Identification of Factors Associated with Disrespect and Abuse of Women During Child-Birth in the Major Hospitals in Yenagoa, South-South Nigeria

Identification of Factors Associated with Disrespect and Abuse of Women During Child-Birth in the Major Hospitals in Yenagoa, South-South Nigeria

 Inara Blesing Standley, Lawrence Ayah Iruo* & Rosemary Ezekiel
Department of Nursing Science, PAMO University of Medical Sciences, Port Harcourt, Nigeria

*Corresponding Author

DOI: https://dx.doi.org/10.47772/IJRISS.2023.70636

Received: 10 March 2023; Accepted: 25 May 2023; Published: 22 June 2023

ABSTRACT

The aim of this study was to identify factors associated with disrespect and abuse of women during childbirth in Yenagoa, South-South Nigeria. It was a cross-sectional survey carried out on 165 mothers who delivered within 6 weeks (August and September, 2018), using purposive sampling method. Data was collected using Level of Disrespect and Abuse of Women during Childbirth Scale (LDAWCS). Prevalence of disrespect and abuse during childbirth in selected hospitals was low with 26.7 % (n=44) of women experienced at least one form. Most frequent types of D&A were; detention for non-payment of bills 50.3% (n=83), women never given the opportunity to make choice of birthing position, carrying out procedures without consent 39.4% (n=65), women left naked in the view of many staff 29.7% (n=49) and women abandoned during labour 21.2% (n=35). There was significant relationship between disrespect and demographic characteristics of parity and education, marital status, ethnicity, income and occupation had moderate evidence of relationship with disrespect and abuse while age and religion showed no significant relationship with D &A at α = 0.05 level of significance. National human rights commission should look into cases of D & A of women and they should be encouraged to report such cases as they leave the premises for proper action to be taken. Professional bodies like Nursing/Midwifery Council of Nigeria, Nigeria Medical Association etc, should investigate and institute disciplinary action against any member found to have disrespected and abused women during childbirth.

Key Words: Disrespect and Abuse, Postnatal mothers, Tertiary Hospitals

INTRODUCTION

Childbirth is a unique and unforgettable experience that has a lasting effect on women’s health and wellbeing. If a woman’s childbirth is served respectfully and adequate support is provided in form of comfort, reassurance and praise, the birth experience would be positive. Unfortunately, in many instances women lack the desired exciting childbirth experience. Many mothers report feeling a lack of autonomy in decision-making during their pregnancy and the birth (Vedam, Stoll, Martin, Rubashkin, Partridge, Thordarson, & Ganga- Jolicoeur, 2017). Others report being abused, scolded or shouted at or threatened that their care would be withheld (Averting Maternal Death and Disability, AMDD, 2017). These are disrespectful and abusive treatments that not only affect the health and wellbeing of the women but also an infringement on their fundamental human rights. Sadly, the situations have persisted over time.

In Bohren, Vogel, Hunter, Lutsiv, Makh, Souza, et al (2015), abusive and disrespectful treatment of women at the delivery of a child is described as an emerging problem. But Cohen (2017) noted the issue as a very widespread phenomenon with different manifestations. This was also corroborated by WHO, (2017) that women worldwide face diverse forms of mistreatment when giving birth in the hands of health-care personnel. Several reports exist to support this global happening of abuse and disrespect of women in labour and delivery (Ishola, Owolabi, & Filippi, 2017). In Peru, studies revealed that at least one category of abuse and disrespectful treatment was experienced by women in hospital based maternity care (Montesino-Segura, Urrunaga-Pastor, Mendoza-Chuctaya, Taype-Rondan, Helguero-Santin & Martinez-Ninanqui, 2017). In Britain, Cohen (2017) also reported that abuse and disrespect is taking place among women in labour as women expressed lack of autonomy in decision making.

In the African continent, a study in Ethiopia found that the health care personnels and patients all reported frequent verbal abuse, non-consented care as well as physical abuse during labour and delivery (Burrowes, Holcombe, Jara, Carter,&Smith, 2017). In Tanzania, Shimoda, Horiuchi, Leshabari and Shimpuku (2018) also reported that women experience diverse kinds of abuse and disrespect, approximately 12 to70% have been found during facility-based childbirth. The situation is not different in Nigeria. According to Ishola, Owolabi and Filippi (2017), a broad range of disrespectful and abusive behaviours are experienced by women during giving birth in the hospital. Hodin (2017) not only acknowledged the incidence of disrespect and abuse women experience during childbirth but also noted the various forms of disrespect and abuse that are prevalent. Example in a study by Okafor and Colleagues (2020) 20% of women said to have reported discrimination based on ethnicity, socioeconomic status, age, HIV status and lack of formal education; 10% to 29% reported felt neglected.

