Respectful Maternity Care as perceived by the Birth Companions of Women who gave birth in a Tertiary care Teaching Hospital in South India: A pilot study

Respectful Maternity Care as perceived by the Birth Companions of Women who gave birth in a Tertiary care Teaching Hospital in South India: A pilot study

Papa Dasari^1*, Mahalakshmi Thulasilingam², Jayagowri Shasthry³, Jane Fischer⁴

¹Former Senior Professor, Dept of OBGY, JIPMER, Puducherry

¹Currently, Professor, Dept. Of Obstetrics & Gynaecology, Dean Research, SVMCHRC. Puducherry, INDIA.

²Additional Professor, Dept. of Preventive and Social Medicine, JIPMER, Puducherry, 605006, India.

³Senior Research Fellow Global Health, Public Health and Preventive Medicine, Monash University, Australia

⁴Finkel Professor of Global Health, Head, Division of Social Sciences, Public Health and Preventive Medicine, Monash University, Australia.

*Corresponding Author

DOI: https://doi.org/10.51244/IJRSI.2024.11150054P

Received: 24 October 2024; Revised: 04 November 2024; Accepted: 06 November 2024; Published: 05 December 2024

ABSTRACT

Background: Continuous maternal support during labour and childbirth is one of the evidence based interventions that proved to be associated with good maternal and perinatal outcomes. It is also reported to increase maternal satisfaction and decrease the disrespect and abuse. But few studies report the occurrence of D&A even in presence of birth companion. Objective: To determine the proportion of women treated with Disrespect and Abuse and to identify the type of disrespect and abuse as perceived by the birth companions of women who gave birth at Women and Children Hospital. Methods: Prospective observational mixed method pilot study undertaken from September 2020-December 2020 as a part of the Project on Respectful Maternity Care. Thirty birth companions were recruited randomly after informed consent to participate soon after (72hrs) delivery of their ward (postpartum women). They were asked to fill the answers to USAID-MCHIP Questionnaire on RMC, Rate the Disrespect and abuse on a 10 point scale to measure D&A quantitatively. They were interviewed to tell their views on the care given during labour and postpartum period for qualitative analysis. Results: As per their observations, 43.3% opined that the women experienced at least one type of D&A, 13.3% opined women experienced 2 types of D&A, 10% percent witnessed 3 types of D&A; 3.3% felt 5 types of D&A as per the USAID Standards. On rating scale they felt that D&A was experienced by only 20% and 3.3% experienced severe D&A. The most common type of D&A was non-dignified care followed by physical abuse. Qualitative analysis revealed 93% felt the women received quality care and had positive experience and appreciated RMC as good and 6.7% gave suggestions to improve RMC. Conclusion: RMC as witnessed by birth companions and assessed quantitatively by Questionnaire was high but on rating scale it is low. Only few felt, women in labour still experience D&A in their presence and the most common type was non-dignified care. The overall experience of childbirth care was perceived as good and they were grateful to have allowed them to give maternal support

Keywords: Birth companion; Disrespect and Abuse; Respectful maternity care; Perceptions.

TEXT

Introduction:

To promote respectful maternity care (RMC) and curb disrespect and abuse (D&A), presence of birth companion of choice is one of the important interventions adviced by various organisations. (WHO,2018; MOH&FW,NHM 2017; Alliance, W. R. 2011). There are studies which assessed D&A and reported less prevalence of the same with the implementation of birth companion and improved maternal and fetal outcomes (Sharma, S. K., et al 2022; Seth I et al 2013; Dubey, K.,et al 2023). But there are no studies that assessed D&A as observed by birth companion during labour and postpartum. We aimed to find out the prevalence and type of D&A as observed by the birth companions of women as one of the components of the major project which assessed disrespect and abuse among postpartum women. The results of the major part of the project i.e., disrespect and abuse as experienced by the postpartum women were published in IJOG^. (Dasari P et al 2024) This observation by birth companions may further confirm the prevalence of D&A and help to formulate strategies to eliminate the same.

The objective of this part of the study was to assess the proportion and type of disrespect and abuse as per Questionnaire modified from USAID-MCHIP protocol (MCHIP, J. 2012). quantitatively and also to know the perspectives of the birth companions (Qualitative) regarding their support and the care rendered by the hospital health care workers.

