Status of institutional-level respectful maternity care: Results from the national Ethiopia EmONC assessment.

OBJECTIVE: To assess the availability of an institutional-level respectful maternity care (RMC) index, its components, and associated factors. METHODS: A cross-sectional study design was applied to a 2016 census of 3804 health facilities in Ethiopia. The availability of an institutional-level RMC index was computed as the availability of all nine items identified as important aspects of institutional-level RMC during childbirth. Logistic regression analysis was used to identify factors associated with availability of the index. RESULTS: Three components of the institutional-level RMC index were identified: "RMC policy," "RMC experience," and "facility for provision of RMC." Overall, 28% of facilities (hospitals, 29.9%; health centers, 27.8%) reported availability of the institutional-level RMC index. Facility location urbanization (urban region), percentage of maternal and newborn health workers trained in basic emergency obstetric and newborn care, and availability of maternity waiting homes in health facilities were positively associated with availability of the institutional-level RMC index. CONCLUSION: Only one in three facilities reported availability of the institutional-level RMC index. The Ethiopian government should consider strengthening support mechanisms in different administrative regions (urban, pastoralist, and agrarian), implementing the provision training for health workers that incorporates RMC components, and increasing the availability of maternity waiting homes.

Risk Factors for Positive Appraisal of Mistreatment during Childbirth among Ethiopian Midwifery Students.

The maternal mortality ratio and neonatal mortality rate remain high in Ethiopia, where few births are attended by qualified healthcare staff. This is partly due to care providers' mistreatment of women during childbirth, which creates a culture of anxiety that decreases the use of healthcare services. This study employed a cross-sectional design to identify risk factors for positive appraisal of mistreatment during childbirth. We asked 391 Ethiopian final year midwifery students to complete a paper-and-pen questionnaire assessing background characteristics, prior observation of mistreatment during education, self-esteem, stress, and mistreatment appraisal. A multivariable linear regression analysis indicated age (p = 0.005), stress (p = 0.019), and previous observation of mistreatment during education (p < 0.001) to be significantly associated with mistreatment appraisal. Younger students, stressed students, and students that had observed more mistreatment during their education reported more positive mistreatment appraisal. No significant association was observed for origin (p = 0.373) and self-esteem (p = 0.445). Findings can be utilized to develop educational interventions that counteract mistreatment during childbirth in the Ethiopian context.

Development and use of a scale to assess gender differences in appraisal of mistreatment during childbirth among Ethiopian midwifery students.

Mistreatment during childbirth occurs across the globe and endangers the well-being of pregnant women and their newborns. A gender-sensitive approach to mistreatment during childbirth seems relevant in Ethiopia, given previous research among Ethiopian midwives and patients suggesting that male midwives provide more respectful maternity care, which is possibly mediated by self-esteem and stress. This study aimed a) to develop a tool that assesses mistreatment appraisal from a provider's perspective and b) to assess gender differences in mistreatment appraisal among Ethiopian final-year midwifery students and to analyze possible mediating roles of self-esteem and stress. First, we developed a research tool (i.e. a quantitative scale) to assess mistreatment appraisal from a provider's perspective, on the basis of scientific literature and the review of seven experts regarding its relevance and comprehensiveness. Second, we utilized this scale, the so-called Mistreatment Appraisal Scale, among 390 Ethiopian final-year midwifery students to assess their mistreatment appraisal, self-esteem (using the Rosenberg Self-Esteem Scale), stress (using the Perceived Stress Scale) and various background characteristics. The scale's internal consistency was acceptable (α = .75), corrected item-total correlations were acceptable (.24 - .56) and inter-item correlations were mostly acceptable (.07 - .63). Univariable (B = 3.084, 95% CI [-.005, 6.173]) and multivariable (B = 1.867, 95% CI [-1.472, 5.205]) regression analyses did not show significant gender differences regarding mistreatment appraisal. Mediation analyses showed that self-esteem (a1b1 = -.030, p = .677) and stress (a2b2 = -.443, p = .186) did not mediate the effect of gender on mistreatment appraisal. The scale to assess mistreatment appraisal appears to be feasible and reliable. No significant association between gender and mistreatment appraisal was observed and self-esteem and stress were not found to be mediators. Future research is needed to evaluate the scale's criterion validity and to assess determinants and consequences of mistreatment during childbirth from various perspectives.

Mistreatment of women in public health facilities of Ethiopia.

