Experience of respectful maternity care during childbirth and associated factors in public hospitals of the South West Region of Ethiopia: an institution-based, cross-sectional study

Abstract

Objective

To determine women’s level of experience of respectful maternity care during childbirth and associated factors in public hospitals in the South West Region of Ethiopia.

Design

Institution-based, cross-sectional study.

Setting

The study was conducted at secondary-level healthcare institutions in the South West Region of Ethiopia from 1 June to 30 July 2021.

Participants

384 postpartum women were sampled from four hospitals using a systematic random sampling technique, allocating a proportion to each health facility. Pretested structured questionnaires were used to collect data from the postnatal mothers through a face-to-face exit interview.

Outcome measures

The level of respectful maternity care was measured according to the Mothers on Respect Index. P values of <0.05 and 95% CIs were used to determine statistical significance.

Results

Of the 384 sampled women, 370 postnatal mothers participated in the study (response rate 96.3%). 11.6% (95% CI 8.4% to 15.1%), 39.7% (95% CI 34.3% to 44.6%), 20.8% (95% CI 17.3% to 25.1%), and 27.8% (95% CI 23.5% to 32.4%) of women experienced very low, low, moderate, and high levels of respectful maternal care during childbirth, respectively. Having no formal education was negatively associated with experience of respectful maternal care (adjusted OR (AOR)=0.51, 95% CI 0.294 to 0.899), while daytime delivery (AOR 8.53, 95% CI 5.032 to 14.47), giving birth through caesarean section (AOR 2.19, 95% CI 1.410 to 3.404) and future intention to give birth within the health facility (AOR 5.18, 95% CI 3.019 to 8.899) were positively associated with respectful maternal care.

Conclusion

In this study, only one-fourth of women experienced high-level respectful maternal care during childbirth. Responsible stakeholders must develop guidelines and strategies to monitor and harmonise respectful maternal care practices at all institutions.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study collected specific data regarding experiences of respectful maternal care, measured using four ordinal levels and analysed via an ordinal regression model.

• The study used a probability sampling method and had a high response rate.

• The study might be affected by social desirability bias, due to fear or desire to avoid blaming providers for negative experiences.

• Respectful maternity care was measured only from the mother’s perspective; it should also be investigated from different perspectives, including investigation of community-related and health system-related factors.

• The study findings may not be generalisable beyond public hospitals in the South West Region of Ethiopia.

Introduction

Respectful maternity care (RMC) is a universal human right that each childbearing woman in each health structure around the world should be included in it.¹ The relationship between women and maternity care providers during the antenatal, delivery and postnatal periods is critically important.² Women’s familiarity with caregivers can enable and comfort them, or on the other hand, when women are treated disrespectfully, their negative encounter with healthcare providers during delivery leaves long-lasting damage and emotional trauma.³ RMC is a major component of safe motherhood; at the same time, it is an exceedingly critical, open well-being and human rights issue containing regard for maternal independence, self-respect, emotional state and preferences.^{4 5}

Disrespect and abuse are depicted as abuse, obstetric savagery or dehumanised care, and could be a violation of a woman’s rights during maternity care.⁶ The negative effect of disrespect and abuse during childbirth constitutes a significant barrier to increasing skilled care utilisation and improving maternal health outcomes as defined by the Millennium Development Goal 5.⁷ Many women experience disrespectful and abusive treatment during childbirth in facilities around the world and it acts as a restriction to current and/or future utilisation of facility-based childbirth services.⁵ This report demands more prominent action, discourse, investigation and advancement on this vital maternal health and human rights issue.

