Magnitude and associated factors of respectful maternity care in Tirunesh Beijing Hospital,Addis Ababa,Ethiopia,2021

Abstract

Objective:

The main aim of this research was to assess the magnitude of respectful maternity care and associated factors during labour and delivery in Tirunesh Beijing General Hospital, 2021.

Methods:

Facility-based cross-sectional research was employed among 319 postnatal mothers who were selected by systematic random sampling technique. Bi-variable and multi-variable logistic regression analysis was used to identify associated factors. Variables whose p-value < 0.05 in the multivariable model with 95% confidence interval were considered as statically significant.

Results:

A total of 319 respondents participated in the research with a response rate of 100%. The overall prevalence of respectful maternity care was 87.8%. Type of delivery in which caesarean section (adjusted odds ratio = 10.4, 95% confidence interval: (1.8, 61) and spontaneous vaginal delivery (adjusted odds ratio = 2.9, 95% CI: 1.4, 6). Getting delivery service by the provider of their preference (adjusted odds ratio = 2.6, 95% CI: 1.3, 5.2), still birth (AOR = 5.8 95% CI: 1.3, 25.8) and sex of delivery attendant (adjusted odds ratio = 3.6, 95% CI: 1.8, 7.5) were associated factors RMC.

Conclusion and recommendation:

In our research area, a sizable number of women have received respectful maternity care, but abuse and disrespect are still complaints. Therefore, emphasis should be placed on respectful maternity care by every healthcare professional and health service manager.

Keywords

Respectful maternity care labour and delivery Ethiopia

Introduction

All childbearing women have a fundamental right to respectful maternity care (RMC), which goes beyond just guarding against mistreating pregnant women.^1,2 Every woman has the right to the highest level of health possible, which includes the right to kind, considerate medical care. But many women around the world experience disrespectful and abusive treatment in facilities when giving birth.³

In order to reduce maternal mortality globally, it is essential to guarantee that all women have access to skilled care prior to, during, and after childbirth. However, the psycho-social aspects of labour and delivery dominate a woman’s birth experience.^4–6

Lowering maternal mortality is one of the global objectives outlined in the Sustainable Development Goals. Ethiopia had one of the highest maternal mortality ratios (MMRs) in the world.^7,8 In addition, Ethiopia had one of the highest rates of perinatal mortality in sub-Saharan Africa.^9,10 Enhancing the standard of care given during childbirth is the most efficient method for reducing perinatal mortality.¹¹

Institutional delivery in Ethiopia fell short (48%).¹² Disrespectful maternity care is also typical (49.4%).⁴ The mistreatment, abuse, and neglect of health workers have fueled dissatisfaction, mistrust, and avoidance of facility-based delivery care.¹³

During childbirth, one-fifth of Ethiopian women claimed to have been treated disrespectfully.¹⁴ The most typical forms of mistreatment and disrespect included failing to respect one’s right to information, informed consent, the right to choose one’s childbirth position, and being neglected while in labour.¹⁵

Despite the fact that assessing RMC during childbirth is crucial for improving the quality of maternity care services and lowering maternal morbidity and mortality rates. In our field of study, there is a lack of evidence. As a result, the primary goal of this study was to evaluate the extent of RMC and related variables during labour and delivery in Tirunesh Beijing Hospital, 2021. The Tirunesh Beijing Hospital, other healthcare organizations, managers of health services, and future researchers may find the study’s findings to be significant.

Material and methods

Research design, period, and area

Institutional-based cross-sectional study design was employed to assess the magnitude of RMC and associated factors during labour and delivery in Tirunesh Beijing General Hospital from 1 May to 30 June 2021. Tirunesh Beijing General Hospital was named after a famous Ethiopian Olympic gold medallist Tirunesh Dibaba during Beijing Olympics (China) and the Hospital is found in Akaki-Kaliti sub-city, Addis Ababa, Ethiopia. The Hospital serves about 2 million people. The hospital renders all MCH, delivery and postnatal care services. Currently, the Hospital has 47 midwifes and more than 3500 annual delivery.

Source and study population

The source population was all women who delivered at Tirunesh Beijing General Hospital. The study population was all women who delivered at Tirunesh Beijing General Hospital during the data collection period and selected by systematic random sampling. Women who were referred from another health facility after giving birth were excluded.

