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. 2020 Sep 4;15(9):e0238653. doi: 10.1371/journal.pone.0238653

Respectful family planning service provision in Sidama zone, Southern Ethiopia

Melese Siyoum 1,*, Ayalew Astatkie 2, Zelalem Tenaw 1, Abebaw Abeje 1, Teshome Melese 1
Editor: Gizachew Tessema3
PMCID: PMC7473780  PMID: 32886923

Abstract

Introduction

Disrespect and abusive care is a violation of women’s basic human rights and it is serious global problem that needs urgent intervention. Poor quality client-provider interaction is commonly reported from family planning programmes. In Ethiopia, disrespect and abusive care is very common (21–78%) across health facilities.

Objective

To assess the status of respectful family planning service (client-provider interaction) in Sidama zone, south Ethiopia.

Methodology

Health facility-based cross-sectional study was conducted from June to August 2018. Data were collected from 920 family planning clients recruited from 40 randomly selected health facilities. The Mother on Respect index (MORi) questionnaire was used to collect the data through client exit interview. Partial proportional odds ordinal regression was employed to identify determinants of respectful family planning service.

Result

Among family planning clients, the level of respectful family planning service was found to be zero (0%) in the very low respect category, 75(18.5%) in the low respect category, 382(41.52%) in moderate respect category and 463(50.33%) in high respect category. Being a short acting method client (AOR = 0.30, 95%CI [0.12, 0.72]), being an uneducated client (AOR = 0.39, 95%CI [0.25, 0.61]) or a client with elementary education (AOR = 0.41, 95%CI [0.23, 0.73]), client’s poverty (AOR = 0.75, 95%CI [0.56, 0.99]), and long waiting time (AOR = 0.46, 95%CI [0.30, 0.69])significantly reduced the odds of moderate and high respect compared to low respect. Conversely, preference of male service providers, service providers’ work satisfaction and health workers’ prior training on respectful care significantly increased the odds of moderate and high respect.

Conclusion

Considering the current strategy of zero tolerance for disrespect and abuse in Ethiopia, the level of respectful care in this study is sub-optimal. Short term training for service providers on respectful care seems valuable to enhance the level of respectful care for family planning clients irrespective of their socioeconomic background.

Back ground

Respectful maternity care (RMC) is an individual (client) centered approach, which is based on principles of ethics and respect for human rights and women’s needs and preferences [1]. There are many evidence based definitions of disrespectful maternity care [2–8]. The most commonly used definition is proposed by Bowser and Hill (2010), which includes physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination, abandonment of care and detention in health facility [1, 5, 9–13]. Disrespect and abuse of service seeking women is an urgent problem that needs multisector response including health care research, quality and education, human rights and civil rights advocacy throughout the entire world [3].

A growing body of evidence shows that disrespect and abuse during maternity care is becoming an increasing problem worldwide [1, 3, 7, 10, 14]. A cross-sectional study conducted in Nigeria showed that 98% of childbearing mothers had faced at least one category of disrespect [15]. A systematic review conducted in the same country revealed that disrespect during child birth is common and the most frequent category of disrespect was non-dignified care (11.3% to 70.8% across the health facilities [16]. In Tanzania, 70% of respondents were disrespected where non-consented care was reported in 50% of participants [12].

A study done in Addis Ababa, Ethiopia showed that 78% of women who gave birth at health facilities experienced one or more type of disrespect. The right for information such as self-introduction and consent was violated in 94% of the cases [17]. It is common to see disrespect and abusive care at the point of client-provider interaction [2, 4, 11, 14, 18]. In addition to the high prevalence of disrespect and abusive care worldwide, it is neglected and even considered normal in many areas [5, 10, 16, 19]. For instance among 78.6% of participants who were disrespected based on observational checklist in Addis Ababa during child birth, only 22% of them considered it a disrespectful care [17].

Lack of RMC constitutes a barrier to the use of health service and it affects the basic human dignity and human rights. Disrespectful and abusive behavior tends to be higher among women identified as having low socioeconomic status and lower educational attainment. Disrespectful care is also higher when there are weak health care systems, poor managerial systems, provider demotivation, lack of equipment and supplies, and weak or non-existing legal system [16, 19–22].

Though RMC continues to be a problem, there is evidence that interventions such as health care provider training and community mobilization have a positive impact on the promotion of RMC [4, 15, 18, 19]. To overcome the problem of disrespectful and abusive care in Ethiopia, L10K and the Ethiopian Midwives Association have been providing training for higher institution instructors and obstetric care providers who are working in the labor and delivery ward [14, 23]. The Ministry of Health has also started to provide training for all health care workers since March 2017. However, family planning units where respectful care is highly needed as women need correct and accurate information, privacy and confidentiality, respect for their choice of method, dignity and freedom from physical abuse, are still neglected. In Ethiopia the contraceptive prevalence rate is low (36%) for married women. There is also low uptake of long acting methods, high discontinuation rate of long acting methods and poor counseling services [24], all of which could be related to lack of respectful care, yet there is lack of evidence on the level of respectful care for family planning service users in Ethiopia. While qualitative researches show poor client-provider interaction during family planning provision, there is lack of evidence on the prevalence of disrespect and abuse [25]. Therefore, this study aimed to assess the level of respectful family planning services and its determinants in Sidama Zone, southern Ethiopia. Unlike previous qualitative studies, disrespect and abusive care during family planning service are quantitatively measured.

