Respectful Maternity Care during Childbirth among Women in a Rural Area of Northern India

Abstract

Background:

Respectful maternity care (RMC) is increasingly being accepted as an essential element for health systems. Every childbearing woman has a right to get dignified and respectful healthcare. Initial research has highlighted that disrespect and abuse are widespread, however, there is a paucity of quantitative evidence.

Materials and Methods:

In this community-based cross-sectional study, among 485 participants, conducted in 28 villages of Northern India, we ascertained the experience of RMC during childbirth by using the person-centered maternity care (PCMC) scale.

Results:

The majority (88.7%) of women experienced RMC. The domain with the lowest score was communication and autonomy (62.9%), followed by supportive care (76.1%). Self-introduction by health providers, the position of choice during delivery, relief from pain, and availability of preferred companions during delivery were the deficient areas. Women who gave birth in private health facilities were more likely to receive RMC than those who gave birth in government facilities, while those belonging to marginalized social groups had lesser odds of receiving RMC as compared to other women.

Conclusion:

Communication skills should be promoted to maternity care providers. Self-introduction by healthcare providers and choice of position during delivery are the deficient areas, which should be focused upon.

INTRODUCTION

Every childbearing woman has the right to receive dignified and respectful healthcare throughout her pregnancy and childbirth. World Health Organization (WHO) defines respectful maternity care (RMC) as “care organized for and provided to all women in a manner that maintains their dignity, privacy, and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labor and childbirth.”[1] The relationship that develops between a woman and the maternity care providers during the period of pregnancy and delivery is crucial. The experience at this vulnerable time may either boost her self-esteem, leading to the building of confidence and trust or may inflict lasting damage and emotional trauma if there is disrespect or abuse. Either way, childbearing experiences are often exchanged among women, which contributes to an environment of confidence or doubt regarding maternity care services, thus influencing their decisions to seek these essential and potentially life-saving services. This, also, has a bearing on the health of the mother as well as the newborn.[2]

RMC is increasingly being recognized as an essential element of health systems, more so from a human rights perspective.[3,4] The White Ribbon Alliance developed the RMC charter that delineates the rights of childbearing women against disrespect and abuse in seven key domains. These include “respect for women’s dignity, autonomy, empathy, privacy, confidentiality, choices, and preferences, including companionship during maternity care and continuous care during labor and childbirth. It protects women from any harm and mistreatment.”[5]

Initial research related to experiences of women during delivery highlighted that disrespect and abuse are widespread, but are grossly under-reported due to lack of awareness, and normalization of disrespect.[6,7] Studies have been conducted on women’s experiences throughout the continuum of maternity care, however, there is a paucity of data related to disrespect and abuse rates.[8] There are a limited number of studies available from India, particularly among rural women.

In India, over the last two decades, policy measures and financial incentives under the National Health Mission have led to a marked increase in institutional deliveries from 39% in 2005–06 to 79% in 2015–16 and 89% in 2019–20.[9] In 2017, the Government of India incorporated RMC in its priorities under the Labour Room Quality Improvement Initiative (LaQshya) program, an initiative aimed at reducing maternal deaths, by elevating the standards of labor rooms and fostering a positive birthing experience for all women attending public health facilities.[10] With more and more women accessing health facilities for childbirth, it becomes pertinent to assess the experiences related to RMC. In the present study, we assessed the perception of RMC by women during childbirth in rural areas of North India, quantitatively, by using a validated tool.

MATERIALS AND METHODS

Study design and study site

This was a cross-sectional community-based study. It was conducted in 28 villages under Ballabgarh block, Faridabad district in Haryana, a Northern Indian state. The total population of the study area was nearly 100,000 in the year 2020. An average of 2800 births took place in the area annually. The health and vital statistics information in the Health and Demographic Surveillance System (HDSS) of Ballabgarh were recorded fortnightly by village-level health workers during domiciliary visits, and in a yearly census. This information was maintained in a computerized database – Health Management Information System (HMIS).

The two primary health centers (PHCs), i.e., PHC Chhainsa, and PHC Dayalpur with their 12 subcenters (six under each) provide primary health services in the area. A 50-bed sub-district hospital (SDH) run by the State Government in collaboration with the study institute – an apex medical and research institution of Northern India provided secondary care services, including referral services for obstetric care.[11]

Other health facilities in the area included a district hospital (BK hospital), a community health center (CHC Kurali), and six PHCs run by the State Government. Besides this, there were an array of private health facilities in the area that provided maternal and child health (MCH) services. Most of these facilities were primary or secondary-level health facilities.

Study participants

Women residing in the study area, who had an institutional delivery within 6 months preceding the data collection period were included as study participants. Women who had abortions or home delivery or who were not available after three domiciliary visits were excluded.

