Eye of the beholder? Observation versus self-report in the measurement of disrespect and abuse during facility-based childbirth

Abstract

Human rights has been a vital tool in the global movement to reduce maternal mortality and to expose the disrespect and abuse that women experience during childbirth in facilities around the world. Yet to truly transform the relationship between women and providers, human rights-based approaches (HRBAs) will need to go beyond articulation, dissemination and even legal enforcement of formal norms of respectful maternity care. HRBAs must also develop a deeper, more nuanced understanding of how power operates in health systems under particular social, cultural and political conditions, if they are to effectively challenge settled patterns of behaviour and health systems structures that marginalise and abuse. In this paper, we report results from a mixed methods study in two hospitals in the Tanga region of Tanzania, comparing the prevalence of disrespect and abuse during childbirth as measured through observation by trained nurses stationed in maternity wards to prevalence as measured by the self-report upon discharge of the same women who had been observed. The huge disparity between these two measures (baseline: 69.83% observation vs. 9.91% self-report; endline: 32.91% observation vs. 7.59% self-report) suggests that disrespect and abuse is both internalised and normalised by users and providers alike. Building on qualitative research conducted in the study sites, we explore the mechanisms by which hidden and invisible power enforces internalisation and normalisation, and describe the implications for the development of HRBAs in maternal health.

Résumé

Les droits de l’homme sont un outil vital dans le mouvement mondial pour réduire la mortalité maternelle et exposer le manque de respect et la maltraitance que les femmes subissent pendant l’accouchement dans les établissements de santé autour du monde. Cependant, pour véritablement transformer les relations entre femmes et prestataires, les approches fondées sur les droits de l’homme devront aller au-delà de l’articulation, la dissémination et même l’application juridique des normes formelles de services de maternité respectueux. Pour véritablement remettre en question les modes établis de comportement et de structure des systèmes de santé qui marginalisent et maltraitent, les approches fondées sur les droits de l’homme doivent aussi parvenir à une compréhension plus profonde et plus nuancée du fonctionnement du pouvoir dans les systèmes de santé dans des conditions sociales, culturelles et politiques particulières. Cet article rend compte des résultats d’une étude avec des méthodes mixtes, réalisée dans deux hôpitaux de la région tanzanienne de Tanga, qui a comparé la prévalence du manque de respect et de la maltraitance pendant l’accouchement, mesurée par l’observation d’infirmières formées présentes dans les services de maternité, avec la prévalence mesurée par l’autodéclaration quand les mêmes femmes ayant fait l’objet de l’observation quittent l’hôpital. L’écart très important entre ces deux mesures (valeurs initiales : 69,83% pour les observations contre 9,91% pour les autodéclarations ; fin de l’étude : 34,17% pour les observations contre 6,83% pour les autodéclarations) donne à entendre que le manque de respect et la maltraitance sont assimilés et normalisés aussi bien par les utilisatrices que par les prestataires des services. Nous fondant sur une recherche qualitative menée dans les sites de l’étude, nous étudions les mécanismes par lesquels un pouvoir caché et invisible impose l’assimilation et la normalisation, et nous décrivons les conséquences pour la mise au point d’approches fondées sur les droits de l’homme dans la santé maternelle.

Resumen

Los derechos humanos han sido una herramienta vital en el movimiento mundial por reducir la mortalidad materna y exponer la falta de respeto y el maltrato que las mujeres enfrentan durante el parto en unidades de salud a nivel mundial. Sin embargo, para transformar verdaderamente la relación entre las mujeres y los prestadores de servicios, el enfoque basado en los derechos humanos (EBDH) debe trascender la articulación, difusión y aplicación legal de normas oficales relativas a la atención materna respetuosa. Además, para poder cuestionar eficazmente los patrones de comportamientos establecidos y las estructuras de los sistemas de salud que marginan y maltratan, el EBDH debe desarrollar una comprensión más profunda y más matizada de cómo el poder funciona en los sistemas de salud bajo condiciones sociales, culturales y políticas específicas. En este artículo, informamos los resultados de un estudio con métodos combinados realizado en dos hospitales en la región de Tanga de Tanzania, que comparó la prevalencia de falta de respeto y maltrato durante el parto medida en observaciones por enfermeras capacitadas en los pisos de maternidad con la prevalencia medida por el autoinforme de las mujeres que habían sido observadas en el momento de recibir alta. La gran disparidad entre estas dos medidas (línea de base: 69.83% observación vs. 9.91% autoinforme; línea final: 34.17% observación vs. 6.83% autoinforme) indica que la falta de respeto y el maltrato son internalizados y normalizados tanto por las usuarias como por los prestadores de servicios. Basándonos en los estudios de investigación cualitativa realizados en los lugares de estudio, exploramos los mecanismos por los cuales el poder oculto e invisible aplica la internalización y normalización, y describimos las implicaciones para el desarrollo de EBDH en la salud materna.

Keywords:

• Disrespect and abuse
• respectful maternity care
• human rights
• human rights-based approach
• power
• practical norms
• internalisation
• normalisation

Acknowledgements

The authors thank the Regional Administrative Secretary, the Regional Medical Officer and all Regional Health Management Team officials from Tanga region and the District Executive Directors, District Medical Officers and Council Health Management Teams of Muheza and Korogwe, for their support and guidance. We are grateful to the health facility in-charges and maternity ward staff from Muheza District Designated Hospital and Korogwe District Hospital who allocated precious time and energy to participate in this study. We extend our deep appreciation to the women and their families who participated in the study at such vulnerable and meaningful moments in their lives. Finally, we thank the many data collectors and research assistants who worked under difficult circumstances to collect and analyse the data, as well as Francesca Heintz for research support and Amy Manning for assistance in preparing the manuscript for publication.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Lynn P Freedman https://orcid.org/0000-0003-4288-605X

Stephanie A Kujawski http://orcid.org/0000-0001-7915-8553

Selemani Mbuyita http://orcid.org/0000-0003-2113-6137

August Kuwawenaruwa https://orcid.org/0000-0001-8459-443X

Margaret E Kruk https://orcid.org/0000-0002-9549-8432

Kate Ramsey https://orcid.org/0000-0002-8784-0779

Godfrey Mbaruku https://orcid.org/0000-0001-5285-5877

Notes

*The humanisation of childbirth movement, particularly active in Latin America starting in the 1990s, is a forerunner of the current (post-2010) wave of initiatives on disrespect and abuse and the global movement now coalescing around respectful maternity care.

^†Every effort described in the peer-reviewed literature to measure D&A quantitatively (including ours) has used a typology of D&A, ideally adapted to and validated for the specific setting.^8,9 However, such typologies^10,11 are not definitions. They list types of D&A, but they do not tell us the criteria that must be met in order for an event, interaction or condition to qualify and be counted as D&A.

^‡“Jim Crow” refers to the laws and practices that enforced racial segregation in public places, primarily in the southern states of the United States, in the period between the abolition of slavery (mid-19th century) and the civil rights era (1960s).

^§The possibility that providers’ awareness of being observed would itself change their behaviour.

Additional information

Funding

This work was supported by the Bill and Melinda Gates Foundation under award number OPP1133821, and the American people through the United States Agency for International Development (USAID) and its Translating Research into Action (TRAction) Project, managed by the University Research Co., LLC (URC), under Cooperative Agreement Number GHS-A-00-09-00015-00. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.