Methods and materials

Study design and setting

This study was a health facility-based cross sectional study conducted in Sidama zone, Southern Ethiopia from 29 June to 20 July 2018. Hawassa, the capital city of the Southern Nations, Nationalities and Peoples Region (SNNPR) and Sidama Zone, is 273 km south of Addis Ababa, the capital of Ethiopia. The zone is situated in the southern region of the country and has 19 districts and 3 town administrations. According to a report from Sidama Zone Health Department, the total population of Sidama zone is estimated to be 5,499,683 of which 719,937 are women of reproductive age. There are three governmental hospitals, 130 health centers and 522 health posts providing family planning services. The overall contraceptive coverage of SNNPR is 39.9% [26]; and the coverage for long acting contraceptive in Sidama zone is 13% according to report from zonal health department.

Sample size and sampling technique

The sample size was determined using double population proportion formula using Open Epi version 2.3 with the assumptions of 95% confidence level, power 80%, unexposed-to-exposed ratio of one and proportion of cases among exposed (respectful care by trained service providers) 87% and proportion of cases among controls (respectful care by untrained providers) 80% [27]. Accordingly a sample size of 940 was calculated and proportionally allocated to the health facilities included in the study based on the number of client flow for three months preceding the data collection time. Accordingly, systematic random sampling was used to select every other client who visited family planning units for contraceptive use, and all 66 family planning service providers of the 40 health facilities during data collection period were included. Health facilities (40) were randomly selected from 655 health facilities of Sidama zone.

Data collection tools and techniques

Data were collected through client exit interview using questionnaire adapted from the Mothers on Respect index (MORi) questionnaire [28]. The MORi questionnaire was developed to assess the client provider interaction and their impact on personal sense of respect. We preferred this tool than other previously used tools because Bohren et al., who developed the most commonly used tool for measuring disrespect and abusive care at health facility, have recommended to develop new validated and reliable tool. Moreover, that tool has a gap in measuring disrespect and abusive care during family planning programme [25]. Accordingly MORi questionnaire is developed through a participatory research process in Canada and USA and the tool was found to be valid and reliable. The tool has 14 items with six point Likert-type scale (ranging from strongly disagree to strongly agree). Very few words like maternity care were modified into family planning context (family planning service) and used directly in this data collection process after translation to the local languages (Amharic and Sidaamu Afoo).

Data were collected through face to face interview with contraceptive user mothers at exit time. To see service provider’s characteristics that affect respectful family planning service provision, self-administered questionnaire was used to collect data from service providers using a tool adapted from respectful maternity care training manual developed by the Federal Ministry of Health and Ethiopian Midwives Association [23]. Service providers were given a code without their knowledge when they provide family planning service and after all mothers were interviewed, data were collected from the service providers and linked to maternal data based on the code provided.

Operational definitions

Based on the result of Mother on Respect index (MORi), the range of score is from 14–84 with higher score indicating more respectful care. Accordingly, participant respectful care is classified as: high Respect if the client scores 67–84 (which means they received at least 79.67% services in respectful manner), Moderate Respect if the client scores 50–66 (59.5%– 78.57%), low Respect if the client scores 32–49 (38.1% - 58.33%) and very low Respect if the client scores 14–31 (which means they received respectful care only in 16.67–36.9% case).

In this study, below poverty line is defined as average daily income less than 1.25 dollar (equivalent to 28 Ethiopian birr).

Data processing and analysis

All quantitative data were checked for completeness, coded and entered in to Epi Data version 3.1 and exported to Stata version 13 for analysis. Frequencies, Mean, standard deviation and proportions were calculated for descriptive purposes and the results were presented using tables and charts. To identify factors associated with the level of respectful family planning service, a partial proportional odds ordinal regression was employed using the gologit2 command of Stata, since some of the variables violated the proportional odds assumption.

Ethical approval and consent to participate

Ethical clearance was obtained from the Institutional Review Board of Hawassa University and communicated with Sidama Zone Health department and the selected woredas. A formal letter was obtained from the woredas and communicated with selected health institutions. After the purpose and objective of the study was explained, verbal consent was obtained from each study participant. There was a “Yes/No” question (prompt) on the data collection tool where the data collectors tick whether the selected study participant volunteered or not to participate in the study. If they volunteer to participate, the data collector tick (put” Π”) in the box in front of the “Yes” option. In this study, the consent obtained from four participants who were aged less than 18 years were considered valid since all of them were married.

Results

Socio-demographic characteristics

A total of 920 individuals from 40 health facilities participated in the study making a response rate of 97.9%. The minimum and maximum ages of the participants were 14 and 46 years, respectively with a mean (±standard deviation [SD]) of 27.19 (± 5.42) years. Among the participants, 905(98.37%) were married, 830(90.22%) were Sidama in Ethnicity, 783 (85.11%) were protestant, 453(49.24%) had elementary school education, 633 (68.8%) identified themselves as housewives and their average annual income ranged from zero to 600,000 birr (equivalent to $21,428.57) with a mean of 26,144.3 birr (equivalent to $933.73) [see Table 1].

Table 1. Socio-demographic characteristics of study participants, Sidama Zone, Southern Ethiopia, 2018.