Methodology: This was a prospective cross sectional mixed-method pilot study conducted from June 2020 to December 2020 in the department of Obstetrics and Gynaecology, JIPMER, Puducherry, a tertiary care Teaching Institute South India. This is one part of the Project, “SPARC-862 Actions louder than words: Development and Evaluation of a Curriculum for Health Professionals and a Mobile Phone App for intra-partum women to actualize Respectful Maternal Care (RMC) in India” which had 6 objectives and assessment of D&A as observed by the birth companions was one of the objectives.

The study was approved by Institutional Ethics committee (Ethics no. JIP/IEC/2019/340). Participants were birth companions of women (who supported the labouring women through- out labour and immediate postpartum) who delivered at JIPMER Women children hospital and who were willing to participate in the study.

Study tool and data collection:

The data was collected after the women was shifted out of labour room and ensuring adequate privacy and after ensuring confidentiality. Informed consent was taken Questionnaires were adapted from USAID-MCHIP protocol (MCHIP, J. (2012). and modified for birth companions, which had binary response, yes/no and these were translated in to local language i.e Tamil. Disrespect and Abuse was captured under seven standards Viz; Physical abuse, Non-consented care, Non-confidential care, Non-dignified care (verbal abuse), Discrimination based on special attributes, Abandonment or Denial of Care and detention in facility as per the criteria described by Browser and Hill (Bowser, D., & Hill, K. 2010).

“Physical abuse was considered to have been experienced when the Health care worker (HCW) had beaten/ slapped/ pinched/ pushed, physically restrained / gagged/forcefully pushed the abdomen of the labouring woman or applied force to pull the baby; not helped to control the pain; denied food or fluids and separated the mother from her baby when it was not indicated medically. (Standard I of RMC). Non-consented care (Standard II) was considered to have been experienced when – HCP not talking in the language and manner that mother could understand/ not taking permission or explaining before examining or doing procedure. Non-confidential care (Standard III) – HCP sharing information without mother’s consent/ not covering with blankets/ screened without curtains. Non-dignified care (Standard IV)-is said to have been experienced when HCP not treated with respect, used abusive language and not encouraged to have birth companion. Standard V of RMC was not considered to have been achieved when women felt discriminated and were made to pay money unofficially for few workers. Abandonment or denial of care was experienced when women felt ignored or unattended to (Standard VI). Standard VII of RMC was considered to be not followed when women were not sent home at request or on time”.

The woman was considered to have experienced Disrespect and Abuse if the answer was affirmative (YES) for any one of the seven standard questions.

Birth companions were asked to rate the standard of care in their own perspective on a 10 point score from no experience of D&A (0) to severe D&A (10). They were asked to identify the individuals giving labour care who were indulged in D&A by their designation like doctors, nurses etc. They were also asked to express their perception, experience and views regarding the care received in their own words and suggestions to improve any part of the care provided. (Qualitative analysis).

Statistical analysis: Disrespect and abuse as per RMC Standards I to VII was expressed as frequency and percentage.

Results: The Socio-demographic profile of birth Companions is shown in Table 1.

TABLE 1: Socio-demographic profile of Birth companion (N=30)

S. NO	Characteristics of Birth Companions	N=30	(%)
I	Gender
	Male	4	16.7
	Female	26	83.3
II	Age in Years
	Mean age in years	46.2±13.2
	≤25	1	3.33
	26-35	8	26.7
	36-45	7	23.3
	46-55	5	16.7
	56-65	8	26.7
	≥66	1	3.33
III.	Relationship with Woman
	Mother	15	53.3
	Husband	4	13.3
	Mother-in-law	2	6.67
	Aunty	2	6.67
	Sister	5	16.7
	Sister-in-law	1	3.33
	Friend	1	3.33
IV.	Educational Status
	No Formal Education	3	10
	< Primary level	1	3.33
	Primary level	2	6.67
	Secondary school education	4	13.3
	Higher Secondary	4	13.3
	Under graduate	10	33.3
	Post graduate	2	6.67
	Super specialists	4	13.33
V.	Socio economic status (BJ Prasad)
	I    (7533 and above)	15	50
	II   (3766-7532)	6	20
	III  (2260-3765)	5	16.7
	IV  (1130-2259)	0	0
	V   (1129 and below)	4	13.3
	Residence
	Urban	25	83.3
	Rural	5	16.7
VI.	Religion
	Hindu	25	83.3
	Christian	3	10
	Muslim	2	6.7
VII.	Caste
	FC	1	3.3
	BC	13	43.3
	MBC	10	33.3
	SC	6	20