Sample size

The sample size calculation was based on the reported prevalence of disrespect and abuse experienced by women during childbirth. A systemic review and meta-analysis of studies conducted in India reported that the prevalence of disrespect and abuse ranged from 20.9% to 100%.[12] Considering the lowest reported prevalence (20.9%), with a relative precision of 20% with a 95% confidence interval, using the formula 4pq/d² for a cross-sectional study (where, P = reported prevalence, q = (1 − p), and d is an allowable error), the calculated sample size was 364. Accounting for 10% pregnancy wastage, 5% migration, and 10% non-response, the sample size was increased to 485 pregnant women.

Study tools

The person-centered maternity care (PCMC) scale was administered to ascertain the childbirth care experience. As defined by the Institute of Medicine, PCMC refers to “maternity care, which is respectful and responsive to individual women and their families’ preferences, needs, and values, and ensuring that their values guide all clinical decisions”.[13] For India, the PCMC scale is a 27-item scale with each item having a score of 0–3 based on the experience of the women during their stay in a healthcare facility. The scale has been validated in India and is available in Hindi.[14] It has a total score of 0–81 in which a higher score indicates better care. For ease of comparison between different domains, the score can be rescaled to get a total out of 100. The scale has three main domains that have questions/items related to the domains, namely dignity and respect (six items), communication and autonomy (nine items), and supportive care (12 items).

Data collection

Data collection was done from 17 December 2020 to 26 January 2021. A list of women, who had a childbirth during the 6 months preceding the data collection, was obtained from the HMIS. A total of 920 women had childbirth during this period, out of which, 485 women were selected by simple random sampling. The participants were contacted by domiciliary visits. A written informed consent was obtained, and an interview schedule was administered that included sociodemographic, and obstetric details. The PCMC scale was administered to ascertain the status of RMC during childbirth. The outcome variables were the PCMC score obtained in each domain as well as the total score. Women who scored more than 66.7% on PCMC scale domains were considered to have received RMC. As per the scoring system of the PCMC scale, a score of 66.7% or more implied that women had received RMC “all of the time” or “most of the time.”

The data entry was done using Google Forms, which was then transferred to Google Sheets and subsequently Microsoft Excel 2019.

Statistical analysis

The statistical analysis was carried out with Stata 15.2 (College Station, Texas, USA). Summary statistics (mean, standard deviation (SD), and frequency (percentage)) were reported for sociodemographic variables. The mean (SD) for normal distribution and median Inter-Quartile Range (IQR) for skewed distribution were calculated.

Logistic regression analysis was conducted to find the association between sociodemographic factors and receipt of RMC. The variables included age, education, economic status, caste, type of family, mode of delivery, and type of healthcare facility (government or private). Univariate analysis followed by multivariate logistic regression analysis was carried out. Multivariate logistic regression was conducted for variables with P values less than 0.25 in univariate analysis (age, education, caste, and type of facility). The significance level was considered as P < 0.05.

Ethical considerations

Ethical approval was obtained from the Institute Ethics Committee of All India Institute of Medical Sciences, New Delhi, before conducting the study. Permission for the use of the PCMC scale and guidelines for its scoring were obtained from the author. Written consent was obtained from the study participants. Confidentiality of the data was maintained throughout the study.

RESULTS

Out of 485 pregnant women selected from the HMIS, 20 were not available despite three domiciliary visits, and three women refused consent. The remaining 462 women were contacted, out of which 32 reportedly had abortions, and six had delivered at home. Hence, they were excluded and finally, 424 participants were included in the study. The mean (SD) age of the participants was 24 (3.3) years. Most women (69.1%) were multipara. Almost half (51.4%) of the women delivered in a government health facility, and nearly equal proportion (48.6%) had delivered in private health facilities. The percentage of normal vaginal delivery and caesarean section was 68.6 and 31.4, respectively [Table 1].

Table 1.

