Introduction
Despite promising global advances in reducing maternal mortality, Africa's progress in this area has been slow. As a result, many African nations have failed to realize the maternal health target of Millennium Development Goal 5 related to improving maternal health.1-3 Currently the mortality rate is 14 times higher in developing regions than developed regions.4,5 Everyday, approximately 800 women die from preventable pregnancy and childbirth-related causes worldwide; poorer women living in developing countries comprise 99% of these deaths.6 With the current mortality rate, it is very likely that Africa will not achieve the Sustainable Development Goal 3 to reduce maternal mortality ratio to less than 70 per 100,000 live births by 2030.7
Maternal mortality has no single cause or solution, but the single most effective preventive strategy as proposed by the World Health Organization (WHO) is ensuring that every woman gives birth in an equipped health facility with the help of skilled providers.8,9 Improved access to timely and appropriate care has been proven to reduce up to 75% of maternal death.10,11
However, African women have limited access to obstetric care for several reasons including, but not limited to, gender discrimination, traditional beliefs, financial constraint and lack of accessible, reliable transportation.12,13 In addition, even when services are accessible, the quality of these services is often substandard and does not meet their needs. As a result, women are dissatisfied and decline to attend facility-based delivery.14-17 This has led to a greater focus on the quality of maternal health services as a key reason for sustained death of women in developing nations.18
Recent studies have identified that poor perceived quality of care, and lack of respect and courtesy from providers are among the factors that deter women from seeking skilled delivery services.17,19-21 Specifically, poor interpersonal care may manifest as disrespect and abuse (D&A), which is defined as any form of uncaring behavior or inhumane treatment, specifically towards a laboring woman.22
Disrespectful treatment of women during facility-based childbirth represents a violation of basic human rights in a situation where women are psychologically, socially and physiologically vulnerable.23 Research on D&A reveals that it is not an isolated phenomenon. Rather, it is a broad problem that runs wide and deep within maternity services. Not only are individual providers responsible, but the whole health system is implicated when conditions in facilities deviate from the accepted standards of care.24-28 Individual and structural drivers of D&A have been highlighted. Poor physical infrastructure, heavy workloads and lack of supervision and supplies are structural factors29 and are associated with individual level factors like provider overwork, stress, stigmatizing attitudes and low motivation.24,30,31
In this protocol and future systematic review, D&A of women is defined as any verbal, physical, and/or sexual abuse; stigma; discrimination; substandard care; neglect; and trust and communication problems birthing women experience during child birth. This might be expressed in the form of non-consensual care, non-confidential care, non-dignified care, physical abuse, discrimination based on specific patient attributes, abandonment of care and detention in facilities.24
A preliminary search for existing literature on care providers’ perspectives on D&A of women during childbirth in Africa conducted in Cochrane Database, PROSPERO, JBI Database of Systematic Reviews and Implementation Reports, CINAHL, and PubMed identified 20 primary studies. Twelve research studies17,20,21,32-40 addressed views of both women and care providers; three41-43 focused only on care providers perspectives and another two studies from Ghana involved final year midwifery students.44,45 Two studies from Kenya46 and Mali47 used mixed methods. No systematic review or registered protocol to date has been identified that specifically addresses how care providers’ view D&A of women during facility-based childbirth in Africa.
Healthcare providers have an irreplaceable and vital role in reducing maternal deaths, and therefore any effort to improve quality of maternal health care should place them at the center of the issue. Specifically, the abusive treatment women experience in birthing facilities cannot be addressed without involving healthcare providers. However, the perspectives of healthcare providers are not well understood. The objective of this review is to identify and synthesize the best available qualitative evidence to understand healthcare providers’ view on D&A of women during facility-based childbirth in Africa. This will then provide Africa's healthcare practitioners and policymakers further evidence to guide policies and improve quality of obstetric care.
This review is part of the lead author's doctoral research and is intended to inform further primary research to be conducted on D&A during facility-based childbirth in Ethiopia.
Review question
What are care providers’ views towards the D&A of women during facility-based childbirth?
Inclusion criteria
Participants
This systematic review will consider studies that include views of care providers regarding D&A of women in birthing facilities. Care providers in maternity units are those taking part in the care of laboring women. Thus, healthcare professionals involved in delivery services in birthing facilities of any African country will be considered. In this review, care providers including qualified and accredited midwives, nurses, general practitioners and obstetricians; and non-qualified birthing assistants will be excluded.
Phenomenon of interest
Provider experiences and/or perceptions of D&A of birthing women including verbal, physical and sexual abuse; stigma, discrimination, substandard care and neglect; and trust and communication problems. This might be expressed in the form of non-consensual care, non-confidential care, non-dignified care, physical abuse, discrimination based on specific patient attribute, abandonment of care and detention in facilities.
