Disrespect and abuse during focused antenatal care and associated factors among pregnant women who visited public health facilities in Awsi Rasu of Afar Region Northeast Ethiopia

Abstract

Objectives:

Maternal disrespect and abuse are the top significant barriers to the use of maternal health services. However, poor attention has been given to the hospitality and suitability of care provided to women in the facilities where they have been moved to utilize health services. This study is aimed to assess the prevalence of maternal disrespect and abuse during focused antenatal care and its associated factors among pregnant women who visit public health facilities in Awsi Rasu of Afar Region Northeast Ethiopia.

Methods:

Institution-based cross-sectional study design was employed from March 1 to 30, 2022 in selected health facilities of the Awsi Rasu of Afar Region, Northeast Ethiopia. A total of 1278 mothers were included using consecutive sampling techniques. The data were entered into Epi-data version 3.1 and exported to SPSS version 23.0 for statistical analysis. Statistical significance is declared using adjusted odds ratio (AOR) with a corresponding 95% confidence interval (CI).

Results:

The overall prevalence of disrespect and the abusive experience was 56.7% (95% CI: 54–59.3%). A low average monthly income of less than or equal to 3000 Ethiopian birrs (AOR = 0.72; 95% CI: 0.55–0.94), Age (20–25) years (AOR = 2.33; 95% CI 1.72–3.2), having no formal education (AOR = 2.01; 95% CI: 1.35–3.15), and having unplanned pregnancy (AOR = 1.6; 95% CI: 1.21–2.01) were significantly associated with disrespect and abuse during focused antenatal care.

Conclusion:

The prevalence of disrespect and abusive experience during antenatal care in the study area was high relative to other studies. In the multivariable logistic regression model age of the mother (20–25 years), no formal education, low family income, and unplanned pregnancy are the predictors of disrespect and abusive care. Providing respectful health care during antenatal care with a suitable approach for all mothers irrespective of their age, unplanned pregnancies, and educational status is the most substantial to encourage maternal service use.

Introduction

Maternal health has become one of the leading public health concerns for developing countries following the inauguration of the safe motherhood initiative which marked the beginning of rigorous international movements to decline maternal mortality.¹ Antenatal care (ANC) has great potential to improve maternal and child health outcomes through the early identification of diseases. But, without a suitable approach for mothers, the service cannot be provided.²

Disrespectful maternity care is a global problem that affects mothers during pregnancy, birth, and afterward.³ For the poor acceptance of maternity care services at the facilities, disrespect and abuse during ANC are the substantial predictors.^4–7 For example, evidence from countries with high maternal mortality showed that disrespect and abuse in a health facility are one of the major unpredicted leading problems.⁸ Maternal disrespect and abuse are the most substantial impediments to maternal service use.^9–14

Despite the efforts made so far, estimated global maternal deaths in 2017 in Sub-Saharan Africa and Southern Asia recorded 86% of the global maternal deaths.¹⁵ According to the Ethiopian demographic and health survey 2016 report, the maternal mortality ratio was 412 per 100,000 live births and this report also indicated that antenatal care utilization was found to be 62% nationwide and 51% in Afar.¹⁶

Every woman has the right to get respectful health care that is free from discrimination throughout pregnancy and childbirth.⁴ However, studies conducted in Pakistan and Kenya showed that women are disheartened from getting health services during pregnancy and childbirth.^9,17

Reducing maternal mortality is the life-threatening challenge to reaching sustainable development goal 3 to end preventable deaths and ensure well-being for all ages.¹⁸ In Ethiopia, several activities were undertaken by the Federal Ministry of Health to improve maternal healthcare utilization in the last two decades. Compassionate and respectful maternity care training for health professionals were among the applied approaches.¹⁹

Despite the efforts, many women continue to experience disrespectful care at health facilities. Previous studies conducted in Ethiopia showed that lower educational status, low family income, and unplanned pregnancy were associated with disrespect and abuse.²⁰

In considering this, detailed information on the prevalence of disrespect and abuse during focused antenatal care and associated factors among pregnant would have been crucial to improving maternal health, and survival by formulating targeted interventions on risk factors of disrespect and abuse in Ethiopia, particularly in pastoral communities of Afar Region. This study aimed to assess the prevalence of disrespect and abuse during focused antenatal care and associated factors among pregnant women who visited public health facilities in the Awsi Rasu Afar Region, Northeast Ethiopia.