Although motherhood is considered a positive experience, pregnancy and childbirth-related complications are a driving cause of death for women of childbearing age in developing countries.⁸ The total estimate for maternal mortality rate in the world’s least developed countries is high at 415 maternal deaths per 100 000 live births, which is more than 40 times higher than that of the subregion of Europe. Sub-Saharan Africa and Southern Asia accounted for approximately 86% of the estimated global number, and sub-Saharan Africa alone accounted for roughly 66% of maternal deaths.⁹

Even though maternal mortality has decreased by half in Ethiopia since 2000, the maternal mortality rate is still 412 per 100 000 live births.¹⁰ Moreover, an incredible advancement has been made in the rate of live births that happened in a health facility, which expanded from 5% in 2005 to 48% in 2019.¹¹ However, guaranteeing the quality of service at health facilities remains an inescapable challenge. These conditions are exacerbated as the health system struggles to meet both the request for routine quality healthcare and the frequent need to react to the drought, conflict and infection episodes including the COVID-19 epidemic.¹⁰

A qualitative synthesis conducted in low/middle-income nations recommends that one of the key obstacles to facility-based delivery was fear of discrimination against facility-based delivery. When confronted with the prospect of facility birth, women in low/middle-income countries may favour giving birth at home with a traditional birth attendant.¹² Another comparative study on perceptions and experiences of women and healthcare providers done in Abuja, Nigeria reported that women and providers detailed encountering physical and verbal mishandling.¹³

Studies in Ethiopia on the prevalence of RMC and abuse appear that women on average got 5.9 (66%) of the nine recommended RMC practices (ie, (1) receiving and greeting the pregnant women, (2) explaining each step of the examination, (3) encouraging women to ask questions, (4) responding to women and their companions politely when they asked questions, (5) explaining to women what will happen in labour, (6) encouraging women to walk and change position, (7) ensuring light eating, (8) asking women which position they would like to deliver in and (9) allowing women to give birth in the position they want). Health centres illustrated higher RMC execution than hospitals.¹⁴ Another study in Addis Ababa, Ethiopia in one teaching hospital and three health centres evidenced that the violation of the right information, informed consent and preference of position during childbirth was reported by all women who gave birth within the hospital and 89.4% of respondents who gave birth in the health centres.¹⁵ Also, a study conducted to assess compassionate and respectful maternity care during facility-based childbirth and women’s intention to use maternity services in Bahir Dar town showed that 34% of women have no intention to give birth within the health facility. The foremost reason given by the women was the lack of satisfaction with caring during childbirth.¹⁶

Most of the factors associated with RMC in the previous studies were giving birth at a health centre, discussion on the place of delivery, daytime delivery, longer time of stay (≥13 hours), involvement in decision-making, inquiring for consent before the procedure, unintended current pregnancy and the presence of <3 health workers during childbirth. On the other hand, women who come from rural areas experienced a caesarean delivery and had complications during delivery were significantly associated with disrespect and abusive care.^{16 17}

The government of Ethiopia has been reacting to increase institutional deliveries by applying interventions like maternal waiting homes in health facilities, free services and transportation, pregnant women conferences and media promotion campaigns to avoid neonatal and maternal mortality which happens in the absence of a skilled birth attendant.^{11 18} Despite the intervention, only 48% of women deliver at health facilities. Moreover, the decrease within the continuum of care between pregnancy care contacts (74%), health facility delivery (48%) and postnatal care (34%) may show an issue with the quality of care.^{11 19} RMC is one key component of the quality of care that women get during the continuum of maternity care. Delays in looking for care for obstetric complications contribute to maternal deaths. Disrespect and abuse contribute to first and third delays (delay in seeking care and delay in receiving adequate and suitable care, respectively).¹⁹ High rates of unavoidable maternal and infant mortality and morbidity are regularly due to poor quality of care.²⁰

Moreover, to handle this issue, currently, the Ethiopian federal minister of health has created compassionate and respectful maternity care in-service training guidelines and begun their execution for healthcare providers all over the country. This pointed to diminishing the predominance of disrespect and abuse during pregnancy, delivery and postpartum in health facilities. RMC is one of the components of compassionate and respectful maternity care.^{19 21} However, the results of the past studies were not steady and constrained in number within the setting of Ethiopia, and the magnitude of RMC and related variables in the study region is not well-known to require intervention measures. Therefore, this study intended to fill the baseline information gap within the study region.

