Impact of Disrespect & Abuse on Women in Pregnancy

In a post-child-birth exit survey of 641 women, Abuya, et al. (2015a) found that D&A is perpetuated by health workers and other facility staff. Further, a systematic review of fourteen studies conducted in Nigeria by Ishola, Owolabi, and Filippi (2017) corroborates this and suggests that D&A was mostly reported as perpetrated by facility staff in their systematic review of fourteen studies conducted in Nigeria. Sadler et al. (2016) also report that D&A can occur when women interact with the providers or simply by the systemic failures at the facilities. The evidence, therefore, confirms that D&A is very likely to occur during any stage of pregnancy, including childbirth and ANC services, and a typology for D&A during ANC services should be looked into. However, even though the typology by Bohren et al.(2015) is based on evidence synthesis from a study conducted on women during childbirth, it has aspects which can be applied to women during ANC services.

Misago et al. (2001) noted that the 1970s and 1980s saw the inception of the humanization of childbirth movement in Brazil which was aimed at promoting respectful maternity care. Ratcliffe (2013) further suggests that the movement only lost its spotlight in the late 1990s and early 2000s having realized many of the principles of the movement and the concept of respectful care. Regarding the history of quality of care as a human rights need, Miller and Lalonde (2015) acknowledge that it was after the 1994 International Conference on Population and Development in Cairo, Egypt, that the quality of care was first framed in a human rights perspective and the rights of girls and women were strengthened in the context of reproductive health and health care. This human rights lens was, however, perceived to have failed not only to focus on D&A during childbirth but also to establish a link between adverse maternal health outcomes to abusive practices and the poor quality of care (Miller & Lalonde, 2015). The authors further note that it was not until the year 2000 that women’s rights to dignity and respect in childbirth became acknowledged in Latin America where, following a Birth Humanization Conference in Brazil, the Latin American and Caribbean Network for the Humanization of Childbirth (RELACAHUPAN) was founded.

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The term D&A was introduced and conceptualized in the year 2010 (Ishola et al. 2017). The same study, however, suggests that research related to this subject has been going on for many years and supports the assertion that although D&A has been in existence for a while, it had not, until recently, received much attention (Ishola et al., 2017).

Hodges (2009) suggests that despite the presence of many caring and supportive physicians and hospital staff in the USA, anyone involved with birthing women had come across a form of abuse directed at women giving birth in hospitals, hence D&A. In 2012, it was reported that a woman sued the Southern General Hospital in Glasgow, United Kingdom, where she had gone to deliver her third baby and the hospital admitted to bullying her into taking precautionary antibiotics that she did not want or need (The Guardian, 2012). Vedam et al. (2017) cite a qualitative study of women's experiences of hospital-based birth by Baker et al. (2005) that reported that over half of British women interviewed commented on the negative attitudes and behaviors of mid-wives.

Patel (2013) confirms that the prevalence of D&A in India is better illustrated by a young doctor, who on finishing his internship in a hospital, equated giving birth in a public hospital in India to third-degree torture in jails (Patel, 2013). In Pakistan, D&A is reported to be highly prevalent although under-recognized by women (Azhar, et al., 2017)

A systematic review (Ishola et al., 2017) suggests that D&A during childbirth occurs frequently in Nigeria and takes many forms with non-dignified care being the most common. Kruk, Paczkowski, Mbaruku, Pinho, and Galea (2009) conducted a discrete choice experiment in two hospitals in rural Tanzania where previously only a third of women would deliver in health facilities to find out the preferred place of delivery. Of the six facility attributes looked into such as distance from hospital, cost, type of provider, provider attitude, drugs and equipment, availability of free transport, the study revealed that the most important attribute to the patients was respectful attitude and availability of drugs and medical equipment, an indication of the presence of D&A.

Abuya et al.(2015b) in a baseline study measured the effect of a package of interventions to reduce D&A by women during facility childbirth in 13 hospitals using an exit survey. The findings revealed that 20% of the women reported a form of D&A within the 13 hospitals studied. Ratcliffe (2013) notes that even though D&A is a global issue affecting both developed and developing countries, there is no accurate estimate of its global prevalence

All this evidence suggests that D&A is prevalent and could be one of the major contributing factors to low facility-based delivery. However, all the literature indicates that even the history and prevalence of D&A mostly cover the problem during childbirth.

McMahon et al.(2014) report that women view D&A as being caused by overworked providers who are, as a result, unable to provide the required ideal care. Reader and Gillespie (2013) in a review of literature around neglect of patients in hospital, found that both proximal (mostly high workload) and distal (mostly organizational management) were responsible for the prevalence of D&A. This could be attributed to structural violence and perhaps the reasons for D&A in many Kenyan hospitals where the patient/provider ratio is very high.