FC-Forward Caste; BC-Backward Caste; MBC-Most backward caste;

SC-Scheduled Caste

Majority were female (26 ;83.3%) and only 4 were male. Mean age of birth companions was 46.2±13.2. (,years) majority belonged 56-65 years of age. Birth companion was mother for 15 (53.3%) women, sister for 5 women and husband for 4 women. Rest were mother-in-law, sister, sister-in-law, friend and aunty. The educational status of BC was graduation among 10, and postgraduation among 6. Majority belonged to Class I socioeconomic status (15 ;50%) and 4 were Class V and below. The residence was in Urban area in 83% and 5 (17%) were in rural area. Twenty five of them were Hindus and 3 were Christians and two were Muslims. Most of them belonged to Backward and most backward castes and 20 % were scheduled caste.

The clinical profile of labouring women is shown in Table 2.

Table 2: Clinical profile of pregnant women cared by Birth Companion

Characteristics of Child bearing Women	N=30	Percentage
Mean age in years with SD	28.1±2.8
Age at delivery in years
≤19	0	0
20-25	6	20
26-30	19	63.3
31-35	4	13.3
36-40	1	3.33
Gravidity
Primi	24	80
Multi	6	20
Mean BMI with SD	30.4±4.9
18.5-22.9 (Normal)	1	3.3
23-24.9 (Over weight)	4	13.3
≥25 (Obese)	25	83.3
Antenatal visit at same health care facility	28	93.3
No of Visits to this facility (n=28)
<4	3	10
4-6	13	43.3
7-13	12	40
Emergency Admission	7	23.3
Recommendation Letter	2	6.7
Relatives working in Hospital	24	80
History of Infectious disease	1	3.33
Mode of delivery
SVD	18	60
Emergency LSCS	12	40
Instrumental	0	0

The mean age of the labouring women was 26.5±2.5 years Majority (63.3%) were between 26- 30 years and 20% were between 20-25 years. Most of them 80% were primigravidae. The mean BMI was 30.4 ± 4.9 Kg/m². And 83.3 % were obese. Almost all of them (28; 93.3%) had antenatal care in our hospital. Twenty four (80%) had relatives working in our hospital and two of them had recommendation letter. Sixty percent delivered normally and 40 % (12) had emergency Caesarean section.

Table 3 depicts the observations of birth companion on the prevalence of D&A as per the categories on USAID – MCHIP questionnaire. They observed 30 % to have had physical abuse as per the items included and under this standard I 8 (26.7%) did not receive any measures for pain control and one woman was physically abused. On the whole 23.3 % had non consented care and among the items in questionnaire 13.3 % were not explained regarding the examinations and procedures and 4 (6.7%) were not allowed the position of their choice. The prevalence of non-confidential care was observed to be 16.7% and the women were exposed. Non dignified care was observed among 10, (33.3 %) as the birth companions were sent back and were not allowed to be present with the labouring women. Discrimination was observed among one. And another woman was abandoned or ignored. None were detained in the facility against their will.