Objectives

General objective

• To determine women’s level of experience of RMC during childbirth and associated factors in public hospitals in the South West Region of Ethiopia, 2021.

Specific objectives

• To determine women’s levels of experience of RMC during childbirth in the South West Region of Ethiopia.

• To identify the factors associated with RMC experiences in the South West Region of Ethiopia.

Methodology

Study area

The study was conducted at Mizan Tepi University Teaching Hospital, G/Tsadik Shawo General Hospital, Tepi General Hospital and Bachuma Primary Hospital, which are located in Bench Sheko, Kaffa, Sheka and West Omo zones, respectively. These zones (second-level administrative in Ethiopia) are found within the South West Region. The South West Region, officially known as the South West Ethiopia Peoples’ Region, is 1 of the 11 regions in Ethiopia. In the region, there are no private hospitals to provide labour and delivery service, which indicates that almost all of the women who demanded to give birth in hospital settings are required to deliver in public hospitals. All hospitals provide payment-free labour and delivery service for 24 hours, and the total average annual expected deliveries in those nominated hospitals were about 8100 (source: 2020/2021 each hospital’s annual report). All of these hospitals have antenatal and postnatal clinics, Expanded Program on Immunization, delivery wards and psychiatry clinics. Currently, Mizan Tepi University Teaching Hospital is anticipated to provide services for more than 829 000 people, whereas G/Tsadik Shawo General Hospital and Tepi General Hospital are anticipated to provide care for more than 500 000 people.

Study design and time frame

An institutional-based, cross-sectional study was conducted from 1 June to 30 July 2021.

Participants

All mothers who gave birth at Mizan Tepi University Teaching Hospital, G/Tsadik Shawo General Hospital, Tepi General Hospital and Bachuma Primary Hospital during the study period were the study populations. On the other hand, those mothers who were critically sick, women incapable of communicating and referred mothers after giving birth were prohibited from the study.

Sample size and sampling technique

The sample required for this study was calculated using the single population proportion formula by considering the following assumptions: the proportion (p)=35% of women who received RMC in the West Shewa zone, Oromia region,¹⁷ Z=standard normal distribution (Z=1.96) with a CI of 95%, d=tolerable margin of error (d)=0.05 and 10% non-response rate. Accordingly, the total sample size required for this study was=384. To ensure the adequacy of sample size, Epi Info was used to calculate sample size for factors associated with RMC services.

Four out of seven hospitals in the region (ie, Mizan Tepi University Teaching Hospital, Tepi General Hospital, G/Tsadik Shawo General Hospital and Bachuma Primary Hospital) were selected purposively depending on the administrative arrangement of people from each zone and the presence of higher delivery services. The allocation of the sample to hospitals was made proportionally based on the average number of delivery services at each hospital in the past 2 months before the data collection period (Mizan Tepi University Teaching Hospital=118, Tepi General Hospital=89, G/Tsadik Shawo General Hospital=99 and Bachuma Primary Hospital=78). The sampling interval, ‘K’=4, was determined by dividing the source population (ie, total 2-month deliveries from the nominated hospital) to total sample size. Finally, the individual participants were selected by using a systematic random sampling technique based on the sampling frame obtained from the delivery registration logbook. After randomly selecting the first woman among the first four postpartum mothers in the sampling frame, the next woman will be chosen every four intervals until the required sample size at each hospital was obtained.

Outcome variables

Level of RMC

Women’s level of experience of RMC was measured according to the Mothers on Respect (MOR) Index: scores extending from 14 to 31 were considered very low respect, scores extending from 32 to 49 were considered low respect, scores extending from 50 to 66 were considered moderate respect and scores extending from 67 to 84 were considered high respect.^{22 23}

Independent variables

Sociodemographic-related factors

Age, religion, ethnicity, marital status, educational status, occupation, family size, monthly income and residence.