Methods and materials

Study area

This study was conducted in Afar regional state Awsi Rasu public health facilities. Afar Region is found in the great east African rift valley. Awsi Rasu is found at Afar National and Regional State. It covers a total area of 30,242.10 km². There are three public hospitals, one private maternity hospital, and 25 health centers providing preventive, curative, and rehabilitative services. More than 90% of the Afar community has a pastoralist livelihood system. They are highly dependent on extensive livestock production. Afar communities have mobile lifestyles and are associated with very limited and often difficult and expensive access to social services. Awareness and knowledge are low among women on the best practice for utilizing appropriate health services.²¹

Population

Source population: All pregnant women attending antenatal care in public health facilities of Awsi Rasu, Afar region.

Study population: Pregnant women attending Antenatal care in selected public health facilities in Awsi Rasu of the Afar Region were used as the study population.

Study design and period

An institution-based cross-sectional study design was used in Awsi Rasu selected health facilities from March 1 to 30, 2022

Inclusion and exclusion criteria

All pregnant women attending antenatal care in Awsi Rasu public health facilities of the Afar region were eligible for the study. Whereas mothers who were seriously sick during the data collection period and unable to hear and speak were excluded.

Sample size determination

For the first specific objective (i.e., to determine the prevalence of disrespect and abuse among pregnant women in Awsi Rasu public health facilities Northeast, Afar, Ethiopia), the sample size was estimated using a single population proportion formula by considering a 95% confidence level (CI), 5% margin of error, and disrespect of 37%, taken from the study conducted in Shashemene town Ethiopian public hospitals.²⁰

$$n\left[\frac{{(z(\alpha /2))}^{2}p(1-p)}{d^2}\right]$$

where n = required sample size, zα/2 = critical value for normal distribution at 95% CI (1.96), p = proportion of disrespect and abuse, and d = margin of error. Based on the above assumptions, the sample size was 394.

The sample size for the second specific objective (i.e., to identify the factors associated with disrespect and abuse among pregnant women attending antenatal care in public health facilities of Awsi Rasu, Afar Region) was estimated using Epi-info version 7.2.3.1 by considering different variables that have a statistically significant association with disrespect and abuse,²⁰ the ratio of exposed to unexposed to be 1:1, 95% CI, and power of 80%, the sample size was 778. Finally, from the sample sizes estimated for both specific objectives, the largest sample size was 778 (i.e., the sample size of the second objective). Then, with a design effect of 1.5, with a 10% non-response rate, the final sample size was 1284 ANC attending women.

Sampling technique and procedure

A simple random sampling using a lottery method to select the health facilities and a consecutive sampling technique was applied to select study participants. A total of 1420 pregnant women were registered in the antenatal care unit of selected health facilities in Awsi Rasu in 1 month. The sampling interval was calculated by dividing the monthly number of women who visited antenatal care clinics in selected health facilities with the calculated sample size of 1420/1284 = 1. Therefore, the sampling interval is 1.1. The samples were proportionally allocated to each facility according to their target population. This study was conducted in two hospitals (Dubti General Hospital and Aysaita Primary Hospital) and 12 health centers (Semera, Logia, Chifra, Dersagita, Afambo, Ada’ar, Berga, Mesgid, Gelaha, Guyah, Elida’ar, and Harsis health centers).

Data collection procedure and tool

Interviewer-administered questionnaires were used to collect the data. The data collection tool was developed from the Maternal and Child Health Integrated Program and different related literature and modified according to the local context.^20,22,23 Two days of training were given to the data collectors. Four-degree midwives supervised the data collection and 10 diploma midwives who were not employees of the study area collected the data.

Study variables

Dependent variable: the dependent variable was “Disrespect and abuse during focused antenatal care” dichotomized as disrespect and abuse “Yes” (if experienced disrespect and abuse) and “No” if not experienced).

Independent variables: Sociodemographic characteristics such as maternal age in years, ethnicity, religion, marital status, educational status, maternal residency, maternal occupation, husband education, average family income, and family size. Obstetric-related characteristics such as gravidity, parity, history of abortion, history of stillbirth, previous history of Antenatal care type, frequency of current antenatal care, pregnancy status, and history of health facility delivery.

Operational definition

Disrespectful focused antenatal care was measured based on the respondents who responded at least two “No” from 15 prepared Questions items, whereas for respectful care, the respondent was considered as having respectful care if they responded yes to at least ⩾10 questions from 15 questions.