Distribution of participants by sociodemographic and other characteristics

Variable	Number (n=424)	(%)
Age group (years)
<25	233	55.0
25–29	157	37.0
≥30	34	8.0
Education
Illiterate	65	15.3
Literate	359	84.7
Economic status
Above poverty line	369	87.0
Below poverty line	55	13.0
Religion
Hindu	402	94.8
Others	22	5.2
Caste
Scheduled caste/tribe	150	35.4
Others	274	64.6
Type of family
Nuclear	124	29.2
Extended	300	70.8
Parity
Primipara	131	30.9
Multipara	293	69.1
Type of facility
Government	218	51.4
Private	206	48.6
Type of delivery
Normal vaginal	291	68.6
Caesarean section	133	31.4

The receipt of RMC is indicated by the PCMC scores [Table 2]. The total PCMC score was 76.3% [median (IQR) =80.2 (67.0–92.5)]. The highest score, i.e. 91.1% was observed in the domain of dignity and respect, with a median (IQR) score of 18.0 (16.0–20.0). The score for supportive care was 76.1% [median (IQR) =29.0 (10.0)]. The domain with the least score, i.e. 62.9% was communication and autonomy [median (IQR) =18.0 (13.0–23.0)]. In this domain, introduction by the doctors or nurses, consent before examination or procedures, and choice of position for delivery were the areas where the scores were low (2.7%, 45%, and 3.7%, respectively). In the domain of supportive care, the areas with least scores were availability of a ‘companion of choice during delivery’ (22.9%), and ‘pain control/management during labour’ (11.6%).

Table 2.

Scores in various domains of respectful maternity care (RMC)

Domain (Score: Min–max)	Median (IQR)	Score (%)
Total PCMC score (0–81)	65.0 (10.0)	76.3
Dignity and respect (0–18)	18.0 (4.0)	91.1
Communication and autonomy (0–27)	18.0 (10.0)	62.9
Supportive care (0–36)	29.0 (10.0)	76.1

Women with a total score of more than 66.7% on the PCMC scale were considered to have received RMC. As per the scoring system of the PCMC scale, a score of 66.7% or more implied that women had received RMC “all of the time” or “most of the time” in all the domains. Hence, a cut-off of 66.7% was chosen.

We found that 355 (83.7%) women in our study scored more than 66.7% and hence received RMC. Table 3 shows an association of receiving RMC with various sociodemographic and obstetric factors. Women who delivered in a private health facility had higher odds of receiving RMC as compared to those who delivered in a government health facility. Women belonging to scheduled castes or tribes had lesser odds of receiving RMC as compared to other women. Other factors, such as age, education, economic status, religion, and parity, were not significantly associated with RMC.

Table 3.

Sociodemographic and obstetric factors associated with respectful maternity care (RMC)

Variable	Total (n=424)	RMC		Unadjusted		Adjusted
		Received (n=355)	Not received (n=69)	OR (95% CI)	P	OR (95%CI)	P
Age (years)
<25	233	201 (86.3)	32 (13.7)	1		1
25–30	157	127 (80.9)	30 (19.1)	0.67 (0.39, 1.16)	0.156	0.64 (0.37, 1.15)	0.136
>30	34	27 (79.4)	7 (20.6)	0.61 (0.25, 1.53)	0.294	0.67 (0.25, 1.89)	0.435
Education
Illiterate	65	49 (75.4)	16 (24.6)	1		1
Literate	359	306 (85.2)	53 (14.8)	1.89 (1.00–3.56)	0.05	1.41 (0.72, 2.79)	0.325
Economic status
Above poverty line	369	311 (84.3)	58 (15.7)	1		_
Below poverty line	55	44 (80.0)	11 (20.0)	0.75 (0.36, 1.53)	0.424	_
Caste
Others	274	242 (88.3)	32 (11.7)	1		1
Scheduled caste/tribes	150	113 (75.3)	37 (24.7)	0.40 (0.24, 0.68)	0.001	0.48 (0.28, 0.83)	0.009
Family
Nuclear	124	102 (82.3)	22 (17.7)	1		_
Extended	300	253 (84.3)	47 (15.7)	1.16 (0.67, 2.02)	0.599	_
Parity
Primipara	131	110 (84.0)	21 (16.0)	1		_
Multipara	293	245 (83.6)	48 (16.4)	0.97 (0.56, 1.71)	0.928	_
Type of facility
Government	218	165 (75.7)	53 (24.3)	1		1
Private	206	190 (92.3)	16 (7.8)	3.81 (2.10, 6.93)	<0.001	3.34 (1.82, 6.14)	<0.001
Type of delivery
Normal	291	241 (82.8)	50 (17.2)	1		_
Caesarean	133	114 (85.7)	19 (14.3)	1.24 (0.70, 2.21)	0.454	_