Obstetrics-related factors

Parity, antenatal care follow-up, pregnancy intended, discussion on the place of delivery with a partner, visit type of current delivery, initiation of labour, duration of labour, mode of delivery, professional who attended the delivery, sex of care provider, number of attendants during delivery, person(s) other than the care providers were allowed into the birthing room who could observe the mother while naked on the bed, time of delivery, future intention to give birth within the health facility, complication during delivery, the outcome of delivery and duration of stay at the health facility.

Data collection and quality assurance

Primary data were collected by interviewer-administered structured questionnaires from mothers through face-to-face exit interviews, quickly before discharge from the postnatal care unit, in a separate room to preserve privacy. Incentives were not given to study participants for their participation. Four BSc midwives and two master’s degree holder nurses who have no clinical relationship with the women were recruited for data collection and supervision, respectively. The training was given 1 day before the actual data collection for supervisors and data collectors. A pretest was conducted on 20 mothers before the actual data collection to check the consistency of the questionnaire and the capacity of the data collectors to carry out their duty. The questionnaire was modified based on the pretest outcomes. Data collection tools were prepared in English and interpreted into the local language (Amharic), and to keep its consistency, it was back-translated into English by language experts. Tools for evaluating RMC were received from the MOR Index with a few adjustments to fit the setting.²² The tool has 14 questions, and each question is rated on a 6-point Likert scale and contains a maximum score of 84 and a minimum score of 14. This MOR Index was developed through a participatory investigation process and could be a reliable and valid measure of RMC. The instruments evaluating independent factors were adjusted from different literature.^{22 24–27} To keep the quality of information, all the questionnaires were reviewed and its completeness checked each day by supervisors and principal investigators (online supplemental annex I).

Data processing and analysis

Data were entered by using EpiData Manager V.4.0.12 and exported to SPSS V.26 software package for analysis. Data cleaning was made to check for precision, consistency and values. Descriptive statistics (frequency, mean, median, SD and percentage) were used to depict the sociodemographic characteristics of the study population. Since the response for the dependent variable is ordinal (very low respect, low respect, medium respect and high respect), the method of analysis used was an ordinal logistic regression. From the ordinal logistic regression investigation models, we used the proportional odds model, which is the most well-known, and states that the effect of each figure is expected to be equal over the outcome categories. A bivariate ordinal regression method was done to see the crude association between the independent factors and the ordinal outcome variable. Before going on multivariable ordinal logistic regression analysis, the issue of the relationship among independent factors (multicollinearity) was checked by collinearity diagnostic tests, and factors with variance inflation factor less than 10 were considered as a candidate for analysis. At this level, the fitness of the proportional odds model was checked by the test of parallel lines, which was >0.05. Finally, factors having a p value less than 0.05 with 95% CI were considered a significant association with the outcome.

Patient and public involvement

Patients and/or the public were not involved in the design or conduct or reporting or dissemination plans of this research.

Results

Sociodemographic characteristics of study participants

Among a total of 384 sampled subjects, 370 (96.3%) postnatal mothers participated in the research. The mean age of the participants was 28.6 (SD±6.7) years with a minimum and maximum age of 17 and 46 years, respectively. Among the whole respondents, almost 151 (40.9%) were Protestant religious believers and approximately 130 (35.2%) of the women were Kaffa by ethnicity. The larger part of the study members (315 (85.1%)) were married and nearly half (175 (47.3%)) of the women completed higher education. Almost one-third (119 (32.2%)) of the women were working as government employees, and 164 (44.3%) of study participants have a monthly family income of between 3201 and 7800 Ethiopian birr (table 1).

Table 1.