Sample size and sampling procedure

The sample size was calculated by using single population proportion formula considering the following assumptions. The prevalence of RMC, p = 74.8%,¹⁶ confidence interval (CI) = 95%, and none response rate = 10%. The final sample size was 319. Systematic random sampling technique was used to collect data using women registration numbers from the delivery logbook and k = 2. Data were collected from every other woman who gave birth during the research period. The first client was selected by simple random sampling (lottery method).

Data collection instrument, procedure and data quality assurance

Interviewer-administered structured questionnaire was used to collect the data. The tool was adapted from similar studies conducted in Ethiopia.^17,18 This assessment tool was developed using English language and then translated to Amharic language and back to the English language to ensure convenient information was retrieved. Questionnaires we used to assess RMC have Cronbach’s alpha value of 0.845.¹⁹ Pre-test was done in Debre Berhan comprehensive specialized Hospital which was out of our actual data collection site among 5% of the sample to assess the internal consistency and repeatability of the tool. Four BSc midwifes were recruited for data and authors were supervised the overall data collection process. Mothers were interviewed after 4 hours of delivery and before discharge. Data were collected in a calm and separate room.

Operational definition

Respectful care was measured by four performance standards (friendly care, timely care, discrimination-free care, and abuse-free care).¹⁷ In each performance standard, there were items to measure each category 7 items from friendly care, 3 items from abusive free care, 2 items from timely care, and 4 items from discrimination-free care. During analysis, the responses of ‘Yes’ for positive meaning questions and ‘No’ for negative meaning questions were considered as received RMC, and the responses of ‘No’ for at least one positive meaning question or response of ‘Yes’ for at least one negative meaning item were considered as disrespected and abused. Finally, women were considered as respected during labour and delivery services when the responses for the four performance standards were classified as ‘Yes’.

Statistical analysis

Data were checked for completeness and entered into Epidata version 3.1 and then exported to SPSS version 25 for further data cleaning and analysis. Frequency distributions were obtained to check for data entry error (missing/unrecognized values and codes). Descriptive statistics was done and presented by Tables and Graph. The presence of an association between the independent and outcome variable was checked by the Pearson chi-square test. In addition, each independent variable was fitted separately into bivariable logistic analysis to evaluate for the degree of association with RMC. Variables with p-values less than 0.25 in bivariable model was candidate variable for multivariable logistic regression analysis. In multivariable model, backward stepwise regression was used and variables with p-value < 0.05 in 95% CI were considered independent predictors of RMC.

Ethical approval for this study was obtained from Institutional Review Board (IRB) of Debre Berhan University with protocol number Po 27. Then, permission letter to conduct the study was obtained from the hospital administration office. The respondents were informed about the purpose of the study, and data were collected after obtaining oral informed consent from the study participants. This method of obtaining informed consent was approved by the Institutional Review Board of Debre Berhan University.

Results

Socio-demographic characteristics of research subjects

From the total eligible post-natal mothers, everyone gave a voluntary consent to participate in the research, and there was a 100% response rate. The mean age of respondent’s was 28.17 with a standard deviation of (SD ± 4.381) and the minimum and maximum ages were 19 and 40 years, respectively. Two hundred seventy-two (85.3%) of participants were married and about half 167 participants (52.4%) of participants were Amhara ethnicity, and 168 (52.7%) of participants were followers of Orthodox Christian religion (Table 1).

Table 1.

Sociodemographic characteristic of women (n = 319) in Addis Ababa Tirunesh Beijing Hospital.

Type of variables	Frequency	Percent (%)
Age
<25	92	28.8
25–29	113	35.4
30–34	84	26.3
>34	30	9.5
Marital status
In marital union	272	85.3
Nonmarital union	47	14.7
Religion
Orthodox	168	52.7
Catholic	12	3.8
Protestant	75	23.5
Muslim	64	20.0
Ethnicity
Amhara	167	52.4
Oromo	112	35.1
Tigray	31	9.6
Other’s	9	2.9
Mother’s education level
No formal education	48	15.1
Primary-secondary school	153	47.9
College and above	118	37.0
Mother’s occupation
House wife	80	25.1
Employee	160	50.1
Self-employee	61	19.2
Student	18	5.6
Family income
⩽2000	76	23.8
>2000	243	76.2

Obstetric history of women

Regarding women’s obstetric information, 308 (96.6%) of study participants had history of an antenatal follow-up during current pregnancy period. More than half 174 (56.5%) attended their ANC visits at government health centres and most of them 194 (62.9%) of women were completed their fourth visit which is recommended by the World Health Organization (Table 2).