In literature, abusive treatment during delivery could be in the form of humiliation, discrimination, denial of care, physical, psychological or verbal abuse, and the implementation of contraindicated or improper procedures. Mesenburg, Jacob, Serruya, Ponce De León, Damaso, Domingues, and Da Silveira. (2018),Cohen (2017), Hodin (2017) reported some percentages of women who experienced abusive treatments in literature like scolding or shouted at 7%; threat to withhold care, being tied down or restrained during labour, 17%; giving of episiotomy without anesthesia, 9%, being beaten or slapped,7%; sexually abused by a health worker 2%.

A study recorded in the Niger Delta region revealed that there is limited space as a result no privacy was observed. This can be seen from the statement made by a woman “There was not enough space in the labour room…and they don’t have the facilities. There were only two rooms and about 4 doctors…you could hear them (doctors) talking to other women” (Hodin, 2017). The aforementioned disrespectful and abusive behaviours are also experienced in Bayelsa State. Whereas, no documented  incidence regarding disrespect and abuse during childbirth in Bayelsa State was accessed during the period of study, the researcher has personal experiences of abusive and disrespectful conducts of some categories of care providers attending to pregnant and labouring women. Based on this, the researchers considered it important to investigate the incidence and degree of disrespect and abuse of women during facility-based childbirth in selected hospitals in Yenagoa, Bayelsa State.

Statement of Problem

Disrespect and abuse of women during childbirth is a topical issue in maternal and child health. According to Hulton, Mathews and Stone (1996), it is a problem that reduces the quality of maternal care, and it is recognized as an imminent danger to eliminating preventable maternal mortality and morbidity preventable causes (Hodin, 2017). Nevertheless, reports abound that abusive treatment by health-care providers during facility- based childbirth are experienced by women worldwide (WHO, 2017). Several cases and kinds of abuse and disrespect are enumerated in literature (Molla, et al. 2014; Bohren et al.2015; Cohen, 2017; Ishola et al. 2017, Mesenburg et al. 2018).

Although there are various factors encouraging abuse and disrespect in labour and delivery as noted in Ishola et al. (2017), it is relevant therefore to acknowledge that abuse and disrespectful treatment of women at giving birth at any degree has serious consequences on the women, birth attendants and health care system. The women express dissatisfaction with the care they receive and consequently refrain from facility-based maternal care. The result would be that professional care may not be accessed by the women thus exposing them to pregnancy and birth-related complications and compounding the problem of maternal morbidity and death of pregnant women or women within 42 days of delivery (Kassebaum, Bertozzi-Villa, Coggeshall, Shackelford, Steiner, Heuton  et al.,2014). It is also a violation of women’s right (Banks, Karim, Ratcliffe, Betemariam & Langer 2018).

On the part of care attendants, the women’s response to disrespectful and abusive behaviours may evoke sentiments that may result in neglect of care or even inappropriate care even though such is against professional ethics.

The result would again be that women would not utilize the maternal services in those locations (Asefa, Bekele, Morgan & Kermode, 2018). This would again hamper the drive to prevent maternal morbidity and mortality. Finally, maltreatment of women in labour has been recognized as an indicator of poor quality maternal care (Banks, et al. 2018).

Consequently, maternal mortality in 2015 showed that two countries count for a third of global maternal deaths. These are India with 45,000 (15%) and Nigeria 58,000 with MMR of 814 per 100,000 (WHO, 2017)

According to Manning and Schaaf, (2018), abuse and disrespect of women giving birth may undermine efforts to improve mothers’ health as may move women away from acquiring care at health facilities. Based on this and the fact that the researcher has witnessed some instances of harsh words  used on women during labour in some health facilities, that this study was conceived to investigate disrespect and abuse of women during childbirth in selected hospitals in Yenagoa, Bayelsa state.

Objective of the Study:

Identify factors associated with disrespect and abuse of women during childbirth

Research Question

What are the factors associated with disrespect and abuse of women during childbirth?

Research Hypothesis

There is no significant relationship between socio-demographic characteristics of women and disrespect and abuse during childbirth in selected hospital in Yenagoa, Bayelsa state.

EMPIRICAL REVIEW

There are many studies carried out by others at various locations within and outside the country on prevalence, categories and factors encouraging disrespect and abuse.Molla, Muleta, Betemariam, Fesseha and Karim (2014) conducted a study entitle “ Disrespect and Abuse during pregnancy, labour and childbirth in Ethiopia”. A qualitative research was conducted between March and April 2014 in four health centres, among Midwives and women. Data were generated using in-depth interviews and focus group discussion involving 63 family members who accompanied laboring women to the health centres in the past three months before the study. The result revealed that most women faced disrespectful care. Women who faced disrespectful care on their course of attending antenatal care reported to have avoided having their babies at health facilities.

Another study by Okafor, Ugwu and Obi (2014) entitled, “prevalence and pattern of disrespectful and abusive care during facility-based care” on 446 women undergoing immunization services for their babies that delivered 6 weeks before and had received antenatal care and delivered their babies at the hospital. A cross-sectional study was undertaken at ESUTH, Enugu state Nigeria, between May 1- August 31 2012. All respondents reported to have experienced one type of disrespect and abuse but the highest reported were non-consented services and physical abuse. The study used convenience sample of consecutive postnatal mothers who accessed the facility. Each eligible woman was initially approached privately to seek consent.