2.3 Prevalence of Disrespect and Abuse

2.3.1 Experiences of Women with Disrespect and Abuse

McMahon et al.(2014) in their study in Tanzania narrate how a woman experienced neglect that exposed her child to danger. A woman in Nyeri Level 5 Hospital experienced neglect, making her deliver her baby while standing (Daily Nation, 2016). CRR & FIDA (2007) reported in their study that a woman reported that the provider used on her an unsterilized pair of scissors previously used on another patient. In the same study, a woman experienced neglect after the doctor left for the day and the available nurse told her she would not help her until the head of the baby came out and had to be helped to deliver her baby by a fellow patient CRR & FIDA (2007) after which the nurse asked the woman who had just delivered to get off the bed and clean the bed herself. Some women are neglected while about to deliver and end up delivering their babies on the floor (McMahon et al., 2014). A woman in Bungoma, Kenya, was physically assaulted by a nurse after calling for help in vain, causing her to deliver on the floor (Centre for Reproductive Rights, 2018).

McMahon et al. (2014 report that some women experience discrimination at the hands of the health care providers just because of their refusal to bribe or due to their economic status. They report in their study of cases where healthcare providers solicited for bribes from the women in order for them to be treated with speed as their situation demanded. Another case is seen where a woman had been informed of the required amount for the service provided but the cost was increased by the cashier and the woman was further threatened with detainment if she did not pay the amount (McMahon et al., 2014). Medicalization of childbirth including some unnecessary interventions is also experienced by women (Manning & Schaaf, n.d.).

2.3.2 Normalization of Disrespect and Abuse

Extant studies suggest that D&A has been normalized and accepted by both women and the providers. For example, a study by the Kenya Ministry of Health in March 2017 revealed that women justify D&A as a necessity in enhancing the safety of the mothers with the facility providers in the same study also agreeing that D&A is necessary, justified and that it guarantees women cooperation and focus on the birth process. For example, the providers alleged that slapping the women encourages them to push when they have to (The Standard, 2017). This is the same case in South Africa where patients perceived the poor treatment as an inseparable part of the procedure in clinics (Jewkes, Abraham & Mvo, 1998). The said normalization is evident and was manifested during their study in the manner women apologetically confessed to having been treated with care (Jewkes et al., 1998). The authors note that even though women reported neglect as one of the most distressing parts of their hospital experience, few women, including those who delivered without the help of a nurse saw the neglect for what it truly is. Manning and Schaaf (n.d.) suggest that in many cases, the reason women view D&A as normal is because D&A is so common that the women often expect it to happen. Freedman et al. (2014) corroborate this and add that even in cases where some behavior is viewed by the women as disrespectful, the providers would not agree to view it as disrespectful.

McMahon et al.(2014) suggest that a majority of women, but not their partners rationalize that workers were not giving ideal care due to the workload. This suggests that the men are more knowledgeable on what to expect in terms of quality care. Additionally, the authors reported that a woman who participated in their study said she delivered alone but rather than feel frustrated or angry she could only empathize with the working conditions of the workers. Moronkola et al. (2007) suggest that women who were unaware of their rights and had never been treated respectfully during maternity care often see D&A as the norm. Even though some women and providers agree on the necessity for slapping to save the baby's life hence normalization, Warren et al. (2017) stress the need to call abuse for what it is.

Sadler et al. (2016) suggest that it is wrong to assume that women fully understand their options and are always able to make a choice regarding their health, hence the little knowledge on D&A. Perhaps the lack of knowledge calls for awareness creation among women on the need to understand their options and their healthcare rights. This normalization of D&A could be an indication of high prevalence downplayed by the lack of knowledge. D&A is not just as a violation of women’s rights but also as a phenomenon that should be nonexistent. The lack of knowledge on the part of the women is a clear impediment to the fight against D&A and a contributing factor to the perpetuation of this form of violence against women.

2.4 Effects of Disrespect and Abuse

Miller and Lalonde (2015) investigated the global epidemic of D&A and found that there is a link between D&A and negative birth outcomes whether directly or indirectly.