Table 2.

Obstetric characteristic of women at Addis Ababa Tirunesh Beijing Hospital (n = 319).

Type of variables	Frequency	Percent (%)
History of ANC follow-up (n = 319)
Yes	308	96.6
No	11	3.4
Place of receive ANC visit (n = 308)
Health centre	174	56.5
Hospital	120	39
Private clinics	14	4.5
ANC care provider (n = 308)
Doctor	139	43.6
Nurse/midwife	162	50.8
Health extension worker’s	7	2.2
Number of ANC visit’s (n = 308)
<4 visits	114	37.1
Full visits (⩾4)	194	62.9
Total no delivery
One	94	29.5
Two	109	34.2
Three or more	116	36.3
Stillbirth history
No	267	83.7
Yes	52	16.3
Sex of delivery attendant
Male	181	56.7
Female	138	43.3
The profession of delivery attendant
Midwifes	232	72.8
Doctors	87	27.3
Getting of services by care provider they want
Yes	246	77.1
No	73	22.9
Mode of delivery
Normal delivery (SVD)	165	51.7
Caesareans section	73	22.9
Instrumental delivery	81	25.4
Hospital waiting time
Less than 1 day	68	21.3
One day	126	50.2
Two or more days	125	21.5
Facing complication
Mother	85	26.6
Baby	17	5.3
Both	24	7.5

ANC: antenatal care; SVD: Spontaneous Vaginal Delivery.

Level of respectful maternity care during labour and delivery

In our study, more than 85% (87.8%) of study participants received respectful maternity care. From categories of RMC, 99.1% of women received care in kind approach and 312 (97.8%) received friendly care. The other most commonly reported is abuse-free care from the respected maternity care category as a result, 302 (94.7%) women were assisted without physical abuse (slaps, hitting), and 216 (67.7%) women were assisted during childbirth without screaming/shouting (Table 3). Evidence from our study indicated that still, some health care workers did not treat well their clients due to personal attributes, 258 (80.9%) women reported prompt treatment, while 313 (98.3%) reported non-discriminatory treatment (Figure 1).

Table 3.

Level of respectful maternity care during labour and delivery at Addis Ababa Tirunesh Beijing Hospital (n = 319).

Category and type of RMC	Yes	%	No	%
Friendly care
Care in kind approach	316	99.1	3	0.1
Care in friendly manner	312	97.8	7	2.2
Care positively	273	85.6	46	14.4
Care with empathy	306	95.9	13	4.1
Care with respect	311	97.5	8	2.5
Care for her with language that she can understand	267	83.7	52	16.3
Care with call by name	187	58.6	132	41.4
Abuse free care
Provider respond to her need whether she asked or not	282	88.4	37	11.6
Provider slapped her during delivery	17	5.3	302	94.7
Provider shouted on her during delivery	103	32.3	216	67.7
Timely care
She was waiting for a long period before receiving care	83	26.0	236	74.0
Service provision were delayed	39	12.2	280	87.8
Discrimination free care
Some of the health workers did not treat well because of some personal attribute	11	3.4	308	96.6
Some of the health workers insulted me and my companion’s due to my personal attribute’s	7	2.2	312	97.8
Provider did discriminate me by economics status and language	2	0.6	317	99.4
The provider did discriminate against me by race and ethnicity	2	0.6	317	99.4

RMC: respectful maternity care.

Figure 1.

Types of respectful maternity care during labour and delivery at Addis Ababa Tirunesh Beijing Hospital (n = 319).