In a cross-sectional study that used Bowser and Hill’s (2010) landscape analysis and done in Ethiopia among four health facilities, 78 percent of all women reported having experienced a type of D&A during delivery in the maternity unit (Asefa & Bekele, 2015). Specifically, 32.9 percent were not protected against physical harm, 48 percent of them had medical procedures done without consent, and 39.3 percent of the mothers were left in labor without attention while in 33 percent of the cases women’s privacy was not observed (Asefa & Bekele, 2015).

Another study on the “Prevalence of disrespect and abuse of women during child birth and associated factors” was carried out by Wassihun, Deribe, Worede and Gultie (2018) in three selected hospitals in Bahir Dar Town Amhara Regional State Ethiopia. A community based cross-sectional study design triangulated with in-depth interview was conducted to collect data from respondents between March 1- March 30 2017, study subjects 422 mothers were selected through systematic random sampling based on their proportional distribution of sample size to each sub-city. Result showed that all mothers experienced one type of abuse; the most prevalent was physical and non-consented care. Disrespect and abuse were prevalent on the low socio-economic group which has the highest prevalent rate

Ishola, Owolabi and Filippi (2017) also conducted a systematic review to combine current evidence on disrespect and abuse of women during childbirth in Nigeria in order to give a better understanding of its nature and extent, contributing factors, consequences and purpose. The studies were fourteen altogether. 11 were cross-sectional studies, the other was a qualitative study and 2 used a mixed method approach. The result has it that non-dignified care  was reported to be highest due to negative, poor and unfriendly provider attitude and the least frequently observed were physical abuse and detention in facility. The result stated that these behaviours of health personnel were exhibited as a result of poor provider training and supervision, empowerment of women, low socio-economic status, and inadequate form of education, weak health systems, inadequate accountability and legal redress mechanism. In conclusion, the study observed that overall, disrespect and abusive behavior reduced the utilization of health facilities for delivery and built a psychological distance among users.  The authors recommended strengthening health systems to respond to peculiar needs of women at childbearing period, also to improve provider training to encompass interpersonal aspects of care and also implementing and enforcing policies that are enacted on respectful maternity care are important.

In yet another study by Adinew and Asefa (2017) an exploratory study of women’s view of facility-based childbirth was conducted in rural Ethiopia. In-depth interviews (IDIs) and Focus Group Discussion (FGDs) were held with consciously selected study participants who fulfilled the inclusion criteria. The study was carried out in two deliberately selected districts. The population of Women who delivered at least one of their children in a facility during the last five years 2011-2015 but delivered in the facility with the youngest child without skilled attendant. These women with experience of both Facility-based and home delivery were purposively identified and enrolled in the FGDs and IDIs with the help of health extension workers. The study was done from March to June 2016. Digital voice recorder was used to record the discourse. The influencing factors seen as abusive and disrespectful treatment are unprofessional care, lack of privacy, inadequate care, inadequate provider interactions, continuity of care, traditional practices and lack of privacy.Bohren, et al., (2017) also conducted a study entitled,” mistreatment of women during childbirth” in Abuja, Nigeria. The study was a qualitative one that focuses on perceptions and experiences of women and health care providers. Focus Group Discussion (FGDs) and In-depth interview (IDIs) were used with a purposive sample of women within the age of bearing children, Doctors, midwives, and facility administrators. Semi-structured discussion guide was the instrument used. The study was analyzed using thematic analysis to synthesize findings into meaningful sub-themes.

In yet another study conducted in Kenya, 20 percent of the women reported one kind of D&A during hospital delivery. In terms of categories of D&A, non-confidential care accounted for 8.2 percent, non-dignified care 18 percent, abandonment 14.3 percent, non-consented care 4.3 percent, physical abuse 4.2 percent while detention for non-payment was 8.1 percent (Abuya et al., 2015).

A study entitled “Prevalence of disrespect and abuse during facility based maternity care” was conducted by Sethi, Gupta, Oseni, Mtimuni, Rashidi and Kachale (2017) in Malawi. Direct observations were made across 40 facilities, 12 health centres and 28 hospitals involving 2109 women in August 2013 from 27 out of the 28 districts in Malawi. The author used the Bowser and Hill categories of D/A that was presented in the white Ribbon Alliance universal Rights of childbearing framework. Analysis was done using Bivariate tool to assess the relationship used in selected clients. Result showed that clients were denied a relative or significant others to stay with them. Result also showed that women were greeted respectfully and were informed of procedure.  HIV infected patients who delivered in these facilities showed the lowest prevalence of disrespect and abuseMontesinos-Segura et al., (2017) also conducted a study entitle “Assessing the prevalence of disrespect and abuse during childbirth and its associated factors”. This survey took place in nine cities of Peru. A cross-sectional study of women using observation as instrument surveyed within 48 hours at 14 hospitals located in nine Peruvian cities between April and July 2016. The survey was based on Bowser and Hill to investigate factors corresponding with each category, 95 percent confidence intervals (CIs) and prevalence ratios (PRs) were calculated during adjusted poison modes with robust variances among 1528 participants at least each experienced. Frequency of abandonment of care increased with caesarean birth but decreased in the jungle region.