Sociodemographic characteristics of the study participants (n=370)

Variable	Category	Frequency (N)	Percentage
Age	15–24	109	29.5
	25–34	188	50.8
	35–49	73	19.7
Religion	Orthodox	139	37.5
	Muslim	80	21.6
	Protestant	151	40.9
Ethnicity	Bench	116	31.4
	Kaffa	130	35.1
	Amhara	67	18.1
	Oromo	43	11.6
	Other*	14	3.8
Marital status	Married	315	85.1
	Single	25	6.8
	Divorced	15	4.1
	Other†	15	4.1
Educational status	No formal education	77	20.8
	Primary and secondary education	118	31.9
	Higher education	175	47.3
Occupation	Government employee	119	32.2
	Farmer	74	20.0
	Housewife	108	29.2
	Daily worker	55	14.9
	Other‡	14	3.8
Monthly income (ETB)	≤3200	118	31.9
	3201–7800	164	44.3
	≥7801	88	23.8
Family size	≤4	256	69.2
	≥5	114	30.8
Residency	Urban	174	47.0
	Rural	196	53.0

*Sheka/sheko/Tigrawai/Dizu/Gurage.

†Widowed/separated.

‡Merchant/private employee/student/unemployee.

ETB, Ethiopian birr.

Obstetric characteristics of study participants

Of the whole study participants, the majority (294 (79.4%)) of mothers had antenatal care follow-up, and around two-thirds (252 (68.1%)) of pregnancies were planned and wanted. Among respondents, 289 (78.1%) of them discussed the place of delivery with their partners. The majority (309 (83.5%)) of mothers’ labour began spontaneously, and around two-thirds (242 (65.4%)) of women gave birth through spontaneous vaginal delivery. Almost two-thirds (238 (64.3%)) of the ladies gave birth during daytime (06:00–18:00 East Africa Time), and nearly one-fourth (82 (22.2%)) of the women complied with the rule that persons other than caregivers were allowed into the birthing room who could observe mother while naked on the bed during labour and delivery. Of the overall respondents, 87 (23.5%) had no intention of giving birth in a health institution. The main reasons for not giving birth in the health facilities were lack of satisfaction during their current maternal care service (50 (57.4%)) and home preference (26 (29.8%)) (table 2).

Table 2.

Obstetric-related characteristics of the study participants (n=370)

Variables	Category	Frequency (N)	Percentage
Number of parity	1	175	47.3
	2–3	123	33.2
	≥4	72	19.5
Current ANC follow-up	No contact	76	20.6
	One to three contacts	187	50.5
	Four and above contacts	107	28.9
Current pregnancy intended	Yes	252	68.1
	No	118	31.9
Discussed place of delivery with partner	Yes	289	78.1
	No	81	21.9
Visit type for current delivery	First time	248	67.0
	Repeat visit	76	20.6
	Referred	46	12.4
Labour started	Spontaneous	309	83.5
	Induced	61	16.5
Duration of time spent on labour	≤12 hours	260	70.3
	More than 12 hours	110	29.7
Duration of current stay at a health facility	Less than 24 hours	298	80.5
	More than 24 hours	72	19.5
Mode of delivery	Spontaneous	242	65.4
	Caesarean section	32	8.6
	Assisted delivery	96	25.9
Outcome of delivery	Alive	355	95.9
	Stillbirth	15	4.1
Complications during childbirth	No complication	302	81.6
	Had complication	68	18.4
Professional who attended the delivery	Midwife	243	65.7
	Nurse	74	20.0
	Doctor	25	6.8
	Emergency surgeon	28	7.6
Sex of provider	Male	198	53.5
	Female	172	46.5
Asked the mother’s consent before any procedure	No	195	52.7
	Yes	175	47.3
Number of attendants during delivery	One	37	10.0
	Two	159	43.0
	Three and above	174	47.0
Person(s) other than the care providers were allowed into the birthing room who could observe the mother while naked on the bed	Yes	82	22.2
	No	288	77.8
Time of delivery	Daytime	238	64.3
	Night-time	132	35.7
Future intention to give birth within the health facility	Yes	283	76.5
	No	87	23.5
If not, why?	Not satisfied	50	57.4
	Home better	26	29.8
	Not sure	11	12.8

ANC, antenatal care.

