predictability and Transparency,” as compared to other types of health facilities (P < 0.05). Conclusion: Nearly almost all of the respondents (96.5%) faced some form of abuse in one domain or the other. There is a need for greater action, dialog, research, and advocacy on this important public health issue for promoting dignified maternal health-care services.



How to cite this article:
Rajkumari B, Devi NS, Ningombam J, Ingudam D. Assessment of respectful maternity care during childbirth: Experiences among mothers in Manipur.Indian J Public Health 2021;65:11-15


How to cite this URL:
Rajkumari B, Devi NS, Ningombam J, Ingudam D. Assessment of respectful maternity care during childbirth: Experiences among mothers in Manipur. Indian J Public Health [serial online] 2021 [cited 2021 Jun 25 ];65:11-15
Available from: https://www.ijph.in/text.asp?2021/65/1/11/311522


Full Text



 Introduction



Over the recent decades, institutional deliveries in India have increased from 38.7% in 2005–2006 to 78.9% in 2015–2016.[1],[2] Despite these improvements, access to quality services is not guaranteed. The relationship between the lack of quality of care and adverse maternal outcomes is being highlighted globally. Ensuring universal access to safe, acceptable, good quality sexual, and reproductive health care can dramatically reduce the global burden of maternal morbidity and mortality.[3] Bowser and Hill's landmark review of evidence for disrespect and abuse in facility-based childbirth revealed that women avoid seeking care in health facilities because of mistreatment. Disrespect and abuse in facility-based childbirth represent the important causes of suffering for women, an important barrier to skilled care utilization, important quality of care problems, and often a violation of women's human rights.[4] The World Health Organization recently issued a statement for the prevention and elimination of disrespect and abuse during facility-based childbirth.[5],[6],[7]

The concept of respectful maternity care (RMC) acknowledges that women's experiences of childbirth are the vital components of health care and as per the recently launched Labor Room Quality Improvement Initiative (LaQshya) program. RMC includes respect for women autonomy, dignity, feelings, privacy, choices, and freedom from ill treatment, coercion, and consideration for personal preferences including option for companionship during the maternity care. RMC not only contributes in ensuring positive outcomes for the mothers and newborns but also supports cognitive development of the babies later in the life.[8]

Increasing the proportion of women delivering in a health facility is challenging, as it requires comprehensive efforts to overcome sociocultural, economic, geographical, and infrastructural obstacles to reaching facility-based care.[9] No studies have been conducted regarding the RMC in Manipur. However, this study was taken up with the objectives to determine the prevalence and types of disrespect and abuse among mothers during delivery and to assess the association between the levels of disrespect and abuse with selected variables.

 Materials and Methods



Study type/design, setting, and study participants

This cross-sectional study was conducted from October 2018 to December 2018 among women having children <2 years, who had undergone institutional deliveries and accessing immunization clinics during the study period in Imphal-East District of Manipur. Those who did not give consent were excluded from the study.

Sample size and selection of participants

The sample size was calculated based on a prevalence of 29% of maternal abuse from a study conducted by Bhattacharya and Sundari,[10] in 2018. Taking an absolute allowable error of 6 and at 95% significance level, by using formula for single proportion (n = 4pq/d2), the estimated sample size was found to be 219 rounded off to 230. Taking into consideration, the feasibility aspect of the study a convenience sampling method was used for selecting the health facilities. One government tertiary care hospital, namely Jawaharlal Nehru Institute of Medical Sciences (JNIMS) Hospital, 1 Community Health Center (CHC Sagolmang) and two Primary Health centers (PHC), namely PHC Akampat and PHC Bashikhong were selected. Of the health facilities selected, JNIMS hospital is one of the main referral hospitals in the state and caters to patients coming from all the districts of the state. Based on the case load of the selected health centers, the proportion of respondents selected was 60% from JNIMS Hospital, 20% from CHC Sagolmang, and 10% each from the two PHCs.