BACKGROUND: Recent evidence suggests that mistreatment of women during childbirth is a global challenge facing health care systems. This study seeks to explore the prevalence of mistreatment of women in public health facilities of Ethiopia, and identify associated factors. METHODS: A two-stage cross sectional sampling design was used to select institutions and women. The study was conducted in hospitals and health centers across four Ethiopian regions. Quantitative data were collected from postpartum women. Mistreatment was measured using four domains: (1) physical abuse, (2) verbal abuse, (3) failure to meet professional standards of care, and (4) poor rapport between women and providers. Percentages of mistreatment and odds ratios for the association between its presence and institutional and socio demographic characteristics of women were calculated using bivariate and multivariable logistic regression modeling. RESULTS: A total of 379 women were interviewed, of whom 281 (74%) reported any mistreatment. Physical and verbal abuse were reported by 7 (2%) and 31 (8%) women interviewed respectively. Failure to meet professional standards of care and poor rapport between women and providers were reported by 111 (29%) and 274 (72%) women interviewed respectively. Multivariable logistic regression analysis revealed that the odds of reporting mistreatment were higher among women with four or more previous births (aOR = 3.36 95%CI 1.22,9.23, p = 0.019) compared to women with no previous childbirth, Muslim women (aOR = 3.30 95%CI 1.4,7.77, p = 0.006) and women interviewed in facilities with less than 17 births per MNH staff in a month (aOR = 3.63 95%CI 1.9,6.93, p < 0.001). However, the odds of reporting mistreatment were lower among women aged 35 and older (aOR = 0.22 95%CI 0.06, 0.73, p = 0.014) and among women interviewed between 8 and 42 days after childbirth (aOR = 0.37 95%CI 0.15, 0.9, p = 0.028). CONCLUSION: Mistreatment during childbirth in Ethiopia is commonly reported. Health workers need to consider provision of individualized care for women and monitor their experiences in order to adjust quality of their services.

Respectful maternity care in Ethiopian public health facilities.

BACKGROUND: Disrespect and abuse of women during institutional childbirth services is one of the deterrents to utilization of maternity care services in Ethiopia and other low- and middle-income countries. This paper describes the prevalence of respectful maternity care (RMC) and mistreatment of women in hospitals and health centers, and identifies factors associated with occurrence of RMC and mistreatment of women during institutional labor and childbirth services. METHODS: This study had a cross sectional study design. Trained external observers assessed care provided to 240 women in 28 health centers and hospitals during labor and childbirth using structured observation checklists. The outcome variable, providers' RMC performance, was measured by nine behavioral descriptors. The outcome, any mistreatment, was measured by four items related to mistreatment of women: physical abuse, verbal abuse, absence of privacy during examination and abandonment. We present percentages of the nine RMC indicators, mean score of providers' RMC performance and the adjusted multilevel model regression coefficients to determine the association with a quality improvement program and other facility and provider characteristics. RESULTS: Women on average received 5.9 (66%) of the nine recommended RMC practices. Health centers demonstrated higher RMC performance than hospitals. At least one form of mistreatment of women was committed in 36% of the observations (38% in health centers and 32% in hospitals). Higher likelihood of performing high level of RMC was found among male vs. female providers ([Formula: see text], p = 0.012), midwives vs. other cadres ([Formula: see text], p = 0.002), facilities implementing a quality improvement approach, Standards-based Management and Recognition (SBM-R©) ([Formula: see text], p = 0.003), and among laboring women accompanied by a companion [Formula: see text], p = 0.003). No factor was associated with observed mistreatment of women. CONCLUSION: Quality improvement using SBM-R© and having a companion during labor and delivery were associated with RMC. Policy makers need to consider the role of quality improvement approaches and accommodating companions in promoting RMC. More research is needed to identify the reason for superior RMC performance of male providers over female providers and midwives compared to other professional cadre, as are longitudinal studies of quality improvement on RMC and mistreatment of women during labor and childbirth services in public health facilities.

Development of a tool to measure women's perception of respectful maternity care in public health facilities.

BACKGROUND: Maternal mortality continues to be the biggest challenge facing Ethiopia and other developing countries. Although progress has been made in making maternity services available closer to the community, the rate of deliveries attended by skilled birth attendants has remained very low. Absence of respectful maternity care (RMC) is believed to have contributed to low utilization of facility delivery services. This study outlines steps undertaken to construct and validate a scale that measures women's perception of respectful maternity care provided in health facilities. METHODS: An inductive item generation process that included a literature review and in-depth interviews with labor and delivery clients, followed by an expert review, assured face validity and content validity of the tool. A draft RMC scale with 37 items and two additional measures of global satisfaction items, measured on a five-point Likert scale, were administered to a developmental sample of 509 postnatal care clients visiting facilities immediately after childbirth to 7 weeks postpartum. IBM SPSS 20 was used to perform exploratory factor analysis (EFA) using principal component analysis (PCA) with oblique rotation method. RESULTS: The final RMC scale with 15 items was loaded on four components. The extracted components were labeled as friendly care, abuse-free care, timely care, and discrimination-free care. The final RMC scale correlated strongly with the global satisfaction measures, indicating criterion-related validity of the scale. Content-related validity was assured by the process of item generation. Construct validity of the RMC scale was confirmed by high average factor loading of the four components ranging from 0.76 to 0.82 and low correlation between the components. Stability of the scale was confirmed by running PCA in a randomly selected split sample of 320 samples from the validation sample. The final 15-item scale showed an adequate reliability with α = 0.845. CONCLUSION: The 15-item RMC scale is a valid and reliable measure of women's perception of RMC received in health facilities. We recommend that health facilities use the RMC scale in urban public health facilities and that other researchers conduct further exploratory and confirmatory factor analysis in different geographic areas.