In yet another study entitled, “Midwives’ and patients’ perspectives on disrespect and abuse during labour and delivery care in Ethiopia. An in-depth interview was conducted at four health facilities in Debre Markos, among midwives, midwifery students and women who had given birth within the past year. Total population was 45. Report showed that abuse took place but providers claim that most abuse is not intentional and they occur as a result of weakness in the health system or medical necessity. Patient responses suggest that women know that their rights are being infringed on but instead of reporting they rather prefer to avoid facilities with such poor reputations.

Hodin (2017) carried out a systematic review in PLOS One using a qualitative and quantitative study on Nigerian women experiences of disrespect and abuse during childbirth on 14 studies in different states using varying population and instruments. The author employed the 2010 Bowser and Hill framework to categorize and describe different types. Identified lack of autonomy and empowerment, poor quality clinical training related to provider-patient interaction, financial barriers, normalization of disrespect and abuse, a lack of national laws or policies and health care workers’ demoralization due to weak health systems as commonly cited contributing factors.

In another study by Banks et al., (2018) entitled “Jeopardizing quality at the frontline of healthcare: Prevalence and risk factors for disrespect and abuse during facility-based childbirth” in Ethiopia. Frequency and associated factors of disrespect and abuse were explored.  It investigated client provider interactions in labour and delivery. 193 births were observed and 204 who delivered babies at the health centres were interviewed. Patient flow was seen as an environmental factor that may contribute to disrespect and abuse, and that high patient turn out or inadequate skilled staff could be associated because staff are overworked, possibly burned out or may not be able to perform tasks as expected. The author stated further that infrastructure challenges may contribute but observations showed that providers were sometimes active perpetrators of disrespect and abuse.

Furthermore, Shimoda, et al., (2018) conducted a study entitled “Midwives’ respect and disrespect of women during facility-based childbirth in urban Tanzania: a qualitative study”. Fourteen midwives were recruited caring for 24 women in labour.  The midwives were observed in their care and they were analyzed using content analysis. Results has it that all the midwives showed both respectful and disrespectful care and some practices that have not been explained in previous reports of women experiences were observed such as unethical practices and inadequate accountability.  Midwifery and professional nursing management was found to be weak hence a contributor to disrespect and abuse.

Another study on disrespect and abuse was conducted in Pelotas; Brazil by Mesenburg et al., (2018) entitled” Disrespect and Abuse of women during the process of childbirth in the 2015 Pelotas birth cohort “. Household interview was done among women 3 months after delivery. The factors associated were evaluated using Poisson regression with disrespect and abuse. 4275 women were studied and the record shows that disrespect and abuse at childbirth was high.

In yet another study entitled,” Service providers’ experiences of disrespectful and abusive behavior towards women at facility-based childbirth in Addis Ababa, Ethiopia” was conducted by Asefa, Bekele, Morgan and Kermode (2018) with the aim to enhance service providers’ experiences of disrespect and abuse. A hospital based cross-sectional study was conducted in 2013 in one hospital and three health centres. A total of 57 health professionals completed the questionnaire. Personal observations of service providers were also done. Working environment was rated very poor while workload was reported very high. Majority of the participants believed that non-dignified care was observed to be defining factor discouraging pregnant women from accessing health facilities for delivery of their babies.

Theoretical Framework

The theoretical framework for this study was Hildegard Peplau’s interpersonal relations theory. This theory was developed in 1952, chiefly influenced by Henry Stack Sullivan, Percival Symonds and Abraham Maslow. Peplau’s theory defined Nursing as “An interpersonal process of therapeutic interactions between an individual who is sick or in need of health services and a nurse especially educated to recognize, respond to the need for help.” It is a “maturing force and an educative instrument” involving a conversation between two or more individuals with a common interest.

In the health care industry, this common goal provides the incentive for the therapeutic process in which the health personnel and patient respect each other as individuals, both of them learning and growing as a result the exchange between them gains experience. An individual learns when she or he selects stimuli in the environment and then reacts to these stimuli to cause an effect.

The assumptions of Peplau’s Interpersonal Relations Theory are: (1) Health provider and patient can interact. (2) Peplau emphasized that both the patient and health care giver gain experience as the result of the therapeutic relationship. (3) Communication and interviewing skills remain primary nursing tools for practice which serves as the ground work.  (4) Peplau believed that health personnel must clearly understand themselves to promote their client’s growth and to avoid restricting client’s choices to those that the health worker values.