Level of RMC

Among the total of 370 participating women who gave birth in public hospitals in the South West Region, 43 (11.6% (95% CI: 8.4% to 15.1%)), 147 (39.7% (95% CI: 34.3% to 44.6%)), 77 (20.8% (95% CI: 17.3% to 25.1%)) and 103 (27.8% (95% CI: 23.5% to 32.4%)) experienced very low, low, moderate and high respect during childbirth, respectively (figure 1).

Figure 1.

Level of respectful maternal care in public hospitals of the South West Region of Ethiopia, 2021.

Prevalence of RMC described by institutions

Among the total participants included in the study, the highest prevalence of high-level RMC was reported at G/Tsadik Shawo General Hospital (9.2%), followed by Mizan Tepi University Teaching Hospital (8.1%). The median MOR Index score of women at Mizan Tepi University Teaching Hospital, G/Tsadik Shawo General Hospital, Tepi General Hospital, and Bachuma Primary Hospital was 48, 55, 49, and 47, respectively (figure 2).

Figure 2.

Levels of respectful maternal care at each hospital in the South West Region of Ethiopia, 2021. MTUTH, Mizan Tepi University Teaching Hospital.

Factors associated with the level of RMC

To identify the factors associated with the level of RMC, both bivariate and multivariate ordinal logistic regression analyses were done. On bivariate analysis, variables with a p value less than 0.25 were considered candidate variables for multivariate ordinal logistic regression analysis. Finally, after fitting the assumption of the proportional odds model, variables with a p value less than 0.05 and 95% CI (educational status, mode of delivery, time of delivery and mother’s future intention to give birth in the health facility) were found to be significantly associated with RMC practice.

The odds of getting a high-level RMC service among respondents with no formal education were diminished by 49% (adjusted OR (AOR)=0.51, 95% CI: 0.294 to 0.899) compared with those who had completed higher education. The odds of receiving a higher level of RMC service were 2.19 times (AOR=2.19, 95% CI: 1.410 to 3.404) higher among ladies who gave birth through caesarean section than mothers who gave birth through assisted vaginal delivery. Mothers who gave birth during daytime had 8.53 times (AOR=8.53, 95% CI: 5.032 to 14.47) higher odds of higher-level RMC compared with mothers who gave birth at night-time. The chances of a higher level of RMC were 5.18 times (AOR=5.18 95% CI: 3.019 to 8.899) higher among mothers who did have a future intention to give birth in a health facility compared with their counterparts (table 3).

Table 3.

Ordinal logistic regression output showing factors associated with the level of respectful maternal care during childbirth (n=370)

