Respectful Maternity Care Initiative: A Qualitative Study

Abstract

Aim

To assess the available standards for respectful maternity care in a public maternity hospital by evaluation of responses to a questionnaire given to birthing women.

Methodology

Assessment was done to find out the level of respectful maternity care provided under the most sensitive and important areas, namely (1) confidentiality and privacy, (2) physical harm or ill treatment, (3) dignity and respect, (4) left without care, (5) right to information, informed consent, and choice/preferences, by obtaining the response of birthing women.

Results

Confidentiality and Privacy: No birthing woman (0%) expressed her opinion that she was dissatisfied with privacy provided, at any time of her stay in the hospital. Physical harm or ill treatment: It was significant to note that no woman reported being ill-treated or physically harmed. Dignity and Respect: A response of satisfaction regarding this important aspect of maternity care was received by nearly 95% of birthing women, A very small percent of 5.1% of women were not completely satisfied. Left without care or Attention given at all times:1.9% of women felt that they were not given immediate response when they called for any need. Right to information, informed consent, and choice/preferences: The greater majority of 95.7% of women were satisfied with methods engaged by hospital staff regarding right to information, informed consent and practices.

Conclusion

The response from a significant majority of birthing women was that they had respectful maternity care given to them at Government hospital for Women and Children.

Background

The birthing experience in a woman's life is a very important time where she has to be treated with the care and respect deserving to her. A positive birthing experience would help her to bear the severe physical pain associated with childbirth, stamps a lasting impression on her self esteem and her sense of accomplishment, and also a feeling of empowerment. This also affects the baby which is born.

Every woman has the right to be offered respectful maternity care as a part of the prescribed standard of health care norms established today. It remains a true and undeniable truth that far more should be done to enhance policies in use by health care systems including care given by professionals and others within the system to enhance the prevailing maternal health care packages offered to the population, especially to the birthing woman. Facility-based childbirth is one among the key strategies to scale back maternal and perinatal morbidity and mortality. However, many women decide to not seek facility-based care for childbirth, despite recognizing the associated health benefits. This decision is usually supported by their previous experiences of poor quality care, including poor treatment, abuse, discrimination and neglect while in facilities, for example, hitting, slapping, physical restraint during childbirth, women and their newborns being detained due to inability to pay, and the use of threats are documented [1–4].

Studies have also documented that ill-treatment of girls during birthing can affect progress of labor, mother–child bonding, initiation/continuation of nursing and cause post-traumatic stress disorders [5]. These experiences constitute a violation of a woman's human rights, and a violation of the trust women place in caregivers and the health system. It is critical for the maternal health care providers to ask how it can prevent such mistreatment, and better meet the requirements of birthing women's socio-cultural, emotional and psychological [6] needs as a part of broader efforts to supply better quality care [7].

Good quality maternal and newborn care is one that is safe, effective, timely, efficient, equitable and people-centered [8, 9]. In September 2014, WHO issued a press release on the prevention and elimination of disrespect and abuse during facility-based childbirth, emphasizing the rights of each woman to dignified, respectful care during childbirth, and the need for greater action, dialogue, research and advocacy by all health stakeholders on this issue.

Researchers have highlighted the challenges to establishing such a definition, including the necessity to think about not only omen’s and provider's experiences [10, 11], but also intentionality, the role of local societal norms about what constitutes disrespectful or abusive behavior in several cultures, and the way underlying deficiencies in health systems contribute to disrespectful and abusive care. Certain groups of women like those from other ethnicities, pregnant adolescents, the poor, migrants and HIV positive women, could also be more susceptible to mistreatment than others.

However, despite the directives of the Health ministry, implementation of this low-cost, effective intervention remains poor in many settings. Another, useful step needed is: respectful, culturally sensitive communication with women, and their families regarding labor progress and answering their queries, and making efforts to enhance standards of privacy, empathetic, polite communication, respecting the woman’s confidentiality and consent before any clinical intervention in health facilities. The ICMR started the Respectful Maternity Care Initiative along with the White ribbon alliance, in selected obstetric centers. In India,The National Health Mission with the vision responding to the needs of the birthing woman and her baby, introduced ‘The Laqshya program’, in all health centers, to ensure respectful maternity care to all birthing women.

The USAID placed respectful maternity care (RMC) in seven broad domains: (1) dignified care, (2) consented care, (3) confidential care, (4) non-abandonment in care, (5) no physical/verbal abuse, (6) no abuse associated with cost including detention and (7) equity in access. These domains are useful in identifying and quantifying disrespect and abuse and dealing out solutions. It is crucial that health system stakeholders should define respectful maternity care within the Indian context, identify evidence-based and validated measurement tools which will be utilized in different settings and address the mistreatment of birthing women when, where and the way it occurs in order that effective, sustainable, measures/interventions are often implemented within the health system to stop disrespect and abuse and improve women’s birthing experience [12].