Factors associated with respectful maternity care

When testing the bivariable association, factors with a p-value of 0.25 or less were considered potential variables for the multivariable regression model. The variables that went into the final model were the type of delivery, the gender of the primary care provider, the sex of the delivery staff, the history of stillbirth, access to the desired health care provider, and the type of women’s birth. The type of delivery (caesarian delivery and spontaneous vaginal delivery), getting service by the provider of their preference, history of still birth and sex of delivery attendant (male attendant) were significantly associated with respectful maternity care with a p-value < 0.05.

Respectful maternity care varies depending on the delivery method. Compared to mothers who gave birth by instrument, mothers who delivered by caesarian section were 10.4 times more likely to receive respectful maternity care (RMC): adjusted odds ratio (AOR) = 10.4, 95% CI: 1.8, 61, and mothers who gave birth naturally were 2.9 times more likely to receive RMC: AOR = 2.9, 95% CI: 1.4, 6.

Women who chose the provider of their choice for delivery had a 2.6-fold increased chance of receiving respectful maternity care compared to those who did not (AOR = 2.6, 95% CI: 1.3, 5.2). Contrarily, mothers who had a male delivery attendant were found to be 3.6 times more likely than those who had a female delivery attendant to receive respectful maternity care (AOR = 3.6,95% CI: 1.8,7.5).

Another factor that has been linked to receiving respectful maternity care is a mother’s history of stillbirth. Accordingly, mothers with a history of stillbirth were 5.8 times more likely to receive such care than mothers without such a history. AOR = 5.8, 95% CI: 1.3, 25.8 (Table 4).

Table 4.

Factors associated with respectful maternity care in Addis Ababa Tirunesh Beijing Hospital.

Variables	Category	RMC		COR (95% CI)	AOR (95% CI)	p-value
Variables	Category	Yes	No	COR (95% CI)	AOR (95% CI)	p-value
Types of delivery	SVD	137	28	2.1 (1.1, 3.9)	2.9 (1.4, 6)	0.003
	C/S	71	2	14.9 (3.4, 65.9)	10.4 (1.8, 61)	0.010
	Instrumental	24	57	Ref.	Ref.
Main provider	Midwife	183	49	Ref.	Ref.
Main provider	Doctor	82	5	4.4 (1.7, 11.4)	1.1 (0.3, 3.9)	0.926
Getting service by the provider of their preference	Yes	214	32	2.9 (1.5, 5.4)	2.6 (1.3, 5.2)	0.008
Getting service by the provider of their preference	No	51	22	Ref.	Ref.
Stillbirth	Yes	50	2	6 (1.4, 25.6)	5.8 (1.3, 25.8)	0.022
Stillbirth	No	215	52	Ref.	Ref.
Sex of delivery attendant	Male	166	15	4.4 (2.3, 8.3)	3.6 (1.8, 7.5)	0.0001
Sex of delivery attendant	Female	99	39	Ref.	Ref.

RMC: respectful maternity care; COR: crude odds ratio; CI: confidence interval; AOR: adjusted odds ratio; Ref.: reference.

Discussion

Our study primarily focuses on evaluating the level of respectful maternity care and its contributing factors in the Tirunesh Beijing Hospital, which was named after the well-known Ethiopian Olympic runner Tirunesh Dibaba. According to the study’s findings, 87.8% of maternity care was provided in a respectful manner. This finding was higher than the research conducted at Harar (38.4%),¹⁸ Benishangul Gumuz (12.6%),²⁰ Debre Berhan (35.7%),²¹ Bahir Dar Town (57%),²² Iran (24.3%),²³ and Egypt (80%).²⁴ These variations might be due to the difference in the sampling methods, for example, research conducted in Debre Berhan used consecutive sampling, but this is not the case in our study. The other difference might be due to the difference in sample size, study period and area.

According to this research abuse-free care is the most commonly experienced category of RMC, and its provision was 83.6%. This result was higher than the research conducted in Bahir Dar Town (14.4%),²² and Harar, Eastern, Ethiopia (45%).¹⁸ This deviation may be due to difference in staff training (on job training) on compassionate respectful care (CRC) and organizational working culture. The other possible explanation for the difference might be due to the difference in frequency of antenatal care visit because respectful maternity care is associated with the presence of maternal ANC follow-up in many studies.^18,21,25,26 On the other hand, the result is lower than the research conducted at west Shewa zone Oromia region, Ethiopia (89.2%) this might be due to the difference in a research setting and sample size.²⁷

The other category of RMC was timely care during the provision of services, 80.9 % of mothers receive timely care. This finding was higher than research carried out in Bahir Dar (1.4%),¹⁸ and Harar (76%)²² but lower than research conducted at northwest Ethiopia 96.3%.¹⁷ This deviation might be due to the difference in organizational work culture and attitude of professionals towards their work.