Variables (n = 920) Category Frequency (N = 920) Percentage
Age 14–24 289 31.41
25–29 322 35.00
30 and above 309 33.59
Marital status Single 8 0.87
Married 905 98.37
Divorced/widowed 7 0.76
Religion Protestant 783 85.11
Orthodox 53 5.76
Muslim 33 3.59
Catholic 24 2.61
Adventist 27 2.93
Ethnicity Sidama 830 90.22
Amhara 45 4.89
Oromo 13 1.41
Othersa 32 3.48
Residence Urban 273 29.67
Rural 647 70.33
Level of education no formal education 271 29.46
Primary (1–8) 453 49.24
Secondary School (9 -10-) 152 16.52
Above high school (>10) 44 4.78
Gravidity Two or less 506 55
Three and above 414 45
Parity Two or less 485 52.72
Three and above 435 47.28
Occupation House wife 633 68.8
Employed (government/NGO) 54 5.87
Private business) 152 16.52
Student 67 7.28
Othersa 14 1.52
Income Category Under poverty(<1.25$/day) 465 50.54
Above poverty (>1.25$/day) 455 49.46
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othersa Wolayta, Gurage, Tigre, Silte

Family planning service use

Among the participants, 625 (67.93%) had visited the specific health facility three or more times for family planning service while 137 were first time clients. At the time of the study, 708 (76.96%) of the participants used injectable contraceptive. Waiting time for 766(83.26%) of the study participants was less than 30 minutes. Two hundred eighty five (30.98%) of the participants preferred to get served by males [see Table 2].

Table 2. Family planning service use by the study participants, Sidama zone, Southern Ethiopia, 2018.

Variables Category Frequency (n = 920) Percentage
Frequency of FP unit Visit once 137 14.89
Twice 158 17.17
Three and above 625 67.93
Method Used Pills 247 5.11
Injectable 708 76.96
Implant 146 15.87
IUCD 18 1.96
Condom 1 0.11
Waiting time ≤30minute 766 83.26
>30minute 154 16.74
Duration of the procedure ≤10minute 757 82.28
>10minute 163 17.72
Number of FP Service providers One 615 66.85
Two and above 305 33.15
Sex of FP service providers Male 221 24.02
Female 699 75.98
Prefer opposite sex? No 635 69.02
Yes 285 30.98
Did FP Provider introduce his name? No 745 80.98
Yes 175 19.02
Did FP Provider introduce his role? No 778 84.57
Yes 142 15.43
Involved client in decision making No 267 29.02
Yes 653 70.98
Client called by her name No 358 38.91
Yes 562 61.09
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*FP, family planning

Characteristics of the service providers

A total of 66 family planning service providers from 40 health facilities participated in this study. The age of the service providers ranged from 22 to 58 years with a mean (±SD) 28.65 (± 5.9) years. Among the service providers who participated in the study, 47 (71.2%) were females, 49 (74.2%) were married, 43 (65.2%) were protestant. Service providers’ year of experience ranged from one to 30 years. Their monthly salary ranged from 2,181 birr ($77.89) to 9,000 birr ($321.43) [see Table 3].

Table 3. Characteristics of service provider on respectful family planning service in Sidama zone, Southern Ethiopia, 2018.
Variables Category Frequency (N = 920) Percentage
Age 22–30 years 52 78.8
31 and above 14 21.2
Sex Male 19 28.8
Female 47 71.2
Marital status Single 17 25.8
Married 49 74.27
Religion Orthodox 20 30.3
Protestant 43 65.2
Muslim 3 4.5
Level of Education Diploma 43 65.2
Degree 23 34.8
Profession Midwifery 8 12.1
Nurse 57 86.4
Other 1 1.5
Work experience ≤2 years 10 15.2
> 2 years 56 84.8
Ever trained on Respectful care No 28 42.4
Yes 38 57.6
Are you Satisfied with your current status? No 17 25.8
Yes 49 74.2
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Over all respectful family planning service

In this study almost half of the participants reported that they were highly respected during family planning service utilization and no one reported receiving very low respect. Among the respondents 75 (18.5%) of the family planning service users received low level of respect during family planning service provision, 382(41.5%) received moderate respect and 463(50.3%) received high level of respect.

Factors associated with respectful family planning service

In the unadjusted partial proportional odds model, age of the client, place of residence, type of method used (short acting method), clients’ level of education, poverty, gravidity, waiting time, duration of procedure, sex of the service provider, training status of service provider on RMC, preference of opposite male service provider by the clients and service providers satisfaction were associated with respectful family planning service at the P-values of < 0.2.

After adjustment using multivariable partial proportional odds model, type of contraceptive used, client’s level of education, poverty, preference for male service provider by the clients, service providers’ satisfaction and service provider’s prior training on respectful care were significantly associated with respectful family planning service provision [see Table 4].

Table 4. Ordinal regression table indicating factors associated with respectful family planning service in Sidama zone, Ethiopia, 2018.

Variables Low vs moderate and high Low and moderate vs high
Adjusted odds ratio P>|z| [95% confidence interval] Adjusted odds ratio P>|z| [95% confidence interval]
Residence (= urban) 0.774 0.110 .565 1.060 .774 0.110 .565 1.060
Short acting method* 0.296 0.007 .122 .722 2.106 0.000 1.421 3.122
Uneducated** 0.389 0.000 .250 .606 .389 0.000 .250 .606
Elementary school* 0.405 0.003 .225 .729 .711 0.078 .486 1.039
Under Poverty** 0.745 0.040 .563 .986 .745 0.040 .563 .986
Gravida3plus 1.193 0.338 .831 1.714 1.193 0.338 .831 1.714
Age ≤24 1.246 0.343 .791 1.964 1.246 0.343 .791 1.964
Age 25–29 1.027 0.888 .712 1.481 1.027 0.888 .712 1.481
Wait time >30minute 1.485 0.315 .687 3.207 .458 0.000 .302 .693
Duration of procedure >10 minute .700 0.078 .470 1.041 .700 0.078 .470 1.041
Sex of service Provider (= male) 0.782 0.140 .563 1.084 .782 0.140 .563 1.084
Trained on RMC* 8.750 0.000 4.608 16.615 3.0322 0.000 2.245 4.096
Satisfied Providers** 1.553 0.007 1.127 2.138 1.553 0.007 1.127 2.138
Client preferred male service provider* 1.997 0.033 1.057 3.775 .552 0.000 .400 .761
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*Proportional odds assumption not fulfilled

