Table 2.
Third order themes | Second order themes | Illustrative manifestations of experiences and reports of first order themes from Kenya | ||
---|---|---|---|---|
Women | Men | Health providers (HPs)/managers | ||
Intentional mistreatment: use of violence, physical, verbal, negligent withholding of care | ||||
Physical abuse | Use of force | Slapping/pinching | Beaten by HPs | Slap to save a woman’s life |
Physical restraint | Pushing my thighs | Helped to make the woman cooperate or obey | To make room for baby to come out if mother is closing legs. Fear of being reprimand for poor out pregnancy comes | |
Sexual abuse | Sexual abuse | Not recorded in any data from this study | ||
Verbal abuse | Harsh language Threats and blaming |
Insulting language; Threatening and insulting relatives/caretaker Women blamed for negative outcomes Reprimanding client if she calls for help |
Insults from health providers to women and caregivers | Harsh words ‘helps’ women and relatives cooperate; You must appear tough to gain cooperation Personal attitude |
Stigma and discrimination | Discrimination based on ethnicity, socioeconomic status | Women ‘blamed’ for high parity, age and socioeconomic status Tribalism/ethnicity |
Devalues my partner/wife and I or my community | Women take too long to understand. HPs overworked, stereo typing, negative attitude and values ‘that tribe behavior/react like that” |
HIV positive women avoided or abandoned | Men forced to take HIV test | Fear, stigma lack of knowledge | ||
Failure to meet professional standards of care | Lack of informed consent for physical exam and procedures | HPs discuss the examination results with others | Devalues my wife and I | Rooms do not offer audio privacy |
Student allowed to do episiotomy ‘badly’ Frequent vaginal examinations/multiple tests by HPs and students |
Student must learn on clients: too many students must achieve skills in a short time. Lack of HPs skills and confidence. | |||
Lack of confidentiality and privacy | Examination, delivery and treatment required to undress without curtains or partitions | Bed sharing | Lack of curtains Too many clients Limited space |
|
Women have to give personal information in public (within hearing distance of others) | Over crowding | |||
Neglect and abandonment | Older/higher parity women report left to deliver on their own as HPs abandon them due to their previous birth experience | HPs refuse to help women in labor if not come with drugs, supplies, money. Men rush to buy them. | Too busy, overworked, uncooperative mother. Poor staff attitude, “have done my shift for the day”, lack of team work. Inadequate supervision, Demotivated. | |
Ignoring clients’ calls for help | HPs not available or at night | |||
Doctor not available to conduct cesarean section | No doctor available | Absenteeism; report late on duty, no housing for doctors; lack of transport. | ||
HPs not responding to client when in pain | Some women too afraid of pain | Poor staff attitude; Lack of professional ethics; Poor leadership |
||
Poor rapport between women and health providers | Lack of autonomy | Not involved in decision making in my care Used language that I could not understand Lack of food/drink. No bathing facilities |
Poor staff attitude. Too busy to explain, they do not get even if you explained, Ineffective counseling/communication. |
|
Detainment | Lack of money makes mothers avoid going to hospital | Women are detained | Clients are abandoned by their relatives in hospital. | |
Ineffective communication | Not given information about my care Do not understand the need for frequent vaginal examinations |
Not consulted or informed about my wife’s progress or babies condition | HPs have no time to discuss procedures due to high workload Clients do not understand |
|
Structural disrespect deviations | ||||
Health system conditions an constraints | Lack of resources | Lack of equipment. bed sharing, Lack of curtains/clean linen |
Facility request money to buy drugs | Inadequate supplies, lack of funds, misuse of funds, lack of maintenance, poor planning and forecasting |
No water for bathing, dirty bathrooms No food | ||||
No support staff Staff shortage/no supervision/poor leadership. Made to clean up |
Have to buy the drugs and supplies | Shortages Staff and equipment and supplies |
||
Facility culture | Too few staff | Staff not supervised | Staff shortages Ineffective supervision |
|
Corruption/bribery | You must stretch your hand Some behave in a way that they want to be bribed |
Pay bribe to get own bed | Poor and delayed pay. Accepted norm- everyone is doing it anyway |
The illustrative manifestations (first-order themes describing specific events or instances of mistreatment) presented in this table are drawn from the study findings in Kenya. We have adapted these to the framework developed by Bohren et al [2] using a global evidence-based typology (third, second and first order themes) of mistreatment of women during childbirth. The second- and third-order themes classify first-order themes into meaningful groups based on common attributes. The third-order themes are ordered from the level of interpersonal relations through the level of the health system
HP health provider