The other category of RMC experienced during labour and delivery was discrimination-free care. More than 98.3% of mothers received discrimination-free care. This result was higher than research conducted at Harar (45.4%), and Bahir Dar (32.4%).^18,22 The reasons might be due to the difference in measurement of outcome variables, for example, the research conducted in Harar used previous studies and it was categorized as ‘’disrespect care’ if there is 1 response from 15 items to determine cut-off-point for respectful maternal care but our research used the mean score value of responses from the criteria to determine the cut of points the other reason might be due to the study settings.

In addition to this, our research revealed that a high level of friendly care which was 88.4%. This research was higher than research carried out at Bahir Dar which account (26.1%), and Eastern Ethiopia, Harar (59.8%).^18,22 This deviation may be due to research period difference, sample size differences, and research settings as well as socioeconomic and sociodemographic deference’s.

Our research found that mothers who gave birth with caesarean section were 10.4 times more likely to experience respectful maternity care than women who were delivered by instrument (forceps’s and vacuum assisted delivery) this study finding is supported by study conducted in southern Ethiopia which reported that women’s who delivered by caesarean section were faced little mistreatment compared to others.²⁸ On the other hand, women’s who delivered by spontaneous vaginal delivery were 2.9 times more likely to experience respectful maternal care compared to mothers who delivered by instrument assisted delivery. This finding was supported by other similar studies.^22,29,30 This might be due to the nature of the procedure, that is, instrumental delivery has some discomfort and needs more cooperativeness of the labouring mother. To ensure good birth outcome health workers used instrument to shorten the second stage of labour this will be perceived as painful experience for the mothers.

Women who have got service by the provider of their preference were 2.6 times more likely to get respectful maternal care than their counterparts. This might be due to women perception. When Women have got service by the provider of their preference, may feel safe, supported, respected and able to participate in shared decision-making.

Mothers with a history of still birth were 5.8 times more likely to experience respectful maternal care than those who don’t have a history of still birth. This finding seems negative but it might be due to special treatment of mothers with a history of still birth because they are a high-risk group and needs special attention and treatment.

Male birth attendant was found to be remarkably associated with respectful maternal care it was 3.6 times more likely to get kind care than their counterparts (women who gave birth by female birth attendants) these finding was supported by similar studies.^18,29 This might be due to high number of male birth attendants in our study.

Strength and limitation

Face-to-face interviews are used in this study because they are thought to be the most reliable method of gathering data, making it strong. The study also aims to fill a knowledge gap in the area of respectful maternity care, which is somewhat complex and understudied overall and in this study area. Despite the strengths mentioned above, there are some limitations to this study; the problem (RMC) on its own is challenging because the data were gathered from mothers. This makes it challenging to investigate the true causes. In addition, some of the mothers were reluctant to share any unfavourable incidents they had while at the facility, and the research was limited to one hospital.

Recommendation

Health care providers should give more attention to punctuality and be polite while giving care and attending delivery. We recommend for future researchers to explore the reasons for disrespect and abuse by qualitative research.

Conclusion

A significant number of mothers have got respectful maternity care in our study area, but respectful maternity care is not merely the absence of mistreatment. Women value being provided with care that is respectful, inclusive and of good quality. Also, mothers are still exposed to a different type of disrespect and abuse during delivery service.

Footnotes

Acknowledgements

We would like to express our appreciation to the patience of women who participated in this study during the time of the interview and the data collectors for their greatest effort for the success of this project.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical approval

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Informed consent

The respondents were informed about the purpose of the study and data was collected after obtaining oral informed consent from the study participants. This method of obtaining informed consent was approved by the Institutional Review Board of Debre Berhan University.

ORCID iDs

Alemu Basazin Mingude

Samuel Derbie Habtegiorgis

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