Settings: Government Hospital for Women and Children, A Public Referral and Teaching Hospital, Chennai, India.

Aim

To assess the available standard of respectful maternity care (RMC) in a public maternity hospital by evaluation of responses to a questionnaire given to birthing women.

Methodology

The study was carried out in the Institute of Obstetrics & Gynecology, Chennai. Assessment was done to find out the level of respectful maternity care provided under the most sensitive and important areas, namely (1) confidentiality and privacy, (2) physical harm or ill treatment, (3) dignity and respect, (4) left without care, (5) right to information, informed consent, and choice/preferences. A Questionnaire was prepared for birthing women that included twelve questions relevant to the above broad parameters mentioned already, on the five main domains of respectful maternity care for assessing the RMC performance standards. The response of birthing women would be under the mentioned domains and to later formulate a plan to sensitize these areas with Health care providers wherever necessary.

To obtain a thorough observatory report, the pre-assessment of labor room conditions and the quality of respectful maternity care given to birthing women admitted in the hospital were done. This was done over a period of three months and by discreet observation by trained medical researchers, and was carried out on different days including public holidays and the hours of observation was selected from all hours of day and night. The selection of different times of day for observation was to ensure a complete assessment of the prevailing conditions, in the pre-delivery, labor and post-delivery wards, in the hospital.

The reason for administering the questionnaire and the details of the study was explained to all the women in all postnatal wards. The women could voice their opinion regarding their birth experience, and respond to the questions given. They could grade their experience as very good, good, satisfactory or fair, poor or not satisfied. Where needed the option of “other” was given for some questions where the woman could respond with her own words. All postnatal wards were included, namely post natal labor natural, post caesarean ward, postnatal fever and infections ward and high risk postnatal ward. The level of care needed is proportionally more for women in high risk groups and for postnatal women with chronic and acute infections. A representation of all the women should be included to ensure a thorough assessment of the level of satisfaction of the needs of birthing women.

An initial pilot study was done to find out the reliability of the questionnaire. Statistical tests were done to assess the same and confirmed that the questionnaire was found to have good reliability [> 0.8]. The number of women, [sample size] who would be administered the questionnaire with twelve variables was calculated using statistical formula for a large population. This formula selected is used for large-sized population. It was ascertained that the sample size would obtain reliable information within a confidence interval of 95%.

The sample size was found to be 130 women. The questionnaire was then given to 130 willing women after obtaining informed consent and selected by random selection.

The women selected by random sampling method were administered this questionnaire after obtaining informed consent. Complete confidentiality of all participants was maintained. As the names of women were not recorded in the response sheet they were at liberty to voice an unbiased and true response to the questionnaire. It was observed that all women except a few could read and write. The women who could not read but wanted to give their responses could take the help from women who could read and write. All statistical calculations were done using SPSS software (Table 1).

Table 1.

Grading of responses of women to questionnaire

Response Grading	Confidentiality and privacy (%)	Care and treatment (%)	Dignity and respect (%)	Attention given at all times (%)	Right to information, informed consent, and choice/preferences (%)
Very good	57.70	56.20	45.90	55.40	51.80
Good	37.70	36.90	36.20	35.80	34.80
Fair	4.60	6.90	12.80	6.90	9.10
Not satisfied	0	0.00	5.10	1.90	4.30

No woman responded that she was ill-treated or physically harmed

Results

The results obtained by questionnaire given to birthing women were analyzed. The observations of the birthing women clearly indicated by the response to the questionnaire in the following areas most relevant to assess the level of care given to birthing women, namely (1) confidentiality and privacy, (2) if any physical harm or ill treatment, meted unknowingly and the level of care and treatment received by the birthing women, (3) dignity and respect, (4) left without care or was attention given at all times, (5) right to information, informed consent, and choice/preferences were found as follows.

Confidentiality and Privacy

Majority of women responded that they were very satisfied with the confidentiality and privacy provided. Nearly 57.7% of women rated it very good and 37.7% women felt it was good. A small number of 4.6% of the group of women who answered the questionnaire responded that they were just satisfied with confidentiality and privacy provided. No birthing woman (0%) expressed her opinion that she was dissatisfied with privacy provided, at any time of her stay in the hospital.

Physical Harm or Ill Treatment

On analyzing the response of women whether she had experienced any physical harm or ill treatment meted out inadvertently by the health care provider to the birthing women. It was significant to note that no woman reported being ill-treated or physically harmed. They responded by grading the care received as perceived by them. The response of 56.20% of women showed that they had rated care as very good and 36.9% rated it as good, and a very small number of 6.9% of women rated the care given was satisfactory and none (0%)was dissatisfied.

Dignity and Respect

From the analysis of responses to the questionnaire given to birthing women we found that the huge majority of 82.2%women had experienced respectful care and had been treated with dignity in the hospital. They expressed that their stay was extremely pleasant and happy. A response of satisfaction regarding this important aspect of maternity care was received from nearly 95% of birthing women. A very small percent of 5.1% of women were not satisfied.