Statistical analysis

The data were cleaned, coded, and entered into Epi-data version 3.1 and exported to Statistical Package for Social Science (SPSS) version 23.0 for further analysis. A bivariable logistic regression analysis was done and those independent variables with a p value less than 0.25 were considered in the final multivariable logistic regression model. An adjusted odds ratio (AOR) with its corresponding 95% CI was used to declare statistical significance in a multivariable model. Model fitness was checked using Hosmer and Lemeshow fitness test.

Data quality management

Initially, the questionnaire was developed in the English language and translated to the local language (Qafar af), and retranslated back to English to confirm its consistency.

A pretest was conducted on 5% of the sample size out of the study area (i.e., Dubti health center). The tools reliability test was done and Cronbach’s alpha correlation coefficient was greater than or equal to 0.95. The principal investigator, supervisors, and data collectors had a daily discussion to check the completeness and clarity of the questionnaire and to resolve unanticipated problems.

Ethical consideration

Ethical approval and clearance were obtained from the research ethics review committee of Samara University, College of Medicine and Health Sciences with a reference number of ERC 0005/2022. A cooperation letter was obtained from Afar regional health bureau. The mothers who were selected to be interviewed were informed about the purpose of the study, the importance of their participation, and the right to withdraw at any time. Written informed consent was obtained from the study participants before the data collection. For those with no formal education, the data collectors read the form and explained the purpose, procedures of the study, advantages, and disadvantages, and agreed respondents signed the consent form. Privacy and confidentiality of the information obtained from each respondent were kept properly and the name was not recorded. The recorded data were kept in a locking cabinet with confidentiality, and an exit interview was held in a private room outside the facility.

Results

Sociodemographic characteristics of the study participants

Of the total of 1284 mothers who were invited for interview, 1278 consented to participate in the study giving a response rate of (99.5%). The mean age of the respondents was 30.29 (standard deviation: ±7.09) years. Of those, 533 (41.7%) were the age of above 31 years. More than half of the mothers (56.3%) were Afar in their ethnicity and 642 (50.2%) reported having resided in rural areas.

In all, 827 (64.7%) were Muslim religious followers. Around 583 (45.6%) of the respondents attended primary school (1–8 grade) and regarding occupational status more than half (55.7%) of mothers were pastoralists, and about 203 (39.2%) of husbands attained primary school education. In all, 646 (58.4%) of the respondents had average monthly family income of <3000 Ethiopian birrs (Table 1).

Table 1.

Sociodemographic characteristics of pregnant women who visited public health facilities in Awsi Rasu, Afar region, Northeast Ethiopia.

Variables	Frequency (n)	Percentage (%)
Age of the mother (years)
18–25	393	30.8
26–30	352	27.5
31	533	41.7
Ethnicity
Afar	720	56.3
Amhara	513	40.1
Oromo	45	3.5
Place of residence
Urban	636	49.8
Rural	642	50.2
Religion
Muslim	827	64.7
Orthodox	362	28.3
Protestant	89	7
Marital status of the mother
Married	1186	92.8
Divorced	63	4.9
Single	29	2.3
Educational status of the mother
Unable to read and write	357	27.9
Able to read and write	132	10.3
Primary (1–8) grade	583	45.6
Secondary (9–12)	59	4.6
College and above	147	11.5
Husband educational status
Unable to read and write	198	15.5
Able to read and write	198	15.5
Primary (1–8)	501	39.2
Secondary	75	5.9
College and above	306	23.9
Occupation of the mother
Pastoralist	712	55.7
Housewife	93	7.3
Employed	290	22.7
Merchant	183	14.3
Family size
<5	521	40.8
⩾5	757	59.2
Average monthly family income
⩽3000	746	58.4
>3000	532	41.6

Obstetric characteristics of respondents

More than half (52.4%) of the respondents were multiparous, 641 (59.1%) mothers had no previous history of antenatal care follow-up and 777 (60.8%) respondents had a first antenatal care visit currently. More than half (61.8%) of the respondents had planned or supported pregnancy. About (52.6%) of respondents had no history of health facility delivery. About 652 (52.8%) of respondents have planned to give birth at health facilities (Table 2).

Table 2.

Obstetrics characteristics of pregnant women who visited public health facilities in Awsi Rasu, Northeast Ethiopia.