Variables	Level of respectful maternal care
	Very low	Low	Moderate	High	Estimate (B)	AOR (95% CI)
Educational status
No formal education	17 (22)	34 (44.2)	20 (26)	6 (7.8)	−0.664	0.51 (0.294 to 0.899)*
Primary & secondary education	8 (6.8)	55 (46.6)	16 (13.6)	39 (33.1)	−0.475	0.62 (0.380 to 1.016)
Higher education	18 (10.3)	58 (33.1)	41 (23.4)	58 (33.1)	Ref
Pregnancy planned & wanted
Yes	33 (13.1)	113 (44.8)	42 (16.7)	64 (25.4)	−0.438	0.64 (0.409 to 1.017)
No	10 (8.5)	34 (28.8)	35 (29.7)	39 (33.1)	Ref
ANC follow-up
No contact	13 (17.1)	34 (44.7)	15 (19.7)	14 (18.4)	−0.425	0.65 (0.364 to 1.173)
One to three	19 (10.2)	76 (40.6)	46 (24.6)	46 (24.6)	0.137	1.14 (0.701 to 1.871)
Four and above	11 (10.3)	37 (34.6)	16 (15)	43 (40.2)	Ref
Labour started
Spontaneously	42 (13.6)	122 (39.5)	64 (20.7)	81 (26.2)	−0.480	0.61 (0.337 to 1.135)
Induced	1 (1.6)	25 (41)	13 (21.3)	22 (36.1)	Ref
Mode of delivery
SVD	21 (8.7)	11 (34.4)	59 (24.4)	76 (31.4)	0.136	1.14 (0.548 to 2.386)
Caesarean section	7 (21.9)	7 (21.9)	7 (21.9)	50 (52.1)	0.785	2.19 (1.410 to 3.404)*
Assisted vaginal delivery	15 (15.6)	11 (34.4)	11 (11.5)	20 (20.8)	Ref
Labour duration
≤12 hours	27 (10.4)	96 (36.9)	62 (23.8)	75 (28.8)	0.035	1.03 (0.631 to 1.700)
>12 hours	16 (14.5)	51 (46.4)	15 (13.6)	28 (25.5)	Ref
Residency
Urban	19 (10.9)	68 (39.1)	33 (19.0)	54 (31)	0.171	1.19 (0.818 to 1.721)
Rural	24 (12.2)	79 (40.3)	44 (22.4)	49 (25)	Ref
Time of delivery
Daytime	4 (1.9)	75 (31.5)	73 (30.7)	86 (36.1)	2.144	8.53 (5.032 to 14.47)*
Night-time	39 (29.5)	72 (54.5)	4 (3)	17 (12.9)	Ref
Sex of caregiver
Male	26 (13.1)	75 (37.9)	42 (21.2)	55 (27.8)	−0.043	0.95 (0.660 to 1.389)
Female	17 (9.9)	72 (41.9)	35 (20.3)	48 (27.9)	Ref
Future intention to give birth in HF
Yes	5 (1.8)	120 (42.4)	63 (22.3)	95 (33.6)	1.645	5.18 (3.019 to 8.899)*
No	38 (43.7)	27(31)	14 (16.1)	8 (9.2)	Ref

*p-value <0.05.

ANC, antenatal care; AOR, adjusted OR; HF, health facility; SVD, spontaneous vaginal delivery.

Discussion

Background

Estimation of women’s sense of respect during maternity care can give a shred evidence to predict the viability of progressing the quality of the maternal healthcare system.^{28 29} This study examined the level of RMC during childbirth and its related factors at public hospitals within the South West Region of Ethiopia.

Key results

The current study revealed that 11.6% (95% CI: 8.4% to 15.1%), 39.7% (95% CI: 34.3% to 44.6%), 20.8% (95% CI: 17.3% to 25.1%), and 27.8% (95% CI: 23.5% to 32.4%) of mothers experienced very low, low, moderate and high respect during childbirth, respectively. The factors significantly associated with RMC experience were educational status, mode of delivery, time of delivery and mother’s future intention to give birth in the health facility.

Comparison with similar studies

In this study, about one-quarter of ladies have experienced a high level of RMC during their childbirth, whereas a study conducted in Nepal appeared that more than three-quarters of ladies experienced RMC during their later childbirth.²⁸ The difference in RMC experience might be due to study setting, sample size, sociocultural characteristics and differences in the method of measurement. Other studies in Ethiopia (Bahir Dar, West Shewa, Harer and Ilu Aba Bora) showed that the proportion of RMC was 57%, 35.8%, 38.4% and 47.3%, respectively.16 17 24 30 The possible explanation for the low predominance in this study compared with the other studies might be due to the utilisation of distinctive models for the estimation of RMC. This study measures RMC by using the MOR Index tool, which may be a reliable and valid measure of RMC, and it is vital to rating women’s level of consolation, and impact on their inclination to inquire about questions, and/or perceptions of discrimination when getting care.²³

This study revealed that the extent of very low and low respect experienced by the women were 11.6% and 39.7%, respectively. Studies in South Wollo (79.4%), Addis Ababa (78%), North Shewa (100%) and Arba Minch (98.9%) of respondents experienced at least one category of disrespect and abuse (physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination based on particular patient attributes, abandonment of care and detention in facilities).4 15 26 27 31 The variations might be unlike the other studies, as this study uses the ranges of Likert scale scores, not the individual response of the items to measure women’s level of respect.