**Proportional odds assumption fulfilled; RMC, respectful maternity care.

Discussion

Our finding showed that 18.5% of the family planning service users received low level of respect during family planning service provision, 41.5% received moderate respect and 50.3% received high level of respect. This is low compared to the current Ethiopian government strategy which estates “zero” tolerance for disrespect and abuse [29].

The odds of moderate or high respectful care for women who were not educated is 61% lesser relative to women who completed at least secondary school, it is 59% lesser for women who attended elementary school compared to those who completed at least secondary school. This is supported by a systematic review conducted in Nigeria which reported that, disrespect and abuse during child birth was more common among women who were uneducated and of low socioeconomic status [16]. Educated women are better aware of their rights reducing the likelihood of being disrespected. Thus, it seems that higher level of education (secondary school and above) protect females from low respect.

The odds of being in the moderate or high category of respectful care relative to being in the low category is 25% lesser for women who were below the poverty line (whose average daily income was less than $1.25) compared to those who were above poverty line. This is supported by studies conducted in Bahir Dar and Addis Ababa where poor women were found to be more abused and disrespected during child birth [17, 30]. Low socio-economic status leads women to seek services in low-quality facilities where women are prone to be disrespected and abused[10].

Though there is no significant difference in the odds of moderate and high respect relative to low respect for women who wait for more than 30 minutes and those who wait less than 30 minutes to get family planning service, the odds of high respect relative to the combined categories of low and moderate respect were 54% lesser for women who wait long (more than 30minutes). Long waiting time may discourage clients and lead them to feel that they are neglected and not respected. In similar studies, long waiting time to contact a service provider was found to be associated with dissatisfaction with family planning service [31, 32].

Women who use short acting contraceptives had a 70% lesser odds of moderate or high respect compared to those who use long acting methods. One of the priority areas of the plan of the Ethiopian government in terms of family planning is to increase the coverage of long acting reversible contraceptives mainly IUCD from 1.1% in 2016 to 8.25% in 2020 and implant from 5% to 18.15% [33]. This strategy may influence service providers to influence clients to take long acting family planning methods. Consequently, clients who prefer short acting methods may be abused and disrespected. On the other hand, the odds of high respect relative to the combined categories low and moderate respect were two times higher for women who use short acting methods compared to those using long acting methods. This could be due to long procedural time for long acting method insertion. In this study, some clients complained that the procedure for IUCD insertion takes around 50 minutes.

The odds of moderate or high respect for clients served by health care workers who were satisfied with their current status were 1.6 times higher relative to those served by health workers who were not satisfied. This is supported with a mapping review and gender analysis study which reports that lack of respect for health care workers and limited training opportunities erode their ability to deliver high quality care [34]. Provider’s emotional health has the potential to drive mistreatment and affect women's care [8].

The odds of moderate or high respect are two times higher for women who prefer male service providers. This might occur when those women who prefer male providers are those who need more respect for themselves, need attention and may have good socio-economic status. Secondly, it could be due to cultural expectations that males are more respectful and caring for women than female service providers do.

Women who received service from providers trained on respectful care) had almost nine times higher odds of moderate or high respect compared to those who received service from untrained providers Further, the odds of high respect relative to the combined categories of low and moderate respect were three times higher for women who received service from trained providers compared to those who received service from untrained providers. Trainings have a positive impact on the quality of counseling provided to clients seeking family planning services, providers’ interpersonal skills and overall knowledge [35]. This is supported by a pilot study conducted in Tanzania which showed that training reproductive health care nurses to have a positive impact on promoting respectful care [36].

This study has strengths relative to previous studies. To the authors’ knowledge, the present study is the first to assess respectful family planning service provision in Ethiopia (previous studies focus on childbirth). Besides, the study utilized a current validated tool on respectful care which might yield more reliable and valid results. This study has also identified key points affecting client-provider interaction during family planning service provision which may be of importance in informing stakeholders to improve client-provider interaction to ensure respectful family planning service provision. The current tool used to measure respectful service is easily applicable and recommended for use for family planning service, since it measures important areas (autonomy, culture and client provider interaction). This study is not free of limitations. The tool is new and may be difficult for uneducated women to identify the difference in the possible options of the six point scale which may introduce response bias. Secondly, there was skewed distribution of data for type of contraceptive method used and service provided by female service providers.

Conclusion

The respectful family planning service in the present study is suboptimal, in contrast to the current strategy which allows zero tolerance for disrespect in Ethiopia. Type of contraceptive used, participants’ lower level of education, poverty, long waiting time, preference for male service providers, service providers’ satisfaction and service providers’ prior training on respectful care were significantly associated with respectful family planning service. However, the effect of the identified variables across each level of respectful care is not equal. Almost all factors associated with low level of respectful care are preventable. Strengthening training on compassionate and respectful care is necessary to improve respectful care for family planning clients at all health institutions.