Table 3: Observation regarding prevalence of Disrespect and Abuse: Standards I to VII (N=30)

Category/ Standard	Questions	D&A
		n	%
I: Physical Abuse	Overall	9	30
	Physical Abuse	1	3.3
	No help to control pain	8	26.7
	Denied food or fluids	0	0
	Baby separated from mother	0	0
II: Non-Consented Care	Overall	7	23.3
	Language not understandable	1	3.3
	Permission/consent not taken	1	3.3
	Not explained examinations /procedures	4	13.3
	Position of choice not allowed	2	6.7
	Not Encouraged to ask questions	1	3.3
III: Non-Confidential Care	Overall	5	16.7
	HCP shared information to others	0	0
	During examinations in the labour room, women were exposed	5	16.7
IV. Non-Dignified care	Overall	10	33.3
	Not Treated with respect	0	0
	Abusive/bad language used	1	3.3
	Not encouraged birth companion	9	30
V : Discrimination based on specific attributes	Overall	1	3.3
	Discrimination observed	1	3.3
	Paid money other than the official cost of treatment	0	0
VI: Abandonment or Denial of Care –	Felt Ignored/ abandoned	1	3.3
VII : Detention in facility	Detained against will	0	0

Table 4 Depicts the frequency of D&A analysed from the filled forms of Questionnaire. Thirteen (43.3%) felt one category of D&A to have been experienced by labouring women. Four (13.3%) experienced two categories of D&A, 3 experience three categories and 1 one was subjected all categories of D&A.

Table 4: Frequency of D&A

D & A	Number	(%)
Never had D&A	9	30
Experienced one type of D&A	13	43.3
Experienced two types of D&A	4	13.3
Experienced three types of D&A	3	10
Experienced five types of D&A	1	3.3

Table 5 shows the rating of D&A as per the perception of Birth companion on the rating scale and their views regarding the quality of care during childbirth.

Table No. 5 Birth Companion’s Perception and Views on RMC

S. NO	Rating of D&A	Number (30)	Percentage
A	No D&A (0)	24	80
	1	2	6.7
	2	3	10
	10	1	3.3
B	Quality Assessment Parameters	Number	Percentage
1	Experience
	Positive	28	93.3
	Negative	2	6.7
2	Perception
	Perception of best treatment	28	93.3
	Perception of worst treatment	2	6.7
3	Comments
	Appreciation (Good RMC)	28	93.3
	Suggestions to improve RMC	2	6.7
	Components of RMC to be improved	1.       Privacy
		2.       Communication by Doctors
		3.       Emotional support by HCP
		4.       Infrastructure for more privacy
		5.       Training for Birth companion
		6.       Stop verbal abuse

Eighty percent opined that there was no D&A experienced by labouring women. One birth companion out of thirty rated D&A as 10(Severe). On the whole 93.3% percent reported positive experiences, perceived treatment received to be the best and appreciated RMC as “good”.

QUALITATIVE COMPONENTS OF THE STUDY

Following are the examples denoting positive experience:

Husband:

“My wife is more comfortable with my presence in labour room” (participant-1)

“I had a very good experience as birth companion to my wife. My presence helped her to have less stress and good moral support” (participant-2)

“Good experience to hold my wife’s hand during pain and massage her back” (participant-3)

“Doctor treated us with respect and dignity” (participant-4)

Friend:

“Patient felt satisfied by my presence mentally”

Mother:

.“Doctors handled politely and taken good care of my daughter during delivery. They tried for normal as baby weight was more, emergency caesarean section was done to save them both”

.“They treated us well, they treated my daughter well and took care positively”

.“I felt happy that they allowed me inside with daughter during labour”

“Excellent care and they thought my daughter how to push during labour, As they allowed me inside my daughter felt relaxed during labour”

“They allowed me inside but I was weak to console my daughter”

Sister:

“They behaved well as she was in pain and they took great care in treating my sister in my presence”

“They encouraged my presence in labour room and satisfied treatment, I felt better because they tried hard for normal delivery”

“As I accompanied my sister she felt stress free and better”

“Best supportive care for the patients, my sister felt emotionally supportive when they allowed me inside. Even though she was a nursing staff my presence helped her emotionally to relieve her stress during labour”

“Sisters working inside the labour room need to care with additional support”

Mother-in-law:

“Best care and treatment for twin baby”

“Doctors nursing staffs and supporting staffs approached us positively and asked my daughter to take long breath to reduce stress and to reduce pain”

Sister-in-Law:

“I felt overall treatment and care was good, It is fine and absolute, right decision on right time”.

