Measuring mistreatment of women throughout the birthing process: implications for quality of care assessments

Figures & data

Table 1. Mistreatment measurement matrix throughout the birthing process.

	Categories of D&A
Stages of birth	Third order themes	Second order themes	First order themes
Admission	Verbal abuse	Harsh language	Provider did not use dignified language
			Provider used harsh tone/shouted
	Failure to meet professional standards	Lack of informed consent	Provide did not obtain permission before examination
			Provider did not explain what would be done
		Physical examinations and procedures- Lack of privacy	No partitions between beds
			Conducted examinations without privacy
			Provider did not cover mother during examination
Delivery	Verbal Abuse	Harsh language	Provider used abusive/harsh language
	Physical abuse	Use of force	Provider slapped, pinched, /inappropriately handled client
	Failure to meet professional standards	Physical examinations and procedures- unhygienic practices	Provider did not wash hands before conducting delivery
			Provider did not wear gloves during delivery
			Provider did not use one touch technique while using gloves
		Lack of privacy	Mother was not covered when being moved to delivery room
			Mother not covered except perineal area during delivery
Immediate postpartum	Failure to meet professional standards	Physical examinations and procedures Unhygienic practices	Provider did not wash hands during perineal examination
			Provide did not wear gloves during perineal examination
			Provider did not use antiseptic solution
		Lack of privacy	Mother was not surrounded by a partition
			Mother was not covered during the examination
			Audio privacy was not respected
			Visual privacy was not respected
		Lack of informed consent	Provider did not explain procedure during perineal examination

Table 2. Clinical quality measured throughout birthing process.

	Categories of clinical quality
Stages of birth	Quality domain	Indicators
Admission	Creating Rapport (0-3)	Client welcomed in a gentle manner
		Called client by name
		Client told which bed to go
	Medical History taking practices (0-6)	Asked about personal history
		Asked about present history
		Took obstetric history
		Took past medical history
		Asked about surgical history
		Took family history
	Physical assessment (0-6)	Took blood pressure
		Pulse rate taken
		Temperature taken
		Examined legs
		Examined abdomen
		Checked fetal heart sounds
Delivery	Practices on eating, drinking and movement (0-3)	Client was allowed to drink
		Provider allowed her to move
		Client was allowed to eat
	Infection prevention practices during delivery (0-7)	Provider washed hands before delivery
		Provider used gloves during delivery
		Provider used non-touch technique method when using gloves
		Provider swabbed perineum with antiseptic solution
		Providers wore over shoes/delivery room slippers/boots
		Providers wore sterile gown
		Provider wore plastic gown (mackintosh)
Immediate postpartum	Physical assessment of mother after delivery (0-7)	Confirmed uterine contracting
		Checked pulse rate
		Provider took blood pressure
		Checked amount of vaginal bleeding
		Took temperature
		Examined fundal height
		Examined uterine tone

Table 3. Socio-demographics and delivery characteristics of maternity care clients whose care was observed in 13 facilities in Kenya, N = 677^a

Demographics	% (n = 677)
Age
< 19 years	15.3 (103)
20–29 years	67.5 (454)
30+ years	17.2 (116)
Parity
0	43.5 (291)
1–2	45.6 (305)
3+	10.9 (73)
Time of delivery
Night	32.9 (223)
Day	67.1 (454)
Facility sector
Public	94.2 (637)
Private^b	5.9 (40)

^aMissing values < 2%.

^bFaith based or private clinics.

Table 4. Prevalence of clinical quality and mistreatment throughout the birthing process

Stages of birth	Clinical quality (N = 677)		Prevalence of mistreatment (N = 677)
	Quality domain	% (n)	Categories	% (n)
Admission	Creating Rapport (0–3)	52.3 (354)	Verbal abuse (0–2)	18.2 (122)
	Medical History taking practices (0–6)	85.2 (577)	Lack of informed consent (0–2)	58.7 (398)
	Physical assessment (0–6)	15.7 (106)	Lack of privacy (0–3)	67.1 (454)
Delivery	Practices on eating, drinking and movement (0–3)^a	16.6 (44)	Verbal Abuse (0–1)	9.3 (63)
			Physical abuse (0–1)	5.4 (37)
	Infection prevention practices during delivery (0–7)	2.5 (17)	Unhygienic practices (0–3)	74.5 (504)
			Lack of privacy (0–2)	77.6 (525)
Immediate postpartum	Physical assessment of mother after delivery (0–7)	7.1 (48)	Unhygienic practices (0–3)^b	66.7 (26)
			Lack of privacy (0–4)	88.3 (68)
			Lack of informed consent (0–1)	94.7 (36)

^aAmong those who wanted to drink (n = 264), eat (n-129), or sought permission to walk around (n = 108).

^bBased on only 91 cases where an examination of the mother was done immediately postpartum and 39 cases where perineum assessment was conducted.