Supporting information

S1 File

(DOCX)

Click here for additional data file. (17KB, docx)

Acknowledgments

Our great thank goes to PREPSS at Michigan University, Lee Roosevelt (PhD) and Mr. Habtamu Kebebe (Wollega University) for their comments and assistance in editing the manuscript.

Data Availability

The data underlying the results of this study are provided in the article and its supporting information.

Funding Statement

This study was supported by Center for International Reproductive Health Training (CIRHT), Ethiopia. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

References

  • 1.Reis V, Deller B, Carr C, Smith J. Respectful maternity care: country experiences Washington DC: MCHIP/USAID; 2012;3. [Google Scholar]
  • 2.Abuya T, Warren CE, Miller N, Njuki R, Ndwiga C, Maranga A, et al. Exploring the prevalence of disrespect and abuse during childbirth in Kenya. PLoS One. 2015;10(4):e0123606 10.1371/journal.pone.0123606 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Alliance WR. Respectful maternity care: the universal rights of childbearing women. White Ribbon Alliance. 2011. [Google Scholar]
  • 4.Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Medicine. 2015;12(6):e1001847 10.1371/journal.pmed.1001847 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Bowser D, Hill K. Exploring evidence for disrespect and abuse in facility-based childbirth Boston: USAID-TRAction Project, Harvard School of Public Health; 2010. [Google Scholar]
  • 6.Vogel J, Bohren M, Tunçalp Ӧ, Oladapo O, Gülmezoglu A. Promoting respect and preventing mistreatment during childbirth. BJOG: An International Journal of Obstetrics & Gynaecology. 2015. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.World Health Organization W. The prevention and elimination of disrespect and abuse during facility-based childbirth: WHO statement; 2014. [Google Scholar]
  • 8.Ndwiga C, Warren CE, Ritter J, Sripad P, Abuya T. Exploring provider perspectives on respectful maternity care in Kenya: "Work with what you have". Reproductive health. 2017;14(1):99 10.1186/s12978-017-0364-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Moyer CA, Rominski S, Nakua EK, Dzomeku VM, Agyei-Baffour P, Lori JR. Exposure to disrespectful patient care during training: Data from midwifery students at 15 midwifery schools in Ghana. Midwifery. 2016;41:39–44. 10.1016/j.midw.2016.07.009 [DOI] [PubMed] [Google Scholar]
  • 10.Ndwiga Charity, Warren Charlotte, Abuya Timothy, Kanya Lucy, Maranga Alice, et al. Respectful Maternity Care Resource Package; Community Facilitator’s Guide. New York, Population; 2014. [Google Scholar]
  • 11.Rosen HE, Lynam PF, Carr C, Reis V, Ricca J, Bazant ES, et al. Direct observation of respectful maternity care in five countries: a cross-sectional study of health facilities in East and Southern Africa. BMC Pregnancy Childbirth. 2015;15:306 10.1186/s12884-015-0728-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Sando D, Ratcliffe H, McDonald K, Spiegelman D, Lyatuu G, Mwanyika-Sando M, et al. The prevalence of disrespect and abuse during facility-based childbirth in urban Tanzania. BMC Pregnancy Childbirth. 2016;16:236 10.1186/s12884-016-1019-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Warren C, Njuki R, Abuya T, Ndwiga C, Maingi G, Serwanga J, et al. Study protocol for promoting respectful maternity care initiative to assess, measure and design interventions to reduce disrespect and abuse during childbirth in Kenya. BMC Pregnancy and Childbirth. 2013;13(1):21. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.L10K. Assessment of disrespect & abuse during childbirth in two regions of Ethiopia: A qualitative study in four PHCUs (Kebet, Lante, Deneba and Denbecha) 2014. [Google Scholar]
  • 15.Okafor II, Ugwu EO, Obi SN. Disrespect and abuse during facility‐based childbirth in a low‐income country. International Journal of Gynecology & Obstetrics. 2015;128(2):110–3. [DOI] [PubMed] [Google Scholar]
  • 16.Ishola F, Owolabi O, Filippi V. Disrespect and abuse of women during childbirth in Nigeria: A systematic review. PLoS One. 2017;12(3):e0174084 10.1371/journal.pone.0174084 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Asefa A, Bekele D. Status of respectful and non-abusive care during facility-based childbirth in a hospital and health centers in Addis Ababa, Ethiopia. Reproductive health. 2015;12:33 10.1186/s12978-015-0024-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Mannava P, Durrant K, Fisher J, Chersich M, Luchters S. Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review. Globalization and health. 2015;11:36 10.1186/s12992-015-0117-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Ratcliffe HL, Sando D, Lyatuu GW, Emil F, Mwanyika-Sando M, Chalamilla G, et al. Mitigating disrespect and abuse during childbirth in Tanzania: an exploratory study of the effects of two facility-based interventions in a large public hospital. Reproductive health. 2016;13(1):79 10.1186/s12978-016-0187-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Birmeta K, Dibaba Y, Woldeyohannes D. Determinants of maternal health care utilization in Holeta town, central Ethiopia. BMC health services research. 2013;13(1):256. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Kruk ME, Kujawski S, Mbaruku G, Ramsey K, Moyo W, Disrespectful LPF. Evidence and recommendations submitted to the iERG by White Ribbon Alliance on behalf of members of the Global Respectful Maternity Care Community of Concern. 2015. [Google Scholar]
  • 22.Warren CE, Njue R, Ndwiga C, Abuya T. Manifestations and drivers of mistreatment of women during childbirth in Kenya: implications for measurement and developing interventions. BMC Pregnancy Childbirth. 2017;17(1):102 10.1186/s12884-017-1288-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Federal Ministry of Health F. Respectful Maternity Care and Partograph Training Resource Package Participant manual Addis Ababa, Ethiopia 2015. [Google Scholar]
  • 24.Central Statistical Agency C, ICF. Ethiopia Demographic and Health Survey 2016: Key Indicators Report Addis Ababa, Ethiopia, and Rockville, Maryland, USA: CSA and ICF: 2016. [Google Scholar]
  • 25.Harris Shannon, Reichenbach Laura, Hardee K. Measuring and monitoring quality of care in family planning: are we ignoring negative experiences? Open Access Journal of Contraception. 2016;7:9–18. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.ICF CSACEa. Ethiopia Demographic and Health Survey 2016: Key Indicators Report. Addis Ababa, Ethiopia, and Rockville, Maryland, USA: CSA and ICF, 2016. [Google Scholar]
  • 27.Abuya T, Ndwiga C, Ritter J, Kanya L, Bellows B, Binkin N, et al. The effect of a multi-component intervention on disrespect and abuse during childbirth in Kenya. BMC pregnancy and childbirth. 2015;15(1):224. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Vedam S, Stoll K, Rubashkin N, Martin K, Miller-Vedam Z, Hayes-Klein H, et al. The mothers on respect (MOR) index: measuring quality, safety, and human rights in childbirth. SSM-population health. 2017;3:201–10. 10.1016/j.ssmph.2017.01.005 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.FMoH. National Compassionate, Respectiful and Caring Health Workforce training In: Health Mo, editor. Addis Abeba2017.
  • 30.Biresaw W., Z. S. Compassionate and Respectful maternity care during facility based child birth and women’s intent to use maternity service in Bahir Dar, Ethiopia Addis Ababa, Ethiopia: Addis Ababa; 2017. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Savul S, Naeem Z, Naseem S. Satisfaction of Female Patients with Health Care Services at the Peri-urban Community Health Centre in Islamabad. Cureus. 2018;10(8):e3101 10.7759/cureus.3101 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Tafese F, Woldie M, Megerssa B. Quality of family planning services in primary health centers of Jimma Zone, Southwest Ethiopia. Ethiopian journal of health sciences. 2013;23(3):245–54. 10.4314/ejhs.v23i3.7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.(FMoH) EFMoH. Costed Implementation plan for Family planning in Ethiopia, 2015/16–2020. Addis Ababa,2016.
  • 34.Betron ML, McClair TL, Currie S, Banerjee J. Expanding the agenda for addressing mistreatment in maternity care: a mapping review and gender analysis. Reprod Health. 2018;15(1):143 10.1186/s12978-018-0584-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Ugaz J, Leegwater A, Chatterji M, Johnson D, Baruwa S, Toriola M, et al. Impact of Family Planning and Business Trainings on Private-Sector Health Care Providers in Nigeria. International perspectives on sexual and reproductive health. 2017;43(2):51–65. 10.1363/43e3717 [DOI] [PubMed] [Google Scholar]
  • 36.Webber G, Chirangi B, Magatti N. Promoting respectful maternity care in rural Tanzania: nurses' experiences of the "Health Workers for Change" program. BMC Health Serv Res. 2018;18(1):658 10.1186/s12913-018-3463-5 [DOI] [PMC free article] [PubMed] [Google Scholar]