Left Without Care/Attention Given at All Times

On evaluating the responses of birthing women regarding their opinion as to whether they had been neglected at any time during their stay in the hospital, a very small 1.9% of women felt that they were not given immediate response when they called for any need. The majority of 98.1% of women felt that they had been given adequate care and immediate attention when they called for any need. And 91.2% women were more than satisfied and responded that the care received in Govt.Hospital for Women and Children was good.

Right to Information, Informed Consent, and Choice/Preferences

A majority of 87% of women gave their opinion that the practices of the hospital regarding choices, preferences and right to information, and obtaining informed consent was good. The greater majority and almost all the women constituting 95.7% of women who had responded to the questionnaire were satisfied with the above-mentioned methods engaged by hospital health care providers regarding right to information, informed consent and practices. Chi Square for R by C Table is given below as:

Chi Square for R by C Table
Chi Square =	16.19
Degrees-of-Freedom =	12
p-value =	0.1826

From the above chi square analysis P = 0.1826, we came to a conclusion that there is no statistical significance that exists among different domains of respectful maternity care with respect to outcomes such as very good, good, fail and not satisfied. This clearly indicates the health providers are maintaining RMC care under all domains in a uniformed manner and only 2% of patients were not satisfied. This showed overall respectful maternity care was well maintained in this center probably due to the sensitizing of the Laqshya program.

Discussion

All birthing women were encouraged to have a birth attendant, as she would be more confident with them, and also to provide emotional support during labor [13]. Most birthing women did not receive the required support from the birth attendant. It would be best to identify a birth attendant for every pregnant woman in the antenatal period and advise them regarding the support they should provide to the birthing woman. It may be mentioned here that all pregnant women and their identified birth attendant should be counseled in the antenatal visits about birthing.

Most of the birthing women expressed that the care given in hospital was good or very good [14]. Almost 5.1% of women were not completely satisfied with the dignity and respect shown to them. Disrespect and indignity meted to a birthing woman cause many adverse effects during labor and more importantly the trauma lingers on, and the woman suffers from this all her life [15, 16].

Around 1.9% of women felt that they were not given immediate response when they called for any need,and 4.3% of women were not satisfied with the practices of the hospital regarding choices, preferences and right to information, and obtaining informed consent.

From the chi square analysis P = 0.1826, we came to a conclusion that there is no statistical significance that exists among different domains of respectful maternity care with respect to outcomes such as very good, good, fail and not satisfied. This clearly indicates the health providers in public health care services are maintaining RMC care in a uniformed manner and only 2–4% of patients were not satisfied [17].

Conclusion

The response of complete satisfaction regarding the important aspect of maternity care, namely dignity and was received by 95% of birthing women. Regarding care given to the pregnant women before delivery, during period labor and post-natal period the majority of 98.1% of women felt that they had been given adequate care and immediate attention when they called for any need. A small proportion of 1.9% of women was not satisfied with the attention and care given during their stay in the hospital. No birthing woman (0%) expressed her opinion that she was dissatisfied with privacy provided, or was ill-treated or complained of physical harm done to her at any time during her stay in the hospital.

A majority of 87% of women gave their opinion that the practices of the hospital regarding choices, preferences and right to information, and obtaining informed consent was good, though a small group of 4.3% of women were not satisfied with the same. The observations of the birthing women and indicated by the response to the questionnaire showed that majority of 90% and more birthing women who were admitted for delivery received respectful maternity care, both in antenatal, and during delivery of baby and in the postnatal period, and voiced that the birth experience was good. It is pertinent to mention here that the Laqshya program had been recently started and was still under vigilant supervisory stage after initiation. It would be important to sustain the positive impact of the Laqshya program and also to rectify the small lacunae identified in respectful maternity care, in all obstetric care centers in India.

D. M. Christe

worked as medical research officer, in the Institute of Obstetrics and gynaecology, attached to the Indian Council of Medical Research, and currently posted in the NIRT, ICMR Chennai. She was awarded Distinguished Service award on Doctor’s Day for her service for the cause of Women’s health in 2008, by the IMA, DELHI and has worked for more than twenty years in the field of cervical cancer screening. She has published many papers in obstetrics and gynecology. Her study on cervical cancer screening was included in a meta analysis by the IARC and published by the International Journal of Obstetrics and Gynecology [IJGO] in 2011. She was awarded international TRAVEL AWARD by the International Gynaecological Cancer Society in 2010.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

Approval for conducting this retrospective study was given by the institutional Ethics Committee, Institute of Obstetrics and Gynecology, Chennai, India. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.The study was conducted, compliant with ethical standards, and after obtaining clearance from the institutional Ethics Committee.

Informed Consent

Informed Consent was obtained from individual study participants only and was analyzed maintaining complete patient confidentiality.