Sample

A sample of 165 women who delivered within the period of August to September, 2018 representing (100 percent ie census) of the total population was selected through purposive sampling technique for the study. This was distributed as 82 and 83 women who delivered in Federal Medical Center(FMC) and Niger Delta University Teaching Hospital(NDUTH) respectively in Yenagoa, Bayelsa State in Nigeria

Instrument

The data were collected using an instrument called the Level of Disrespect and Abuse of Women during Childbirth Scale (LDAWCS). The LDAWCS was designed by the researchers and it was structured in three parts- A, B, and C. Section A, deals with the socio-demographic data of the respondents, Section B deals with Yes and No questions of the 7 types and prevalence of disrespect and abuse of women while Section C, addresses a Likert type for factors influencing disrespect and abuse of women to collect quantitative data.

Reliability coefficient of 0.87 was obtained using Pearson Product Moment Correlation Coefficient (PPMCC).

Data collection

Each eligible woman was initially approached privately in a separate room by the researchers on each day of data collection for counseling to participate in the study. The data were collected daily in the two facilities for one month. Data was analyzed using descriptive and inferential statistical techniques such as frequency distribution tables and percentages. Chi-square test was used to answer the research questions and test statistical association between relevant variables at 0.05 level of significance.

SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS

A total of 165 copies of the instrument were administered and 165 were correctly completed and returned given a response rate of 100%. With respect to demographic characteristics of respondents 52(31.5%) were between the age of 25-29 years of age, 141(85.5%) were married, 69(41.8%) had secondary education, 67(40.6%) had tertiary education, 26(15.8%) had only primary education while only 3(1.8%) had no formal education. Majority 162(98.2%) practiced Christianity while only 3 representing 1.8% were Muslim. The main occupation of respondents was trading 52(31.5%), 59(35.8%) had an estimated monthly income between N10, 000.00-N20, 000.00 while most of the respondents 70(42.4%) had one or two children with majority 96(58.2%) from Ijaw ethnic group.

Research Question:

What are the factors associated with disrespect and abuse of women during childbirth?

The study revealed that majority of the respondents 105(63.6%) strongly disagreed to the fact that women have normalized some of the behaviours seen among health care providers while only 18(10.9%) and 6(3.7%) agreed and strongly agreed that women have taken their behaviour as a normal thing. Also, 73(44.2%) and 52(31.5%) strongly disagreed and disagreed respectively that finance is an influence to disrespect and abuse of women during childbirth while 24(14.6%) and 16(9.7%) agreed and strongly agreed that finance has a strong influence to disrespect and abuse of women during childbirth. Similarly, 28(17%) of respondents strongly agreed that lack of human rights, ethics and principles has contributed to disrespect and abuse of women during childbirth and 54(32.7%) reporting that lack of community engagement in health care has indeed contributed greatly to disrespect and abuse of women during childbirth. Finally, majority of the respondents agreed to the fact that provider prejudices has a lot to do with disrespect and abuse of women during childbirth in selected hospitals in Yenagoa, Bayelsa State.

Research Hypothesis

Ho: There is no significant relationship between socio-demographic characteristics of women and disrespect and abuse during childbirth in selected hospital in Yenagoa, Bayelsa state.

At 95% confidence interval (p<0.05), the results indicates that no significant relationship exists between the age, marital status, religion, ethnicity, income and occupation of the respondents to their being disrespected and abused with p-values of 0.836, 0.364, 0.580, 0.402, 0.377 and 0.389 respectively. The results however, revealed that there exists a strong relationship between socio-demographics of parity and educational status of women with being disrespected and abused in tertiary hospitals in the study area with p-values of 0.007 and 0.000 respectively.

Factors associated with Disrespect and Abuse of women during childbirth: The study revealed that majority of the respondents 105(63.6%) strongly disagreed to the fact that women have normalized some of the behaviours seen among health care providers while only 18(10.9%) and 6(3.7%) agreed and strongly agreed that women have taken their behaviour as a normal thing. Also, 73(44.2%) and 52(31.5%) strongly disagreed and disagreed respectively that finance is an influence to disrespect and abuse of women during childbirth while 24(14.6%) and 16(9.7%) agreed and strongly agreed that finance has a strong influence to disrespect and abuse of women during childbirth. Similarly, 28(17%) of respondents strongly agreed that lack of human rights, ethics and principles has contributed to disrespect and abuse of women during childbirth and 54(32.7%) reporting that lack of community engagement in health care has indeed contributed greatly to disrespect and abuse of women during childbirth. Finally, majority of the respondents agreed to the fact that provider prejudices has a lot to do with disrespect and abuse of women during childbirth in selected hospitals in Yenagoa, Bayelsa State. However, the study is at variance with Hodin (2017), who identified normalization of Disrespect and Abuse in facility-based childbirth, financial barriers, women lack of autonomy and empowerment, poor quality clinical training related to provider-patient interaction, a lack of national laws or policies and health care workers demoralization due to weak health systems as commonly cited contributing factors. The study also revealed that provider prejudices has a lot to do with disrespect and abuse of women during childbirth in selected hospitals in Yenagoa, Bayelsa State.