Mothers who had no formal education were found to be 49% less likely to receive a high level of RMC compared with mothers who had completed higher education. This finding is supported by studies in Debre Birhan²⁵ and Arba Minch.²⁷ This could be because uneducated mothers might have relatively less information about their rights and claims within the health facility. Besides, an uneducated mother might have poor communication with the care provider and have fewer health-seeking behaviours that might incline care providers to disregard her when giving healthcare services. However, this finding is contradicted by findings in Tigray³² and Jimma,³³ which reported that mothers with secondary and more education were more likely to be disrespected than illiterate mothers. This inconsistency might be due to a difference in study setting and difference in model verification criteria. Similarly, a study conducted in Jimma had a small sample size and study population variation that excludes mothers who gave birth via caesarean section.

In this study, women who gave birth through caesarean section were 2.19 times more likely to experience a higher level of RMC service compared with women who gave birth through assisted vaginal delivery. This finding is comparable with studies conducted in Ilu Aba Bora (South West Ethiopia)²⁴ and Nigeria,³⁴ where mothers who gave birth through instrumental deliveries were less likely to have RMC than those who gave birth through spontaneous vaginal deliveries and caesarean section. The possible reason for this association may be that mothers who gave birth through caesarean section might have been given special consideration and support due to the fear of complications, while mothers who gave birth through assisted delivery may suffer a lot of stress and pain due to the procedure and they may not remember the real situations during that time. On the contrary, studies in Arba Minch (Southern Ethiopia)²⁷ and Bahir Dar¹⁶ showed that respondents who gave birth through caesarean section were more likely to experience disrespect and abuse.

Mothers who gave birth during daytime were 8.53 times more likely to have a high level of RMC compared with mothers who gave birth during night-time. This result was coherent with findings in West Shewa (Oromia region) and Debre Birhan (Amhara region).^{17 25} This might be because during daytime, care providers may provide more respectful care due to fear of supervision from senior health workers and managers and/or more resources or infrastructures (electricity, medications) may also be available. On the other hand, mothers who gave birth during night-time may be prone to less respect due to staff workload (the number of care providers may be small) and tiredness caused by disturbance of sleeping time.

Respondents who have future intentions to give birth in a health facility were five times more likely to report high-level RMC than respondents who have no plan to give birth in a health facility. This finding is upheld by a study conducted in Bahir Dar.¹⁶ This might be clarified by respondents who experience high respectful care in health facilities that they will be more likely to repeat the experience in the future than if they had a negative experience.

Limitations and future work

This study might be affected by social desirability bias due to fear or to avoid blaming providers for negative experiences. In this study, RMC was measured from the mother’s viewpoint; it ought to be surveyed from different viewpoints to provide broader evidence. Future researchers ought to further investigate community-related and health system-related barriers to respectful delivery of care, including through qualitative research.

The study was conducted at public hospitals in the South West Region of Ethiopia. We used a probability sampling technique to select study participants to ensure that the findings could be generalised to all women who gave birth in public hospitals in the region. However, the results may not be generalisable to women who gave birth in health centres in the region, nor to other regions of Ethiopia.

Conclusion

RMC practice within the study area was poor, as only one-fourth of women experienced high respect, and more than half of women experienced low or very low RMC during their childbirth. Caesarean section, daytime delivery and future intention to give birth within the health facility were positively associated with experience of a high level of RMC, whereas having no formal education was negatively associated. Responsible stakeholders must develop guidelines and strategies to monitor and harmonise RMC practices in all institutions.

Data availability statement

Data are available upon reasonable request. The datasets used during the current study are available from corresponding authors when reasonably desired.

Ethics statements

Patient consent for publication

Obtained.

Ethics approval

This study involves human participants and ethical approval for this study was obtained from the Ethical Review Committee of Mizan Tepi University, College of Medicine and Health Sciences (reference number MTU/ERC/00127/21). Participants gave informed consent to participate in the study before taking part.