Aunty:

“I feel worst, Discrimination even to staffs, reckless attitude”

DISCUSSION

Disrespect and abuse in patient care is major violence of human right more so if it happens to child bearing women it is a violation of one of the reproductive rights. Literature shows that the prevalence of disrespect and abuse is high in India especially at Govt. set ups (Singh, A. et al 2018) It is essential to curb the existence of D&A so as to save the lives of women and neonates as experiencing D&A makes them not to utilise the health care services and remain at home. In 2014, WHO released a statement to promote respectable maternity care “every woman has the right to the highest attainable standard of health, which includes the right to dignified, respectful health care’ throughout pregnancy and childbirth” (WHO 2022) Govt of India also issued an order to practice RMC by promoting the presence of birth companion and this was subsequently incorporated in to the LaQshaya guidelines. (MOH & FW, NHM 2017) But in practice birth companions are still not allowed in to the labour room. In the past one decade many studies were initiated to promote birth companionship especially in Institutes (Bharti, J et al 2021) in a phased manner. The current study was conducted after initiation of the practice of birth companionship in 2018 in the Institute.

A community based study from Varanasi reported that the odds of being abused were four times higher in women who experienced complications during delivery though the overall prevalence of D&A was 28.8% only (Bhattacharya, S., & Sundari Ravindran, T. K. 2018). A recent study from central India has reported that every woman in labour has experienced at least one type of D&A (Bohren, M. A., et al 2019). The qualitative synthesis of evidence by Cochrane has shown the benefits of birth companionship (Sharma, S. K., et al 2022; Bohren, M. A.,et al 2019). The review in 2019 which included 51 studies found the barriers affecting implementation included health workers and women not recognising the benefits of companionship, lack of space and privacy, and fearing increased risk of infection (Bohren, M. A.et al)

The question to answer in the present study is that whether women experienced D&A even in the presence of birth companion? The present study found that 20% of women still experienced D&A on qualitative analysis, even in the presence of birth companion.A multicentric study involving 18 tertiary care Government facilities found the presence of birth companion was negatively associated with the occurrence of D&A (Singh, S.,et al). The incidence of discrimination and non-provision of equitable care faced by women increased in the absence of birth companions (n = 66; 83%). Approximately 50% of women during labour were accompanied by the birth companions and these were not present throughout the labour with the women. All types of D&A was significantly high among women without birth companion (Balde, M. D.,et al 2022) In the current study, Quantative analysis revealed that all types of D&A was prevalent even in the presence of birth companion. As per the standards ,physical abuse was found to be experienced by 30%,non-consented care by 23.3%, non-confidential care by 16%, non-dignified care by 33.3%,discrimination by 3.3.%, and care was denied for one women. Though most of the women were found to be subjected to only one type of D&A ( 43.3%), 13.3 % and 10% experienced 2 and 3 types of D&A as assessed by questionnaire. A multi country community based survey at 8 weeks postpartum in Ghana, Guinea, Nygeria and Myanmar reported the prevalence of overall D&A as 39.1% in the presence of birth companion when compared to 40.5% when there was no birth companion. Verbal abuse was the commonest (34.6%) in both the groups. Non-consented care was expressed differently for caesarean section, episiotomy, vaginal examinations and induction of labour , out of which mostly non-consented care was high for vaginal examinations 51.4% overall. In presense of birth companion 43% had non consented examinations when compared to 55% without birth companions (Balde, M. D.,et al 2022). These were the experiences of women who delivered weeks back and not the observations by birth companions. Most of the time the birth companions were family member or the male partner. In India , husbands as birth companions does not happen in Govt hospitals and a study published in 2017, stated the husband saying he would send his mother or sister as birth companion as he felt that the privacy of the other women in labour would be affected by his presence. Regarding the fear of ill treatment from health care providers, one of the woman’s husband stated that he would “not let it happen again” so he would stay with his wife and another stated that in his presence no exchange of baby would happen (Mayra, K., & Kumar, A. I. K. 2017). A study done in Tanzania, which assessed the husbands perception and experiences of supporting wife during child birth by semistructured interviews reported 4 main themes that emerged (Kashaija, D. K et al 2020) Viz;1. demonstrating care, love and affection,2. Men’s adoption to modern life style, 3. Observing women’s rights. 4. meeting socioeconomic difficulties like preparing financially, transport difficulties and facing healthcare workers etc. One of the partners expression in this study was as follows” Caring makes the woman to have no depression, because if you are not close to her she may have depression, and then you will ask why me, sometimes she may be bothered and this distraction is like being filled up with a certain poison, and this may affect the unborn baby. So it is all about making the future of the baby who will be born” On the other hand another partner expressed dissatisfaction. “I was received by the gate keeper, and told to go when my wife was in the ward. On arrival in the ward my wife was handed to a nurse on duty and I was told to go home without any more information. I was not satisfied as I expected to be asked to wait and be informed of the progress of my wife. My wife was not allowed to stay even with the phone.”. In the current study which is a pilot study, only 4 birth companions were husbands and they had satisfying experience being a birth companion and all these were medical professionals. The most companion in our study was mother for more than 50% of women. A study from North India which compared RMC with and without birth companion reported mother-in-law as the most common birth companion (44%) followed by sister-in-law. They also assessed RMC from postpartum women and not from birth companion. They reported that women in the birth companion group experienced statistically less rates of physical and verbal abuse and improved consented and confidential care and favourable behaviour of health care workers apart from good maternal outcomes (Seth I, et al 2023). A cross sectional study conducted in a district hospital of South Africa (Summerton, J. V., et al) requesting the birth companions for a feedback about their experience and perceptions reported both positive and negative experiences. An example of a positive experience was