CONCLUSION

The study revealed that disrespect and abuse of women during childbirth has a low prevalence in the selected tertiary hospitals in Yenagoa, Bayelsa State, since only 26.7% (n=44) of all women in the study experienced at least one form of Disrespect and Abuse during childbirth. However, the types of D & A experienced by women differs, but the most prevalent ones were; detention for non-payment of hospital bills, non-consented procedures, woman not giving opportunity to make choice of birthing position, abandoned and left unattended during the second stage of labour, provision of care without privacy, denied of food/fluid, receiving uncomfortable pain relief treatment, disclosing private health information to third party, shouting and scolding, being beaten, pinched, slapped, insulted and verbally abused etc.

REFERENCES

1. Abuya, T., Warren, C., Miller, N., Njuki, R., Ndwiga, C., Maranga, H., et al. (2015) exploring the prevalence of disrespect and abuse during childbirth in Kenya PLOS one. 2015: 10 (4) http://journals.plos.org/plosone /article?id=10.1371.pone.0123606. Retrieved 22/05/2018
2. Adinew Y.M., and Asefa, N.A., (2017) experience of facility childbirth in Rural Ethiopia an exploratory study of women’s perspective Hindawa the scientific world journal
3. Asfa, A., and Bekele, D., (2015) status of respectful and non-abusive care during facility-base childbirth in a hospital and health centre in Addis Ababa, Ethiopia reproductive health 2015; 12 (1):1
4. Asefa, A., Bekele, D., Morgan, A and Kermode, M (2018) Service Providers’ experiences of disrespectful and abusive behavior towards women during facility-based childbirth in Addis Ababa, Ethiopia Reproductive Healthhttps://reproductive-health- biomedcentral.com/track/pdf/10.1186/s12978-017-044-4. Retrieved 1/6/2018
5. Averting Maternal Death and Disability (AMDD 2017) disrespect and abuse during childbirth. Documenting the problem and tackling it with evidence-based solutions https://www.mailman.columbia.edu/sites/default/files/pdf/disrespect and abuse during childbirth.pdf retreived23/5/2018
6. Banks, K.P., Karim, A.M., Ratcliffe, HL., Betemariam, W. and Langer, A. (2018) Jeopardizing quality at the frontline of Health care: prevalence and risk factors D/A during facility-based childbirth in Ethiopia Health Policy and Planning vol.33 issue 3 pages 317-327 http://doi.org 1093/heapoli/czx180 retrieved 23/5/2018
7. Bohren, M., Vogel, J.P., Hunter, E.C., Lutsiv, O., …..Makh, S.K., et al. (2015) mistreatment of women during childbirth in Health Facilities Globally: A Mixed- Methods Systemic Review on perceptions and experiences of women and healthcare providers. Reproductive health 2017, 14:9doi10.1186/s/2978-016-0265-2 open access cross mark http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001847. Retrieved 23/5/2018
8. Bowser, D., and Hill, A., (2010) exploring evidence for Disrespect and Abuse in facility-based childbirth report of a landscape analysis Harvard School of Public Health and University Research Corporation
9. Burrowes, S., Holcombe, S. J., Jara, D., Carter, D and Smith, K. (2017). Midwives’ and patients’ perspectives on disrespect and abuse during labor and delivery care in Ethiopia: A qualitative study. BMC Pregnancy and Childbirth, 17(1). https://doi.org/10.1186/s12884-017-1442-1. retrieved 3/6/2018
10. Centre for Reproductive Rights (CRR) VIVO Positivo, furthering (2010) Dignity Denied: violation of rights of HIV-Positive women in Chilean health facilities
11. Centre for Reproductive Rights (2008), Broken Promises: Human Rights Accountability an maternal death in Nigeria
12. Centre for Reproductive Rights & Federation of women Lawyers (FIDA) Kenya, (2007) failure to deliver, violence of women right in Kenyan health facilities United State
13. Cohen, Y (2017) a little respect: Improving Maternity Care https://www.newsecuritybeat.org/2017/08/respect-improving-maternity-care/midwife-Sierra-Leone. accessed 5/6/2018
14. Family Care International the skilled care initiative (2009) Technical Brief: compassionate maternity care provider communication and counseling skills, New York
15. FIGO Mother and Newborn Friendly Birthing Facility (2014). Internal Federation of Gynaecology and Obstetrics London UK 88: 873-881 FMOH, Promoting Respectful Maternity Care Bill & Melinda Gates Foundation, UNICEF and USAID and implemented by JSI Research & Training institute Inc. 2014: vol 3 (issue)