Decision Letter 0

Gizachew Tessema

15 Jun 2020

PONE-D-20-10415

Respectful family planning service provision in Sidama zone, Southern Ethiopia

PLOS ONE

Dear Mr Siyoum,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

ACADEMIC EDITOR: 

The reviewers noted a couple of points that need to be incorporated in the manuscript. It was also suggested that the manuscript needs a thorough review for its language clarity which I also agree. In this regard, i decided that the manuscript requires a major revision.

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Kind regards,

Gizachew Tessema, PhD

Academic Editor

PLOS ONE

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3. Please include additional information regarding the survey or questionnaire administered to service providers and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed this questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

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Additional Editor Comments (if provided):

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors studied an important topic to inform efforts in improving quality of clinical care and provision of client-centered family planning services.

The background presented clearly magnitude of the respectful care or lack of it supported with literature. Overall principles of client-centered care for child birth and family planning are similar. However, there are specificity in defining and addressing individuals’ experiences of care, as well as in the level of client-provider interaction for family planning service. Therefore, rationale for this study can be strengthen with honing in on the family planning service related problems throughout the manuscript.

The sampling and sample size calculation needs further clarity. First, it is not clear how the sample size 940 was determined. It will be helpful if the authors can provide clarity on double population proportion formula used, as it was not clear if the sampling was based on proportions input from two population groups. Second, it was not clear why the 87% proportion was based on a disrespectful care among maternity care clients in Kenya, although the authors presented the proportion for Ethiopia in the background. Third, it will be helpful to clarify how the 40 health facilities were selected out of 130 health center, 522 health post and 3 hospitals in the study area. Forth, it was not clear how many health service providers were interviewed and how they were selected.

The bases for operational definition of the category of high, moderate and low respect should be clearly presented. The referenced article score categorized women who scored in the bottom 10th percentile as those who experienced the least respectful care.