2.4.2.1 Direct Effects

Disrespect and Abuse affects birth outcomes, for example, when a woman is ignored or abandoned while in labor or during delivery leading to negative birth outcomes(Miller & Lalonde, 2015). In their study conducted in the Dominican Republic a woman went through neglect in a facility where she was for over 24 before any check-up was done on her and thereafter was found to have a ruptured uterus and her baby’s heartbeats were missing (Miller & Lalonde, 2015). World Health Organization (2016) agrees that neglecting women could make women suffer life-threatening and yet avoidable complications and constitutes a violation of trust between patients and the health care providers. In their study in Tanzania, a nurse neglected a patient, responded late, and consequently had to hold the baby without the help of gloves which is potential health hazard for the baby (McMahon et al., 2014). Neglect is recognized to have the possibility of negatively impacting the health of either the mother, her newborn or both by preventing timely or proper diagnosis and/or treatment of complications (Asefa & Bekele, 2015; Manning & Schaaf, 2017). Over-medicalization of childbirth including some unnecessary interventions contributes to morbidity and mortality (Manning and Schaaf, 2017). Raj et al., (2017) reported that women who reported D&A during pregnancy were likely to have complications during childbirth and in the postpartum period. A study by Center for Reproductive Rights ; Federation of Women Lawyers--Kenya (2007) reported that a woman reported to have tested HIV positive after delivery while the husband was negative, attributing her new status to the use of unsterilized scissors which had been used on another patient during her last delivery.

Additionally, there are other health outcomes of concern like adverse mental health effects over and above other poor physical outcomes (Manning & Schaaf, n.d.). Such mental effects can result in fear of childbirth, influence sexuality and the desire to have children, generate lifelong feelings of guilt and grief, and even trigger memories of sexual assault, if any, in some women (Manning & Schaaf, n.d.). Other forms of D&A such as lack of autonomy during childbirth has also been reported to disempower women reducing them to a state of passivity hence disabling them from being active participants in the birthing process (Warren et al., 2017).

In a study where 98% of the study participants had delivered in a facility and were attended to by skilled health care personnel, Miller and Lalonde (2015) found that maternal mortality was still high, a factor that was attributed to D&A. This is further explained by (Warren et al., 2017: 12) who noted that treatments of discrimination in a particular facility often led to the stigmatized and discriminated women bypassing the nearest facilities leading to potential morbidities and mortalities associated with delays during self-referrals. Moreover, cases, where a woman’s identification card is withheld until the bill is settled, indicates the woman in question is unable to seek further care or other social services where necessary.

The effects of D&A can only be underscored. Poor ANC care could lead to complications and even death and the ripple effect is that the lack of trust arising from D&A during ANC services could dissuade women from seeking skilled attendance. In order to address [maternal and] neo-natal mortality it is extremely important to increase ANC coverage and attendance (Doku et al., 2012). This perhaps is achievable if the matter of D&A is conclusively addressed.

Most of this evidence derived from studies conducted during childbirth point to the fact that D&A directly affects women negatively and therefore a hindrance to the effort of reducing maternal mortality. There was need, therefore, to look into the likely effects of D&A during ANC services.

2.4.2.2. Indirect effects of Disrespect and Abuse

While examining the global epidemic of D&A during childbirth, Miller and Lalonde (2015) reported that indirect effects may occur in cases where women who have previously experienced D&A in past deliveries, avoid future use of facilities, even if they suspect complications. Asefa et al. (2018) confirm this in their study of service providers, with most of the respondents (79.6%) agreeing that lack of respectful care discourages pregnant women from coming to health facilities for delivery. As corroborated by Kipronoh (2009), despite high utilization of ANC in Kenya, ANC has not adequately influenced the use of skilled personnel at delivery.

Indirect effect is also reported in cases of inadequate facility infrastructure by McMahon et al.(2014) while exploring the experiences of, and responses to disrespectful maternity care and abuse during childbirth as likely to foster demoralizing atmosphere for both providers and patients. The authors further report that D&A could not only make patients lack the necessary trust in a facility but also view health facilities as inhospitable. Similarly, patients who perceive interrogations on their cultural practices and use of herbal medications as criticism of their social status by providers, are likely to be demoralized to use facility services in their present or subsequent deliveries, thus increasing the number of births by non-skilled personnel (Ishola et al., 2017; Manning and Schaaf n.d.; McMahon et al., 2014). Women’s experiences at the health facilities and their perceptions of quality of care in health facilities also influence their care-seeking tendencies for their expected newborns and children (Manning and Schaaf, n.d.). CRR; FIDA (2007) study confirms this and adds that the negative effects may have long-lasting effects. In a study on the violations of women’s human rights in Kenya health facilities, a woman narrated how her experience made her resolve to never bear another child, and that when she ‘accidentally’ got pregnant later, she chose to deliver at home (CRR; FIDA, 2007). It is no wonder that the same study reports that TBAs still deliver 28% of babies while relatives and friends assist in 22% of births at home and only 42% of deliveries happen in the care of a health professional.

WHO (2015) also recognizes that D&A constitutes a violation of trust between women and their health care providers hence a powerful disincentive for women to seek and use maternal health care services. This is not good for the health of any nation and is likely to contribute to the high morbidity and mortality rate in both the infants/children and their mothers.