Variables	Frequency (n)	Percentage (%)
Gravidity
Primigravida	193	15.1
Multigravida	1064	84.9
Parity
Nulliparous	193	15.1
Primipara	156	12.2
Multiparous	669	52.4
Grand multiparous	260	20.3
History of abortion
Yes	375	34.6
No	710	65.4
History of stillbirth
No	1085	100
Previous history of antenatal care
Yes	444	40.9
No	641	59.1
Frequency of current antenatal care
1st	777	60.8
2nd	386	30.2
3rd	64	5.0
4th	51	4.0
Pregnancy status
Planned	790	61.8
Unplanned	488	38.2
History of health facility delivery
Yes	514	47.4
No	571	52.6
Plan to give birth at health facilities
Yes	675	52.8
No	603	47.2
Reason not to give birth at health facilities (n = 603)
Home is better	493	81.8
Fear of health care providers (fear of per vaginal examination)	34	5.6
Not satisfied with antenatal care	76	12.6

Prevalence of disrespect and abuse during antenatal care

The prevalence of disrespect and abuse during antenatal care was 56.7% (95% CI: 54–59.3%), and out of this, about (50.8%) of respondents experienced disrespect and abuse during antenatal care during general examination (Table 3).

Table 3.

Prevalence of disrespect and abuse during focused antenatal care of pregnant women who visited public health facilities in Awsi Rasu, Northeast Ethiopia.

Respectful client-centered item	Yes (N%)	No (%)
Did the healthcare provider respect your culture and religion during the general examination?	629 (49.2)	649 (50.8)
Did the healthcare provider explain procedures by giving a greeting before the examination?	648 (50.7)	630 (49.3)
Did the healthcare provider treat you in a friendly manner?	850 (66.5)	428 (33.5)
Did the healthcare provider show his/her concern and empathy?	919 (71.9)	359 (28.1)
Did the healthcare provider explain the types of laboratory investigation in a satisfactory way?	921 (72.1)	357 (27.9)
Did the healthcare provider care for you with a kind approach by calling your name?	930 (72.8)	348 (27.2)
Did the healthcare provider respond to your needs whether or not you asked during counseling on birth preparedness and complication readiness?	947 (74.1)	331 (25.9)
Did the healthcare provider assure your privacy during the examination?	944 (73.9)	334 (26.1)
Was waiting time fair for examination	890 (69.6)	388 (30.4)
Did the healthcare provider treat you compassionately and respectfully during ANC follow-up	927 (72.5)	351 (27.5)
Were you involved in decision-making as much as you want	1099 (86.0)	179 (14.0)
Did you have well-informed and good communication with the staff?	1095 (85.7)	183 (53.0)
Did you receive individualized care during the ANC visit?	1056 (82.6)	222 (17.4)
Did healthcare provider promotes partner/accompany during ANC	956 (74.8)	322 (25.2)
Are you happy with all the services you have got today?	880 (68.9)	398 (31.1)

ANC: antenatal care.

Factors associated with disrespect and abuse during focused antenatal care

Variables that were found to have significant statistical associations in the bivariable analysis at a p value of <0.25 (age, place of residence, educational status of the mother, monthly income, pregnancy status, and history of abortion) with disrespectful and abusive maternity care experience during antenatal care were entered into multivariable logistic regression analysis and the result of multivariate analysis showed that age of the mother, educational status of the mother, family income and pregnancy status variables were significantly associated.

Respondents aged 20–25 years were 2.3 times more likely to experience disrespect and abuse as compared to respondents whose age is >31 years (AOR = 2.3; 95% CI: 1.72–3.2). In this study, those who had no formal education were two times more likely to experience abuse during antenatal care as compared to those who attained college and above (AOR = 2.01; 95% CI: 1.35–3.15).

Participants who had unplanned pregnancies were 1.6 times more likely (AOR = 1.6; 95% CI: 1.21–2.01) to experience disrespect and abuse during focused antenatal care than those who had planned pregnancies.

Respondents who had an average family monthly income of less than or equal to 3000 Ethiopian birrs were 28% less likely to experience abusive care as compared to those respondents who have a family monthly income of greater than 3000 Ethiopian birrs (AOR = 0.72; 95% CI: 0.55–0.94) (Table 4).

Table 4.

Factors associated with disrespect and abuse among pregnant women who visited public health facilities in Awsi Rasu, Northeast Ethiopia.