The methodology stated that Mothers on Respect index (MORi) questionnaire adopted with minor changes. However, the authors can clarify if they adopted the binary or the six scale tool. A summary of the changes made to the MORi questionnaire should be presented since the tool was developed for maternity care. Some of the amendments can be presented as the limitation of the original tool, or the necessary adaptation to study site context.

Table 1- it will be helpful to define the cut off point for above and under poverty because there is a wide gap in the presented average income

Table 2- specify if service providers are referring to only family planning service providers in the study facility

Table 3- clarify what ‘satisfied’ provider was referring to

Interpretation of relationship between respectful care with short acting methods as well as with provider gender needs caution with such skewed distribution of the raw data where more than 80% of the clients received short acting methods, 76% of clients were served by female provider and 70% did not prefer opposite sex.

The manuscript will benefit from copy editing.

Reviewer #2: Abstract:

Introduction does not mention family planning and doesn’t specify what aspect of disrespect and abusive care is being referred to (e.g., health care, or more specifically as it relates to family planning service provision).

Results section of abstract is worded awkwardly.

Conclusion: language is not consistent throughout paper. E.g., conclusion refers to disrespect only, not disrespect and abuse.

Background:

There is a large literature on RMC and the authors have done a reasonable job of identifying the key pieces of literature relevant to their study. They are, however, missing some key references that relate RMC specifically to family planning. For example, Harris, Reichenbach and Hardee, “Measuring and Monitoring Quality of Care in Family Planning: Are we Ignoring Negative Experiences?” in Open Access Journal of Contraception, 2016:7, 9-18. This paper reviews the family planning literature using the constructs of D&A from Bowser and Hill.

The background should set the stage better for the unique importance of this study as contributing to the dearth of evidence on the level of respectful care for family planning service provision.

Methods and Materials:

The rationale for the selection of the Mothers on Respect index (MORi) could be explained in greater detail. Why this particular tool? Has it been applied to any non-maternity/delivery examples before this application to family planning? Sharing examples of some of the questions would be useful for many readers. This may also help the reader to understand why there were not more modifications for the family planning context.

The description of the questionnaire administration for the providers is confusing as currently worded.

Results:

Table 2 – some of the variables are not entirely clear and could use rephrasing to be more intuitive for the reader. For example, ‘number of service providers’ is not clear; and ‘involved in decision making’ is unclear – do you mean the client was involved in decision making?

It would be useful to have more description of the finding regarding clients reporting that they were highly respected during family planning service utilization. How was this finding interpreted and what is the definition of being ‘highly respected?’ The operational definition only describes the scale/score and so it is hard to interpret what this means in terms of characteristics of service provision.

What was the justification of setting the level of significance at <0.2? This seems very high.

Discussion:

The discussion section needs a major revision for English and clarity of writing. The findings are certainly interesting but they are hard to tease out given the way the discussion is currently worded.

The discussion section does not describe the implications of the findings. What are the implications for family planning programs?

I was also surprised to not see a more detailed discussion of the degree to which tools developed to measure RMC can be adapted and applied to other health service provision such as family planning. Would the authors further adapt the questions if they were to do the study over again? What would their advice be to other researchers who would like to apply the MORi to family planning? Is there an inherent challenge in using RMC-related frameworks which assess disrespect and abuse at a particular moment in time/single event (labor and delivery) to an ongoing engagement with health providers (provision of most family planning methods)?

The study limitations section needs to be expanded. For example, there are also issues of reporting bias introduced when using self-reported questionnaires such as this.

Conclusion:

The conclusion could be strengthened by expanding the description of the implications of the findings for family planning service provision.

General comment: Careful editing of the manuscript for English is strongly recommended.

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Reviewer #1: Yes: Yordanos B Molla

Reviewer #2: No

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PLoS One. 2020 Sep 4;15(9):e0238653. doi: 10.1371/journal.pone.0238653.r002

Author response to Decision Letter 0

27 Jun 2020

Dear Editor and reviewers,

thank you very much for your constrictive comments and suggestions. Now we revised the manuscript per suggestions. Here we attached important documents used for this manuscript including tools used for data collection. please see our point by point response for your suggestions. we appreciate your comments a lot.

Regards!

the Authors

Manuscript title: Respectful family planning service provision in Sidama zone, Southern Ethiopia

Comments from Reviewer #2 Response

Abstract section:

1. Introduction part lacks information about family planning, Result section is written awkwardly and Conclusion session lacks language consistence

Thank you a lot for raising these issues.

All comments accepted and corrected.

The lack of information on family planning in the introduction is because there is lack of literature regarding respectful care among family planning clients. Now, we have described about poor client-provider interaction at family planning units based on available literature.

The whole document has now been thoroughly revised for language. The conclusion sections is also corrected as per the comment.

4. Background session missed important references

Thank you for this comment. We have done the required revisions.

The lack of information on family planning in the background section was because of the lack of literature related to respectful care among family planning service users. Now, we have incorporated evidence from the available literature about family planning in the introduction (see reference 25).

A description of the gap of measuring disrespectful care at family planning unit using tool developed for maternity care is also provided.

5. Unique Importance of the study need to be strengthened Thank you again

Importance of the study for family planning programme is well described at the end of background session.

6. Rationale for the selection of the Mothers on Respect index (MORi) could be explained in greater detail Thank you. Now we have described it in more detail.