Context
Studies that relate to Africa, published from 1990 onward will be included. This start date was selected for the search because maternal health garnered global attention in 1987 as a result of the Safe Motherhood Initiative convened by the WHO, World Bank and United Nations Population Fund.48 In addition, it is the year when millennium development goals started and quality of care began to be emphasized in maternity services.49
Types of studies
This review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Only studies published in English will be considered.
Methods
This review will involve the analysis of all of the available literature to explore the perspectives of care providers on D&A of women during facility-based childbirth in Africa. The JBI systematic reviews of qualitative evidence methodology will be used.50
Search strategy
The JBI three-stage search strategy will be adopted to include peer-reviewed articles and gray literature published in English from 1990.50 A small number of keywords will be used to conduct an initial search in CINAHL and PubMed. After assessing the titles, abstracts and the index terms of those obtained articles, more comprehensive keywords will be developed. Second, a wide-ranging search will be conducted using all identified keywords and index terms across included databases and websites (see Appendix I for PubMed search strategy). Third, the reference lists of those accessed full-text articles will be assessed against the inclusion criteria. Furthermore, the lead reviewer will contact care providers and researchers in the field of interest for any other relevant documents that may have been missed in the search.
The following databases will be searched: PubMed, CINAHL, Embase, Scopus, African Index Medicus and Web of Science. In addition, key organizations’ websites like World Health Organization, African Union, White Ribbon Alliance and The International Confederation of Midwives will be included. The librarian at the University of Adelaide will also be consulted for their expertise on the search strategies for all databases to be visited.
Key terms used for the initial search will be: disrespect and abuse; obstetric violence; mistreatment; women; childbirth; facility-based childbirth; care providers; names of each African country and Africa.
Study selection
Titles and abstracts of obtained documents will be assessed by the lead reviewer against the inclusion criteria. Documents will then be categorized as “ineligible for full document review” or “eligible for full document review.” Documents labelled as “eligible for full document review” will then be comprehensively reviewed by two independent reviewers to decide eligibility. Arbitration will be sought from a third reviewer in the event of any disagreements.
Assessment of methodological quality
Identified documents will be appraised for relevance and rigor. The current protocol will specifically use the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia) for appraisal. The overall quality assessment will be judged high (for at least 8 YES results from the possible 10), medium (6 or 7 YES results) or low (5 or less YES results). Documents judged high and medium will be included in the review. The critical appraisal will be conducted by two independent reviewers and any disagreements will be resolved through discussion with another review author.
Data extraction
Data will be extracted from papers included in the review using the standardized data extraction tool from JBI SUMARI by two independent reviewers. The data extracted will include specific details about the populations, context, culture, geographical location, study methods and how care providers perceive D&A of women during facility-based childbirth. Findings, and their illustrations, will be extracted and assigned a level of credibility.50
Data synthesis
Qualitative research findings will, where possible, be pooled using JBI SUMARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.
Assessing confidence in the findings
The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.51 The Summary of Findings includes the major elements of the review and details how the ConQual score is developed. Included in the Summary of Findings will be the title, population, phenomena of interest and context for the specific review. Each synthesized finding from the review will then be presented along with the type of research informing it, score for dependability and credibility, and the overall ConQual score.
Funding
This project is funded by a PhD scholarship to YMA from The University of Adelaide.
Appendix I: PubMed search strategy
References
1. Bhutta ZA, Chopra M, Axelson H, Berman P, Boerma T, Bryce J, et al. Countdown to 2015 decade report (2000–10): taking stock of maternal, newborn, and child survival.
Lancet 2010; 375 (9730):2032–2044.
2. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5.
Lancet 2010; 375 (9726):1609–1623.
3. Lozano R, Wang H, Foreman KJ, Rajaratnam JK, Naghavi M, Marcus JR, et al. Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis.
Lancet 2011; 378 (9797):1139–1165.
4. Nyathi LT, Tugli AK, Tshitangano TG, Mpofu M. Investigating the accessibility factors that influence antenatal care services utilisation in Mangwe district, Zimbabwe.
Afr J Prim Health Care Fam Med 2017; 9 (1):1–5.
5. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review.
Lancet 2006; 367 (9516):1066–1074.
6. Alkema L, Chou D, Hogan D, Zhang S, Moller A-B, Gemmill A, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group.
Lancet 2016; 387 (10017):462–474.
7. Murray CJ, Lopez AD. Mortality by cause for eight regions of the world: Global Burden of Disease Study.
Lancet 1997; 349 (9061):1269–1276.
8. Campbell OM, Graham WJ. Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works.
Lancet 2006; 368 (9543):1284–1299.
9. Koblinsky M, Matthews Z, Hussein J, Mavalankar D, Mridha MK, Anwar I, et al. Going to scale with professional skilled care.