Tools and techniques: Data collection

All eligible women attending the immunization clinics of the selected facilities during the data collection period were interviewed. The study tool comprises of a semi-structured questionnaire consisting of (a) sociodemographic profile, (b) questions related to RMC which were adapted from the Person-Centered Maternity Care Scale,[11] a validated instrument which gives a holistic measure of women's experiences during childbirth. The RMC questions were grouped under seven domains namely: (i) dignity and respect, (ii) communication and autonomy, (iii) supportive care, (iv) privacy and confidentiality, (v) trust, (vi) facility and environment, and (vii) predictability and transparency of payments. Each question was given a score of 1 if abuse was present. The questionnaire was translated to the local language and back translated for validity.

Outcome variable: The outcome of interest was the presence or absence of disrespect or abuse in any of the domains. For each domain, a score of 0 was given for those who have not experienced any disrespect or abuse during delivery in the facilities and those scoring 1 and above were considered to have ever faced incidence of disrespect and abuse in the respective domain.[12],[13],[14]

Statistical analysis

Data were entered in MS Excel software and checked for consistency. Data analysis was done with IBM SPSS version 20 (IBM company, Chicago, Illinois, United States). Descriptive statistics such as mean, standard deviation (SD), and percentages were used. Analytical statistics such as the Chi-square test was performed to test for association. P ≤ 0.05 was taken to be statistically significant.

Ethical issues

The present study was approved by the Institutional Ethics committee vide IEC letter No. Ac/IEC/JNIMS/2018 (156) dated the October 23, 2018, for the study protocol No. 156/49/2018. Prior permission was obtained from the head of the institution of each health facility selected for the study. Verbal informed consent was obtained from each respondent before conducting the interviews maintaining strict privacy and confidentiality. All identifiers were removed from collected data.

 Results



Out of 240 eligible women approached, a total 231 responded and interviews were conducted. Mean ± SD age of the respondents was 28.9 ± 5.8 years. Majority of them belonged to the Hindu religion (71.9%). Almost a third of the respondents (31.6%) and their husbands (30.3%) educational status were 10th passed. Maximum of the respondents were unemployed (70.6%), and half of the husbands of the respondents were self-employed (54.1%). A fifth of them were delivered by normal vaginal delivery with episiotomy (22.5%). Almost half of them were multi-para (51.1%) and delivered in tertiary health facility (58.9%). Majority of them (94.8%) had 4 and above antenatal care checkup.

In relation to the “Dignity and Respect” domain, around 07 (3%) of the respondents reported physical abuse and around 20 (8.7%) reported “verbal abuse” [Table 1]. The total prevalence of any form of abuse present was 223 (96.5%) with the domain “Facility and Environment” having the highest score for abuse (179, 77.5%) followed by the domain “Predictability and Transparency of payment” (174, 75.3%). The lowest score of abuse was found in the domain “Trust” (22, 9.5%) [Table 2].{Table 1}{Table 2}

The domains of “Dignity and Respect” (P < 0.004), “Support and Care” (P < 0.001), “Facility and Environment” (P < 0.001), “Predictability and Transparency” (P < 0.002) were significantly found to have the presence of higher abuse in government tertiary care health facilities as compared to the other types of health facilities. “Privacy and Confidentiality” domain (P < 0.01) was significantly found to have more abuse in government primary and secondary health facilities as compared to tertiary care facility [Table 3].{Table 3}

In response to the questions for suggesting measures to improve care in future by the caregivers majority suggested for improving the “Cleanliness and provision of water in the facility,” “To permit family members inside the labor room,” for “better and more cordial behavior of nurses toward the patients” and for “senior doctors to be available round the clock at the facility.”