16. Freedman, L.R.K., Abuya, T., Bellows, B., Ndwiga, C., Warren, CE., Kujawski, S., Moyo, W., Kruk, M.E. and Mbaruku, G. (2014) Defining disrespect and abuse of women in childbirth: a research policy and rights agenda. Bull World Health Organ. 2014;92(12);915-7, pmid:25552776
17. Guskin, S., Ferguson, L., and O’Malley, E. (2007) Ensuring sexual and reproductive health for people living with HIV, an overview of key human rights, policy and health systems issues. Reproductive health matters 2007:15 (29): 4-26
18. Hassan, J.J., Sundby, J., Husseini, A. and Bjertness, E. (2012). The Paradox of vaginal examination practice during normal childbirth. Palestinian women’s feelings, opinions, knowledge and experiences. Reproductive Health 2012: 9 (1): 1
19. Hill, K.., Stalls, S., Seth, R., Bazan, E., and Moffson, S. (2018). Moving Respectful Maternity Care into Practice in Comprehensive MCSP Maternal and Newborn Programs: Operational Guidance DRAFT(pp. 1–72). Retrieved from mcsprogram.org on 23/5/2018
20. Hodin, S (2017) disrespect and abuse during childbirth in Nigeria https://www.mhtf.org/2017/05/12/disrespect. accessed 3/6/2018
21. Hulton, L., Mathews, Z., Stone, RW. (1996) A Framework for evaluation of quality of care in maternity services. University of South Hampton:2000;1-4
22. Human Rights Watch 2010, unaccountable, addressing Reproductive health care gaps New York
23. Idris, S.H., Sambo, M.N and Ibrahim, M.S. (2013) Barriers to utilization of Maternal health services in a semi-urban Community in Northern Nigeria. The client’s perspective Nigeria Medical journal 2013; 54(1): 27-32
24. Ishola, F., Owolabi, O., and Filippi, V., (2017) Disrespect and abuse of women during childbirth in Nigeria: A systematic review. PLoS ONE 12(3): e0174084.https://doi.org/10.1371/journal.pone.0174084
25. Jewkes, R, Abrahams, N, Mvo, Z, (1998) why do nurses abuse patients? Reflections from South African obstetric services Social Sciences and Medicine, 47(11):1781-1795
26. Kassebaum, Bertozzi-Villa, Coggeshall, Shackelford, Steiner…. Heuton et a.l (2014), Jeopardizing quality at the frontline of healthcare: prevalence and risk factors for disrespect and abuse during facility-based childbirth in Ethiopia, Health Policy and Planning, Volume 33, Issue 3, April 2018, Pages 317–327,https://doi.org/10.1093/heapol/czx180
27. Kelly, R.B., Albers, G. and West, S.J. (1996) the American Academy of Family Physicians Family Health & Medical Guide USA
28. Kippenberg, J., Sahokwasama, J.B. and Amon, J.J. (2008) Detention of insolvent patients in Burundian hospitals health policy and planning 2008; 23 (1): 14-23
29. Kruk, M.E., Kujawski, P.M., Mbaruku,, G., Ramsey, H., Moyo, G. and Freedman,, M., (2018) women’s preference s for place of Delivery in Rural Tanzania. A population based Discrete Choice Experiment. American journal of public health 99 (9):1666-72
30. Kumbani, L., Bjune, G., Chirwa, E., Malata, A and Odland, JØ. (2013) Why some women fail to give birth at health facilities: a qualitative study of women’s perceptions of perinatal care from rural southern Malawi. Reproductive Health. 2013; 10:9. https://doi.org/10.1186/1742-4755-10-9. accessed 3/6/2018
31. Manning, A., and Schaaf, M. (2018). Disrespect and Abuse in Childbirth and Respectful Maternity Care. Retrieved fromhttps://www.whiteribbonalliance.org/wp-content/uploads/2018/01/6422_RMC-DA-Brief-Final.pdf accessed 4/6/2018
32. Meeks, L and Heit, P (2001) Meeks Heit sexuality and character education K-12. Content for teachers, a curriculum Guide. Every day learning cooperation Chicago
33. Mesenburg, M. A., Victoria, C. G., Jacob Serruya, S., Ponce De León, R., Damaso, A. H., Domingues, M. R., and Da Silveira, M. F. (2018). Disrespect and abuse of women during the process of childbirth in the 2015 Pelotas birth cohort Prof. Suellen Miller. Reproductive Health, 15(1).https://doi.org/10.1186/s12978-018-0495-6. Retrieved 3/6/2018
34. Molla, M., Muleta, M., Betemariam, W., Fesseha, N and Karim, A (2014) disrespect and abuse during pregnancy, labour and childbirth in Ethiopiahttp://ejhd.org/index.php/ejhd/article/view /1371.retrieved 2/6/2018
35. Montesino-Segura, R., Urrunaga-Pastor, D., Mendoza-Chuctaya, G., Taype-Rondan, A., Helguero-Santin, LM. and Martinez-Ninanqui, F. (2017) disrespect and abuse during childbirth in fourteen hospitals in nine cities of Peru international federation of obstetrics & gynaecology Wiley Doi: 10.1002/jigo 12353