Lancet 2006; 368 (9544):1377–1386.
10. Harvey SA, Ayabaca P, Bucagu M, Djibrina S, Edson WN, Gbangbade S, et al. Skilled birth attendant competence: an initial assessment in four countries, and implications for the Safe Motherhood movement.
Int J Gynecol Obstet 2004; 87 (2):203–210.
11. Koblinsky MA, Campbell O, Heichelheim J. Organizing delivery care: what works for safe motherhood?
Bull World Health Organ 1999; 77 (5):399.
12. Shiferaw S, Spigt M, Godefrooij M, Melkamu Y, Tekie M. Why do
women prefer home births in Ethiopia?
BMC Pregnancy Childbirth 2013; 13 (1):5.
13. Siyoum M, Astatkie A, Mekonnen S, Bekele G, Taye K, Tenaw Z, et al. Home birth and its determinants among antenatal care-booked
women in public hospitals in Wolayta Zone, southern Ethiopia.
PloS One 2018; 13 (9):e0203609.
14. Adinew A. Experience of Facility Based Childbirth in Rural Ethiopia: An Exploratory Study of
Women's Perspective.
J Pregnancy 2017; 2017:2–4.
15. Van den Broek N, Graham W. Quality of care for maternal and newborn health: the neglected agenda.
BJOG: An Int Obstet Gynaecol 2009; 116 (1):18–21.
16. Uzochukwu B, Onwujekwe O, Akpala C. Community satisfaction with the quality of maternal and child health services in southeast Nigeria.
East Afr Med J 2004; 81 (6):293–299.
17. Molla M, Muleta M, Betemariam W, Fesseha N, Karim A. Disrespect and abuse during pregnancy, labour and childbirth: a qualitative study from four primary healthcare centres of Amhara and Southern Nations Nationalities and People's Regional States, Ethiopia.
Ethiop Health Dev 2017; 31 (3):129137.
18. Graham WJ, Varghese B. Quality, quality, quality: gaps in the continuum of care.
Lancet 2012; 379 (9811):e5–e6.
19. Asefa A, Teshome W, Mesele T, Letamo Y. Use of institutional delivery services in the Southern Nations, Nationalities, and People's Region, Ethiopia: a cross-sectional comparative mixed methods study.
Lancet 2013; 382 (1):9.
20. Bohren MA, Vogel JP, Tunçalp Ö, Fawole B, Titiloye MA, Olutayo AO, et al. Mistreatment of
women during childbirth in Abuja, Nigeria: a qualitative study on perceptions and experiences of
women and healthcare providers.
Reprod Health 2017; 14 (1):9.
21. Oluoch-Aridi J, Smith-Oka V, Milan E, Dowd R. Exploring mistreatment of
women during childbirth in a peri-urban setting in Kenya: experiences and perceptions of
women and healthcare providers.
Reprod Health 2018; 15 (1):209.
22. Tayelgn A, Zegeye DT, Kebede Y. Mothers’ satisfaction with referral hospital delivery service in Amhara Region, Ethiopia.
BMC Pregnancy Childbirth 2011; 11 (1):78.
23. Madeira S, Pileggi V, Souza JP. Abuse and disrespect in childbirth process and abortion situation in Latin America and the Caribbean—systematic review protocol.
Syst R 2017; 6 (1):152.
24. Bowser D, Hill K. Exploring evidence for disrespect and abuse in facility-based childbirth. Boston: USAID-TRAction Project, Harvard School of Public Health; 2010.
25. Freedman LP, Kruk ME. Disrespect and abuse of
women in childbirth: challenging the global quality and accountability agendas.
Lancet 2014; 384 (9948):e42–e44.
26. Bradley S, McCourt C, Rayment J, Parmar D. Disrespectful intrapartum care during facility-based delivery in sub-Saharan Africa: a qualitative systematic review and thematic synthesis of
women's perceptions and experiences.
Soc Sci Med 2016; 169 (2):157–170.
27. Kujawski S, Mbaruku G, Freedman LP, Ramsey K, Moyo W, Kruk ME. Association between disrespect and abuse during childbirth and
women's confidence in health facilities in Tanzania.
Matern Child Health J 2015; 19 (10):2243–2250.
28. Filby A, McConville F, Portela A. What prevents quality midwifery care? A systematic mapping of barriers in low and middle income countries from the provider perspective.
PloS One 2016; 11 (5):e0153391.
29. Mannava P, Durrant K, Fisher J, Chersich M, Luchters S. Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review.
Global Health 2015; 11 (1):36.
30. Reader TW, Gillespie A. Patient neglect in healthcare institutions: a systematic review and conceptual model.
BMC Health Serv Res 2013; 13 (1):156.
31. Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, Gülmezoglu AM. Facilitators and barriers to facility-based delivery in low-and middle-income countries: a qualitative evidence synthesis.