 Discussion



This study tries to explore the experiences and presence of disrespect and abuse faced by women during childbirth in health care facilities in the state of Manipur. Efforts to increase the use of facility-based maternity care in low-income countries are unlikely to achieve the desired gains if there is no improvement in quality of care provided, especially the elements of respectful care.[15] Although most of the women 223 (96.5%) reported some sort of abuse in one or more domain, only 3% of the them reported physical abuse which is relatively very less compared to the study conducted in New Delhi[16] and Ethiopia.[12],[17] Abuya et al. reported the prevalence as high as 20% in a study done in Kenya.[18] This may be because of the fact that women enjoy a good social status in our State and the doctor–patient rapport is good hence lesser incidence of physical abuse. In our study, 35.5% of the respondents felt that during delivery they were not in the position of their choice. The usual practice of delivery in health care centers of Manipur is by lying on back on labor room delivery tables. Other studies reported women preferring to deliver in a squatting or kneeling position, rather than the supine position.[19],[20],[21] In the present study, poor maintenance of facility and environment (77.5%) constituted a major proportion, but studies conducted elsewhere[12],[22],[23] reported a much lower proportions which may reflect on the availability of better infrastructure and maintenance facility in bigger cities as compared to smaller states like ours which have poor infrastructure and weak administration. In these study, only 14.7% respondents felt they the waiting time was long before service provision by the doctors which is similar to the study done in Malawi (11.2%),[22] whereas other studies reported much higher proportions reporting delayed service provision.[12],[17] The difference may be due to variation in the study setting, sociocultural, and different doctor–patient ratio in the countries. This study showed that domains such as dignity and respect, support and care, facility and environment, and predictability and transparency were significantly found to have the presence of higher abuse in government tertiary health facilities as compared to lower health facilities. This could be due to the higher client load and accompanying work stress and fatigued faced by the providers in tertiary care centers. Most of respondents suggest measures for improvement of the health facility. A major proportion of the reported disrespect and abuse in this study is accounted from the facility and environment domain. Freedman et al.[14] suggested using separate definitions for “Individual disrespect and abuse” like specific provider behaviors experienced or intended as disrespectful or humiliating such as physical or verbal abuse, and “Structural disrespect and abuse” such as systemic deficiencies that create a disrespectful or abusive environment, such as an overcrowded and understaffed maternity ward or unhygienic conditions, so that researchers measuring prevalence may differentiate such diverse forms of abuse to advocate channels for accountability and change.

In our study, 26.4% of the respondents said that they were asked for money by the health-care provider for purposes other than the official cost which is much higher than the study in Tanzania (5%),[23] Ghana (12.4%), Nigeria (10.7%), but lower than Guinea (47.5%) and Myanmar (40.4%),[24] which may be due to different customs and ethical practices by the health-care providers in these countries.

The limitation of our study is that all of the responses are self-reported, and we were not able to perform direct observation of the practice of respect/disrespect/abuse during delivery or in the ward; moreover, exit interviews could not be conducted at the time of discharge from the health facilities after receiving maternity care services such that the element of recall bias may be reduced. Even though convenience sampling method was used for contacting the women attending immunization clinics at the selected facilities for the interviews, the places of delivery recorded was at both private and government health-care centers located across the state as the practice of women going to maternal home at the time of delivery is practiced by some communities. Moreover, JNIMS is one of the main tertiary care government hospitals in the state catering to patients from all districts. The study's findings may be somewhat representative of the experiences of women undergoing deliveries at such public and private health facilities in the state. There is limited evidence on the prevalence of RMC in facility-based maternity services delivered in low-resource settings. Evidence on the nature and frequency of disrespect and abuse is essential for effective programs, policy, and advocacy.[23],[25] This study which may be the first of its kind conducted in Manipur with less number of studies reported elsewhere in India provides an important insight into the phenomenon of mistreatment during childbirth.

 Conclusion



Nearly almost all of the respondents faced some form of abuse in one domain or the other. Majority of respondents who delivered in tertiary hospitals have a significant association of abuse with most of the domains. A larger study using the probability sampling method and house to house survey can be performed supplemented by direct observations conducted at health facilities is recommended. There is a need for greater action, dialog, research, and advocacy on this important public health and human rights issue for promoting a dignified maternal health care for achieving improved maternal health outcomes for all women.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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