‘I am very happy that I was able to accompany my partner into theatre so that I could hold her hand and allay her anxiety. She didn’t have to be there all alone. It was also very special for me to receive my baby and cut the umbilical cord.’

An example of negative experience was ‘The nurse who was helping to deliver the baby was impatient and rude to the mother. Once the baby was delivered and she had to stitch the mother’s vagina where she had cut her, the mother felt a lot of pain “.

Disrespect and abuse still prevails in presence of birth companions though some of the studies reported less prevalence and it needs to be completely eliminated. For this, the women, family members, community and health care workers themselves should be appraised of the reproductive rights of child bearing women, their special needs during the period of child birth and the health care workers to be trained in delivering more empathetic care.

CONCLUSIONS AND IMPLICATIONS

RMC as witnessed by birth companions and assessed quantitatively by Questionnaire was high (43%) but on rating scale it was low (20%). Only few felt, women in labour still experience D&A in their presence and the most common type was non-dignified care. The overall experience of childbirth care was perceived as good and they were grateful to have allowed them to give maternal support. There is a need to rethink about the methods of assessment of disrespect and abuse as the current standards are yielding high prevalence though this is not the real scenario.

FUTURE RESEARCH

The assessment scales/ Questionnaire to assess standards of RMC in future should be specific to culture and should be simple and not time taking. A feedback from each and every laboring woman and their companion in their local language would be helpful in formulating the type of questionnaire to be adopted, so that future research can adopt them.

Assessment of D&A based on Culture specific Questionnaire for each country may give an idea on the true prevalence of D&A.

ETHICAL CONSIDERATION

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of our Institute, JIPMER: Ethical Board approval number–JIP/IEC/2019/340.

Conflicts of Interest

The author declares that there is no conflict of interests regarding the publication of this manuscript. In addition, the ethical issues, including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, and redundancies have been completely observed by the authors.

Data Availability Statement: Data is available as hard copy with consent forms and also as XL sheet

Acknowledgements:

Ms. Kayathri Karthikeyan, Field investigator for facilitating data collection

Response to Reviewer comments

S. No	Comment	Reply
1	Make a single paragraph for the abstract	Done
2	Revise references for uniformity	APA style as per Journal
3	Replace tables to the text, where it was cited	Done
4	Re-format the tables	done
5	Rearrange and re-format whole manuscripts.	done
6	The sample size is too small. Increase sample size	This was a pilot study and was initially decided at the time of proposal and the same was approved. It can not be increased now
7	More statistical analysis, like logistic regression, could help us understand the factors that are strongly linked to various D&A types	Not applicable for Pilot studies
8	Suggest policy change.	Training the various cadres of Health care workers in delivering RMC is vital for any Health care Organisation to eliminate Disrespect and Abuse. This should be a Policy change across all Health care facilities.

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