Table 5. Multivariate logistic assessing factors for observed clinical quality of care throughout the birthing process among maternity care clients

	Admission AOR (95% CI)			During delivery AOR (95% CI)		Immediate postpartum AOR (95% CI)
	Creating rapport	Medical history taking	Physical assessment	Practices: eating, drinking, movement	Infection prevention practices	Physical assessment of mother
Infrastructural score	1.09 (0.94, 1.27)	1.05 (0.85, 1.28)	2.52 (2.03, 3.21)	1.48 (0.93, 2.35)	4.15 (0.62, 27.3)	2.18 (1.24, 3.82)
Age (ref: <19 years) 20–29 years	0.79 (0.37, 1.69)	1.86 (0.95, 3.62)	0.83 (0.31, 2.22)	1.54 (0.62, 3.84)	0.23 (0.004, 11.59)	1.01 (0.71, 1.43)
30+ years	0.87 (0.45, 1.69)	2.30 (0.89, 5.91)	1.51 (0.88, 2.57)	0.47 (0.22, 1.02)	0.47 (0.005, 50.32)	0.51 (0.30, 0 .89)
Parity (ref: first child) 1–2 children	0.95 (0.63, 1.44)	1.13 (0.59, 2.16)	0.92 (0.58, 1.43)	1.12 (0.50, 2.51)	2.27 (0.40, 12.69)	1.62 (0.91, 2.89)
3 or more children	0.60 (0.29, 1.23)	0.68 (0.32, 1.45)	0.27 (0.04, 1.74)	1.67 (0.64, 4.42)	1.79 (0.71, 4.47)	1.04 (0.31, 3.46)
Time of delivery (ref: day) Night	0.58 (0.41, 0.86)	1.25 (0.88, 1.79)	2.32 (1.28, 4.21)	0.53 (0.26, 1.06)	1.23 (0.46, 3.28)	1.01 (0.72, 1.43)
Facility sector (ref: public) Private	1.62 (0.02, 1.66)	2.71 (0.27, 27.0)	0.14 (0.02,1.14)	6.36 (0.13,310.7)	0.002 (0.00003, 0.11)	0.11 (0.03,0.40)

Table 6. Multivariate logistic assessing risk factors for observed incidences of mistreatment among maternity care clients

	Admission AOR (95% CI)			During delivery AOR (95% CI)				Immediate postpartum AOR (95% CI)
	Verbal abuse	Lack of informed consent	Lack of privacy	Verbal Abuse	Physical abuse	Lack of privacy	Unhygienic practices	Unhygienic practices	Lack of privacy	Lack of informed consent
Infrastructural score	0.93 (0.83, 1.04)	0.92 (0.74, 1.14)	0.092 (0.79, 1.06)	0.88 (0.78, 0.99)	0.88 (0.76, 1.03)	0.90 (0.71, 1.14)	0.87 (0.78, 0.97)	0.85 (0.65, 1.14)	0.87 (0.56, 1.36)	1.50 (1.05, 2.16)
Age (Ref: < 19 years) 20–29 years	0.76 (0.43, 1.34)	0.79 (0.43, 1.45)	0.72 (0.43, 1.21)	0.89 (0.52,1.53)	0.49 (0.25, 1.00)	1.71 (1.02, 2.86)	1.51 (0.91, 2.51)	0.85 (0.11, 6.25)	1.21 (0.84, 17.42)	0.22 (0.07, 0.71)
30+ years	0.53 (0.26, 1.05)	0.66 (0.39, 1.11)	1.05 (0.49, 2.24)	1.29 (0.59, 2.83)	0.45 (0.12, 1.74)	1.36 (0.72, 2.58)	1.27 (0.76, 2.14)	NE	4.09 (0.14, 122.4)	0.15 (0.11,2.23)
Parity (ref: (first child) 1–2 children	1.69 (1.03, 2.77)	1.19 (0.81, 1.72)	0.92 (0.73, 1.16)	0.98 (0.66, 1.45)	0.99 (0.54, 1.81)	1.06 (0.71, 1.59)	0.85 (0.51, 1.42)	0.24 (0.06, 0.98)	NE	1.74 (0.38,7.88)
3 or more children	2.01 (0.92, 4.39)	1.56 (0.94, 2.56)	1.10 (0.60, 2.02)	0.97 (0.42, 2.26)	0.87 (0.26, 2.83)	1.03 (0.55, 1.92)	1.15 (0.43, 3.08)	1.32 (0.021, 80.68)	NE	0.09 (0.02, 0.42)
Time of delivery (ref = day) Night	1.39 (0.71, 2.72)	1.41 (0.95, 2.08)	0.96 (0.70, 1.31)	1.63 (0.88, 2.98)	1.84 (0.90,3.76)	0.78 (0.41, 1.49)	1.11 (0.63, 1.98)	NE	NE	6.24 (2.13, 18.25)
Facility sector (ref: public) Private	0.98 (0.12, 7.78)	2.82 (0.33, 23.9)	0.33 (0.02, 4.53)	0.60 (0.18, 1.93)	1.34 (0.12, 14.27)	5.10 (0.43, 59.71)	7.14 (0.98, 51.96)	13.49 (1.24,145.8)	3.85 (0.27, 54.16)	2.62 (0.22, 31.0)

Note: NE: not estimated due to small numbers the model could not run.