Variables	Disrespect and abuse during FANC		COR (95% CI)	AOR (95% CI)
	Yes	No
Age of the mother (years)
20–25	275	118	2.7 (2.05–3.5)	2.33 (1.72–3.2)*
26–30	202	150	1.6 (1.19–2.05)	1.52 (1.12–2.01)
>31	247	286	1	1
Residence
Urban	378	258	1	1
Rural	346	296	0.79 (0.64–0.99)	1.11 (0.86–1.44)
Educational status of the mother
No formal educational	338	151	1.82 (1.25–2.66)	2.01 (1.35–3.15)*
Primary and secondary	305	337	0.74 (0.51–1.06)	0.98 (0.65–1.51)
College and above	81	66	1	1
Family income
<3000	392	354	0.67 (0.53–0.84)	0.72 (0.55–0.94)*
>3000	332	200	1	1
Pregnancy status
Planned	428	362	1	1
Unplanned	296	192	1.30 (1.04–1.64)	1.6 (1.21–2.01)*
History of abortion
Yes	181	194	1
No	415	295	1.51 (1.17–1.94)	1.08 (0.79–1.46)

^*Statistically significant variables at 95% CI.

AOR: adjusted odds ratio; CI: confidence interval; COR: crude odds ratio; FANC: focused antenatal care.

Discussion

This study aimed to assess the prevalence of maternal disrespect and abuse during focused antenatal care and its associated factors among pregnant women who visit public health facilities in Awsi Rasu of Afar Region Northeast Ethiopia.

The result of this study showed that the prevalence of disrespect and abuse during focused antenatal care was 56.7% (95% CI: 54–59.3%). This prevalence is higher than the study conducted in Gondar town Northwest Ethiopia (49.6%), a systematic review and meta-analysis study conducted in Ethiopia, study conducted in Shashemene, and Bale in Southeast Ethiopia which had 37% and 37.5% prevalences respectively (49.4%).^20,24-26 The difference could be the sociodemographic characteristics of the participants.

This prevalence is lower than the previous studies conducted in the Southwest, Northwest, Western, South Wollo, and Assosa zone of Ethiopia which had 91.7%, 71.8%,74.8%, 79.4%, and 82.4% prevalence respectively.^22,27–30 The possible justification for this difference could be study setting difference, time gap, and population difference.

Respondents aged 20–25 years were 2.3 times more likely to experience disrespect and abuse as compared to respondents >31 years. This finding is in line with a study conducted in brazil.³¹ Most of the time women at this age may be naive about such care and they are very sensitive, ignorance and disrespectful practices of health professionals may be easily seen and some insults may be biased due to their age.

Respondents who did not attend formal education were two times more likely to experience abuse during antenatal care as compared to those who attained college and above. This is in line with studies conducted in Shashemene, Southwest, Addis Ababa, and Western Ethiopia.^20,29,32,33 This might be because women with the least educated may not have an understanding of birth preparedness and complication readiness particularly in pastoral communities and also mothers with no formal education are less likely to be aware of their rights and demand respectful care as compared with those who attained college and above.

Respondents who had unplanned pregnancies were 1.6 times more likely to experience disrespect and abuse during focused antenatal care than those who had planned pregnancies. This finding is consistent with the study conducted in Shashemene town of Ethiopia.²⁰ This might be due to unplanned pregnancies might not be supported by families and may not get appropriate pregnancy care as women with a planned pregnancy.

Respondents who had an average family monthly income of less than or equal to 3000 Ethiopian birrs were 28% less likely to experience abuse care during focused antenatal care as compared to those respondents who have a family monthly income of greater than 3000 Ethiopian birrs. This finding is inconsistent with the study conducted in Ethiopia.^30,33

The limitation was the personal reports of the women were not confirmed by unbiased observations of care and the study is cross-sectional and may not show the cause-and-effect relationship.

Conclusions

In this study, the prevalence of disrespect and abusive experience during antenatal care in the study area was high as compared to other studies. Age of the mother, educational status, family monthly income, and unplanned pregnancy were statistically significant variables in a multivariable logistic regression model.

Recommendations

Health professionals should respect women during ANC with a suitable approach irrespective of their age, unplanned pregnancies, and educational status to encourage maternal service use. Policymakers should give particular attention to women with no formal education to reduce disrespect and abuse by postulating specific laws and policies. Besides, providing awareness creation for those women to be aware of their rights and demand respect.