This tool was preferred than the others because the previous tools were confirmed to have a gap in assessing respectful care at FP ( see ref 25).

In addition, the previously used tool (developed by Bohren et al., was not validated). The current tool we used is validated in USA and Canada.

It can be easily used in family planning context since the focus area was on autonomy (decision making), culture and client-provider interaction.

7. Questionnaire for service providers were not well described Thank you for pointing this out. Now we have provided a clear description as per the comment.

The questionnaire used to assess service providers’ related factors were adapted from the training manual on respectful maternity care (see ref.23) developed by the Ministry of Health of Ethiopia and Ethiopian Midwives Association.

8. Table2: some of the variables were not clear and need rephrasing Thank you. Now it is Corrected as:

a. Service provider =Family planning service providers

b. Involved in decision making = involved client in decision making

9. Interpretation of the finding needs more description. What is “highly respected mean?” Thank you for pointing this out. Now we have thoroughly revised the description and interpretation of the results in the results and discussion sections. We hope now the interpretations would make more sense.

Further, one advantage of the MORi tool is to show the extent to which the client is respected. Previously respectful care was measured as either 100% or 0% based on whether the client missed one component of care or not. This study shows to what extent the client received respectful care..

10. Level of significance 0.2 seems too high. Thank you for raising the issue.

In this study Significance level <0.2 was used for binary analysis, it is not for the final analysis (multivariate).

11. Discussion section doesn’t describe implication of the finding Thank you. Revised accordingly.

The implication of the finding is included at the end of discussion and conclusion sections.

12. Discussion section needs major revision for English and write up Thank you for pointing this out. Now we have thoroughly revised the discussion section.

The overall write up and language was edited by a pre-publication support service (PREPSS) from Michigan University.

13. Limitation section and conclusion part need to be more elaborated Thank you for this comment. Done accordingly.

Elaborated by including the implication of the findings.

Comments from reviewer #1 Response

Background

1. Rationale of this study need to strengthen by honing on family planning related problems. Thank you for raising this very important issue. Now we tried to strengthen it by incorporating important points.

Poor client-provider interaction at family planning unit was described. Additional references were added. The gap of measuring disrespectful care at family planning unit using tool developed for maternity care was clearly stated. Moreover, lack of evidence on family planning is incorporated (see ref 25).

Importance of the study for family planning programme is well described at the end of back ground session.

2. Clarify whether the binary or six scale questionnaire was adopted from MORi tool? Thank you again.

It was described under methodology section that we used the six scale tool because it was confirmed that the six scale tool well measures the level of respectful service provided.

3. Describe the changes(modifications) made to the questionnaire Thank you very much.

The only modification made to the tool was that we modified “maternity care” in to “family planning service”. It can be easily used in family planning context since the focus area was on autonomy (decision making), culture and client-provider interaction.

4. The base for operational definition is not clear Thank you again.

We attached here a one page of the MORi tool as supporting file. It clearly state how to classify the level of respectful care (see S1).

5. Sample size determination is not clear as whether the proportions were taken from two populations.

Thank you for raising this issue,

Yes the proportions were taken from two populations. Respectful service provision was 87% and 80% by trained and untrained providers in Kenya. Now we have corrected the description as per the comment.

6. Why the proportions were taken from study in Kenya while proportion were reported from Ethiopia. Thank you for this question.

This study was needed for intervention to improve respectful family planning service by Center of International Reproductive Health Training (CIRHT) Ethiopian branch. So we preferred to use proportions from interventional studies. Currently different interventions are being implemented in this study area and its impact will be assessed near the future.

7. It is not clear how 40 health facilities were selected Thank you for this comment. Now we have clearly stated in the methodology section how the 40 health facilities were selected.

These 40 health facilities were selected randomly from all health facilities in the zone.

8. Number of service providers participated Now it is clearly stated

All 66 family planning service providers during data collection period were included.

9. Table1: cut off point for under-poverty is needed Thank you for raising this important question.

Now we described it within the table and under operational definition sections.

Income was categorized as under-poverty if their average daily income is equivalent to <1.25$.

10. Table2: service providers were not specifically described Thank you. Now it is corrected

Service provider means Family planning service providers by the time of data collection.

11. Table3: clarify “satisfied provider”. Thank you. Now it is clearly described.

It is service provider’s perceived satisfaction with their current status.

12. Interpretation for relationship between respectful care with short acting methods as well as with provider gender needs caution with such skewed distribution of the raw data Thank you very much for raising this important issue.

As you see it from the regression table, the finding is significant with acceptable confidence interval. However, the skewed distribution of the raw data is now described as a limitation.

13. The manuscript need edition for language clarity. Thank you for pointing this out. Now we have thoroughly revised the discussion section.

The overall write up and language was edited by a pre-publication support service (PREPSS) from Michigan University.

Attachment

Submitted filename: Response to reviwers.docx

Click here for additional data file. (22.2KB, docx)

Decision Letter 1

Gizachew Tessema

21 Aug 2020

Respectful family planning service provision in Sidama zone, Southern Ethiopia

PONE-D-20-10415R1

Dear Mr Siyoum,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Gizachew Tessema, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The manuscript has improved significantly. Thank you for providing an insight into critical issues to improve quality of clinical care and provision of client-centered family planning services.

**********

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Yordanos B Molla

Acceptance letter

Gizachew Tessema

27 Aug 2020

PONE-D-20-10415R1

Respectful family planning service provision in Sidama zone, Southern Ethiopia

Dear Dr. Siyoum:

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