36. Moyer, C.A., Adongo, P.B., Aborigo, R.A., Hodgson, A., and Engmann, C.M. (2014) They treat you like you are not a human being “maltreatment during labour and delivery in rural northern Ghana. Midwifery.2014; 30 (2): 262-8
37. National Population Commission Nigeria Demographic and Health Survey 2013. Abuja Nigeria:NPC,2014
38. Okafor, I., Ugwu, EO., and Obi, SN. (2014) disrespect and abuse during facility-based childbirth in a low in-come countries http:// dr.doi.org/10.10110 jogi 2014.08.2015 0020-7292 ©. International journal of gynaecology & obstetric elsevier.com/located/jigoIreland ltd
39. Otolorin, E., Gomez, P., Currie, S., Thapa, K. and Dao, B. (2015). Essential basic and emergency obstetric and newborn care: From education and training to service delivery and quality of care. International Journal of Gynecology and Obstetrics, 130(S2), S46–S53.https://doi.org/10.1016/j.ijgo.2015.03.007
40. Oyerinde, K., Harding, Y., Amara, P., Garbah-Aidoo, N., Kanu, R., Oulare, M. et al (2008) a qualitative evaluation of the choice of traditional birth attendants for maternity care in Sierra Leone. Implications of universal skilled attendance at delivery maternity and child health journal 2013; 17 (5): 862-8
41. Peplau, H (1952) Hildegard Peplau’s Theory of Interpersonal Relationship
42. Physicians for Human Rights (2007) in Sethi, Gupta, Oseni, Mtimuni, Rashidi& Kachale (2017) the prevalence of disrespect and abuse during facility based maternity care in Malawi Open access (http://creativeorglicenses (by/4.0/)reproductive health 14:11 Biomed central
43. Pillitteri, A, (2014) maternal & child Health Nursing, care of the childbearing & childbearing Family 7^th edition Wollers Klumer/ Lippincott Williams & wilkins
44. Sadler, M., Mário, J.D.S., Santos, C., Ruiz-Berdún,, D,, Rojas, G.L., Skoko, P., Gillen and Jette, A. (2016) Moving beyond disrespect and abuse: addressing the structural dimensions of obstetric violence, Reproductive Health Matters, 24:47, 47-55, https//doi.org/1016/j.rhm.2016.04.002
45. Sethi, A., Gupta, , Oseni, G., Mtimuni, S., Rashidi , A., and Kachale, V. (2017) the prevalence of disrespect and abuse during facility based maternity care in Malawi Open access (http://creative company.orglicenses (by/4.0/) reproductive health 14:111 Biomed central. Accessed 2/6/2018
46. Shimoda, K., Horiuchi, S., Leshabari, S and Shimpuku, Y (2018) midwives’ respect and disrespect of women during facility-based childbirth in urban Tanzania: a qualitative study. https://link.springer.com/content/pdf/10.1186%2fs12978-017-0447-6.pdf.reproductive. Retrieved 2/6/2018
47. Vedam, S., Stoll, K., Martin, K., Rubashkin, N., Partridge, S., Thordarson, D, et al. (2017) The Mother’s Autonomy in Decision Making (MADM) scale: Patient-led development and psychometric testing of a new instrument to evaluate experience of maternity care. PLoS ONE 12(2): e0171804. https://doi.org/10.1371/journal.pone.0171804. retrieved 2/6/2018
48. Vedam, S., Stoll, K., Rubashkin, N., Martin, K., Miller-Vedam, Z., Hayes-Klein, H., and Jolicoeur, G. (2017). The Mothers on Respect (MOR) index: measuring quality, safety, and human rights in childbirth. SSM – Population Health, 3, 201–210. https://doi.org/10.1016/j.ssmph.2017.01.005. retrieved 6/6/2018
49. Wassihun, B., Deribe, L., Worede, N., and Gultie, T. (2018). Prevalence of disrespect and abuse of women during child birth and associated factors in Bahir Dar town, Ethiopia. Epidemiology and Health, 40, e2018029. https://doi.org/10.4178/epih.e2018029. retrieved 6/6/2018
50. World Health Organization, UNICEF, UNFPA, World Bank estimates trends in Maternal Mortality: 1990-2010 Geneva 2012
51. World Health Organization (2013). Maternal and Perinatal health profile, Nigeria, from http://www.who.int/maternal child…/profiles/nga.pdf accessed 2/6/2018
52. World Health Organization (WHO) (2017) statement on prevention and elimination of disrespect and Abuse during child birth.who.int/reproductivehealth/topics/maternal-perinatal/statement-chilbirth/enWHO Maternal mortality fact sheet. From http://wwwhoint/mediacenter/factsheets/fs348/n/2014. Accessed 2/6/2018
53. WHO Ethiopian Demographic Health Survey. The DHS Program ICF Rockville, Maryland USA 2016