DISCUSSION

Disrespect and abuse during childbirth is a public health concern as it is prevalent in many settings in the form of physical abuse, non-consented care, non-dignified care, confidentiality of care, and discrimination. Various studies, globally, have emphasized that during childbirth disrespect and abuse of women are prevalent during childbirth, with the rates varying from 15% to 98%.[2,15,16,17] A systematic review of Indian studies showed that the prevalence ranged from 20.9% to 100%.[12] This difference could be due to methodological issues, such as measurement of disrespect and abuse, variation in conceptualization of domains of RMC, as well as settings where the studies were conducted. In a study conducted in a Northeastern state of India (Manipur), Rajkumari et al.,[18] reported that 96.5% of women experienced some sort of abuse. In studies conducted in Aligarh (2019) and Varanasi (2018), the prevalence of disrespect and abuse was reported to be 84.3% and 71.2%, respectively.[19,20] In our study, 83.7% of participants received RMC, while disrespect was experienced by 16.3% of the women. This is lower than the reported pooled prevalence of 77.3% in community-based studies, as well as other studies conducted in India.[12,19,20] This could be due to better implementation of the LaQshya program in the state of Haryana, which had the highest number of facilities certified by the National Quality Assurance System (NQAS) in the country (besides the southern state of Telangana).[21] Also, a large proportion of deliveries were conducted at the PHCs and the SDH affiliated with the study institute, where much emphasis was laid on RMC.

In our study, two women (0.5%) reported physical abuse and five (1.2%) reported verbal abuse. However, we found that RMC was particularly deficient in the domains of communication and autonomy, as 97% of women reported that the doctors and nurses did not introduce themselves, and 53% of the women reported that consent was not taken before conducting an examination or a procedure. Similar findings were reported in studies conducted in public health facilities of Gujarat (2021) and Delhi.[22,23] Another study conducted recently in Kenya, Ghana, and India that used the PCMC scale also highlighted that it is the absence of positive interactions rather than the presence of negative interactions like physical or verbal abuse that affects the experience of RMC.[24] This indicates the gaps in effective communication and highlights the need for training in communication skills for maternity care providers. Other areas where a lack of RMC was observed were relief from pain and the availability of a companion of choice during delivery. Earlier studies conducted in India as well as other countries have also highlighted these issues.[15,22,23,25] WHO recommends epidural analgesia for pain relief in healthy pregnant women who request the same, depending on their preferences, for a positive childbirth experience. Nevertheless, all women are recommended to have a chosen companion during the process of labor and childbirth. Simultaneously, the preferences of women should be honored and respected, including those who may choose not to have any companion. It has been reported that companionship during delivery is not permitted in many health settings, despite strong evidence to support that it enhances the positive childbirth experience. Hence, extra efforts are required to implement the same.[1] We found that women who belonged to certain castes and tribes had lesser odds of receiving RMC as compared to others. Similar findings were reported by other studies.[12,17] Our study found that women who delivered in private health facilities were more likely to receive RMC as compared to those who delivered in Government health facilities. Nawab et al.[19] and Rajkumari et al.[18] reported similar findings in their studies conducted in Aligarh and Manipur, respectively.

This study had some strengths, first was the use of a standardised and validated measurement tool, i.e. the PCMC scale. Such measurement objectively allows the assessment of RMC and changes over time can be tracked. Community-based study design was another strength, as most of the earlier studies were facility-based, where there was the possibility of bias in the assessment of disrespect and abuse, whether it was based on observation or interview of the study participants.

Our study had few limitations. We used the PCMC scale for interviewing women within 6–24 weeks, i.e. 1.5–6 months of childbirth, respectively. This could have led to recall bias. However, it is understood that childbirth is a vital event, and women tend to remember the experience for a long time. PCMC scale has earlier been used in a study in India to assess RMC among women who had a child less than 2 years of age.[18] Moreover, the PCMC scale has recently been validated among people of color who have given birth in the last 1 year.[26] Hence, we believe that the findings of our study are valid. RMC may differ depending on the level of healthcare, namely, primary, secondary, or tertiary; however, the data regarding the same was not analyzed.

Globally, both quantitative and qualitative studies have been conducted previously; however, very few studies are available from India, particularly among rural women. It is important to conduct a comprehensive assessment of women’s childbirth experiences to enhance the quality of care, thereby influencing MCH outcomes.

CONCLUSION AND RECOMMENDATIONS

RMC was received by a majority of women. Although the prevalence of verbal and physical abuse was low, there was a lack of positive interactions. Self-introduction by health providers, consent before conducting examination, and procedures, allowing a position of choice during delivery, relief from pain, and availability of a preferred companion during delivery were the areas, which were deficient and needed improvement to provide RMC during childbirth. Private hospitals being competition-driven and customer-centric provide more RMC. The government sector should increase investment in training and development (including communication skills), the culture of accountability should be fostered, and there is a need to implement transparent feedback mechanisms to continuously improve service quality.

Patient and public involvement

Consent has been taken from all the study participants.

Ethics approval

The ethical clearance for this study was obtained by the Institutional Ethics Committee of AIIMS, New Delhi. (Reference no.- IECPG-634/25.11.2020).

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.