Reprod Health 2014; 11 (1):71.
32. Burrowes S, Holcombe SJ, Jara D, Carter D, Smith K. Midwives’ and patients’ perspectives on disrespect and abuse during labor and delivery care in Ethiopia: a qualitative study.
BMC Pregnancy Childbirth 2017; 17 (1):263.
33. Balde MD, Bangoura A, Sall O, Balde H, Niakate AS, Vogel JP, et al. A qualitative study of
women's and health providers’ attitudes and acceptability of mistreatment during childbirth in health facilities in Guinea.
Reprod Health 2017; 14 (1):4.
34. Balde MD, Bangoura A, Sall O, Soumah AM, Vogel JP, Bohren MA. Perceptions and experiences of the mistreatment of
women during childbirth in health facilities in Guinea: a qualitative study with
women and service providers.
Reprod Health 2017; 14 (1):3.
35. Warren CE, Njue R, Ndwiga C, Abuya T. Manifestations and drivers of mistreatment of
women during childbirth in Kenya: implications for measurement and developing interventions.
BMC Pregnancy Childbirth 2017; 17 (1):102.
36. Okafor CB, Rizzuto RR.
Women's and health-care providers’ views of maternal practices and services in rural Nigeria.
Stud Fam Plann 1994; 25 (6):353–361.
37. Jaffré Y, Prual A. Midwives in Niger: an uncomfortable position between social behaviours and health care constraints.
Soc Sci Med 1994; 38 (8):1069–1073.
38. Ojelade OA, Titiloye MA, Bohren MA, Olutayo AO, Olalere AA, Akintan A, et al. The communication and emotional support needs to improve
women's experience of childbirth care in health facilities in Southwest Nigeria: A qualitative study.
Int J Gynecol Obstet 2017; 139 (2):27–37.
39. Asuquo E, Etuk S, Duke F. Staff attitude as a barrier to the utilisation of University of Calabar Teaching Hospital for Obstetric Care.
Afr J Reprod Health 2000; 4 (2):69–73.
40. McMahon SA, George AS, Chebet JJ, Mosha IH, Mpembeni RN, Winch PJ. Experiences of and responses to disrespectful maternity care and abuse during childbirth; a qualitative study with
women and men in Morogoro Region, Tanzania.
BMC Pregnancy Childbirth 2014; 14 (1):268.
41. Bohren MA, Vogel JP, Tunçalp Ö, Fawole B, Titiloye MA, Olutayo AO, et al. By slapping their laps, the patient will know that you truly care for her”: A qualitative study on social norms and acceptability of the mistreatment of
women during childbirth in Abuja, Nigeria.
SSM-Popul Health 2016; 2:640–655.
42. Jewkes R, Abrahams N, Mvo Z. Why do nurses abuse patients? Reflections from South African obstetric services.
Soc Sci Med 1998; 47 (11):1781–1795.
43. Webber G, Chirangi B, Magatti N. Promoting respectful maternity care in rural Tanzania: nurses’ experiences of the “Health Workers for Change” program.
BMC Health Serv Res 2018; 18 (1):658.
44. Rominski SD, Lori J, Nakua E, Dzomeku V, Moyer CA. When the baby remains there for a long time, it is going to die so you have to hit her small for the baby to come out: justification of disrespectful and abusive care during childbirth among midwifery students in Ghana.
Health Policy Plan 2017; 32 (2):215–224.
45. Rominski S. Ghanaian midwifery students’ perceptions and experiences of disrespect and abuse during childbirth.
Lancet Glob Health 2015; 3 (1):S13.
46. Ndwiga C, Warren CE, Ritter J, Sripad P, Abuya T. Exploring provider perspectives on respectful maternity care in Kenya:“Work with what you have”.
Reprod Health 2017; 14 (1):99.
47. Warren N, Beebe M, Chase RP, Doumbia S, d Winch PJ. Nègènègèn: sweet talk, disrespect, and abuse among rural auxiliary midwives in Mali.
Midwifery 2015; 31 (11):1073–1080.
48. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.
Lancet 2014; 384 (9947):980–1004.
49. Organization WH. Maternal mortality: to improve maternal health, barriers that limit access to quality maternal health services must be identified and addressed at all levels of the health system: fact sheet.
World Health Organization 2014.
50. Aromataris E, Munn Z (Editors). Joanna Briggs Institute Reviewers Manual [Internet]. Adelaide: JBI; 2017 [cited 2019 May 20]. Available from
https://reviewersmanual.joannabriggs.org/.
51. Munn Z, Porritt K, Lockwood C, Aromataris E, Pearson A. Establishing confidence in the output of qualitative research synthesis: the ConQual approach.
BMC Med Res Methodol 2014; 14 (1):108.
