Disrespect and abuse in maternity care: individual consequences of structural violence

Figures & data

Table 1. Basic characteristics of health facilities

	Health center 1	Health center 2	District hospital
Location	30 km from district town center, access via tarmac road, centrally located	30 km from district town center, rural location, rough road	In the district town center
Staffing	1 assistant medical officer, 4 clinical officers/assistants, 14 nurses and 4 medical attendants (total staff)	2 clinical officers, 6 nurses and 2 medical attendants (total staff)	ANC clinic: 2 enrolled/registered nurses and 2 medical attendants. Maternity ward: 3 nurses and 2 medical attendants (daily presence, morning shift)
Basic facility statistics 2015/2016 (monthly average)	153 ANC visits, 58 births	149 ANC visits, 75 births	550 ANC visits, 262 births

Table 2. Overview of individual characteristics, health care seeking behaviour and outcome

Name^a	Age	No of observations	No of interviews	Years in school	Work	Marital status	SES^b	Age first birth	Previous birth location	Facility distance	ANC visits	Birth location	Newborn Outcome
Rory	22 years	2 ANC visits Birth partial	6	11	Yes	Married	3	18	1F 0H	1–5 km	4	District hospital	Alive
Diana	30 years	3 ANC visits	8	7	Yes	Married	4	22	2F 0H	<1 km	5	District hospital	Alive
Jessica	25 years	3 ANC visits	8	6	No	Married	2	18	1F 3H	5–10 km	5	District hospital	Alive
Angel	22 years	1 ANC visit	5	7	No	Married	3	17	1F 0H	1–5 km	3	Health centre	Stillbirth
Flora	21 years	2 ANC visits	7	7	No	Married	1	19	0F 1H	5–10 km	4	Health centre	Infant died at 3 months
Jane	18 years	0 ANC visit Birth	5	9	No	Relationship	3	-	- -	1–5 km	3	District hospital^c	Infant died at 6 months
Tara	37 years	0 ANC visit Birth assisted by researcher	6	5	No	Relationship	2	16	5F 1H	<1 km	2	Health centre	Alive
Maria	22 years	2 ANC visits	7	7	Yes	Relationship	3	14	0F 1H	<1 km	2	Home	Alive
Bea	29 years	2 ANC visit	5	11	Yes	Married	4	24	2F 0H	1–5 km	3	Home	Alive
Pili	19 years	4 ANC visits	8	7	No	Married	3	17	1F 0H	>10 km	4	Home	Alive
Naima	19 years	1 ANC visit	7	7	No	Married	1	16	1F 0H	>10 km	3	TBA home	Alive
Mariam	32 years	1 ANC visit	6	7	No	Married	2	22	3F 2H	1–5 km	4	Home	Alive
Paulina	37 years	2 ANC visits	8	5	No	Married	1	16	3F 4H	>10 km	5	Home	Alive
Helena	31 years	2 ANC visits	6	4	No	Married	3	17	2F 4H	1–5 km	3	Home	Alive

Note: ANC: antenatal care; No: number; SES: socio-economic status; F: Facility; H: Home.

^aNames are pseudonyms.

^bAll women are poor, but category for socio-economic status is determined based on a number of indicators including possession of assets, living conditions and personal background. Category levels range from very poor category 1 to more well off category 4.

^cShe was transferred from the health centre to the district hospital with the ambulance.

Table 3. Categories and sub-dimensions of supportive behaviour

Category	Sub-dimension
Emotional support	Observes, identifies and responds to signs of emotion, stress, fatigue, pain. Makes statements to reassure and encourage woman. Is friendly, open and gentle. Introduces self, smiles, has a pleasant facial expression. Positive laughter, joking, social chitchat, humour. Uses words, phrases and non-verbal expressions to express concern and empathy. Relaxed calm demeanour, soft calm voice. Keeps company with no tasks being performed, showing undivided attention (eye contact, woman-direct gaze, leaning forward). Birth specific: Active engagement and encouragement during contractions, verbal- and non-verbal, expressions affirming woman’s ability, praise.
Physical support	Assists patient gently and in a culturally sensitive way during examinations. Birth specific: Offers, checks, encourages and assists woman to take fluids/food, go to toilet regularly, changes clothing and linen, showers or bathes. Provides pain medications, encourages relaxation or other ways of support (counter pressure, assists in walking, assuming different positions). Coaches through labour such as with breathing and relaxation or touch (holding hand, massage).
Effective communication	Gives explanations: Explains to woman when to contact the midwife, explains what needs to be done in case a complication occurs. Explains procedures or treatment, what is done and why and informs of findings. Gives information: Provides update on progress of pregnancy and birth. Gives instructions: Instructs woman what to do during pregnancy including how to cope with normal pregnancy symptoms. Informs woman where to go if supplies are not available. Birth specific: instructs patient during and after birth how to participate to improve outcome, information on how to cope with pain, coaching during pushing. Advises patient to change position, walk around, breath in and out for comfort. Involves: Provides woman with options and involves in decision-making. Asks woman if she has questions and encourages her to ask questions.
Nursing proximity	Is accessible, comes quickly when woman or family member calls, expresses accessibility verbally, encourages woman to request assistance and express needs, faces the woman and position at the same level.
Privacy respected	Ensures privacy and confidentiality: uses curtains, sheets, and positions to avoid exposure, discusses privately with client or with colleagues or with family, minimises interruptions.
Consent	Asks for permission before performing examination or medical procedures.

Table 4. Categories and sub-dimensions of non-supportive behaviour

Category	Sub-dimension
Psychological abuse	Verbal aggression such as shouting/scolding, threats, insulting, laughter (negative belittling humour or sarcasm), name-calling. Dominant behaviour such as preventing woman from doing certain things she wants or forcing certain actions. Demanding woman to clean after delivery. Discriminatory behaviour such as not providing care for reasons related to race, gender, age, HIV status, marital status.
Physical abuse	Pinching, slapping, pushing, beating, poking, sexual harassment or rape. Forced (unnecessary) examinations, excessive and inappropriate medical interventions, episiotomy and stitching without anaesthesia.
Non-support	Includes behaviour which is not necessary harmful [in contrast to with physical or psychological abuse] but is also not supportive: ignoring of cues, ignoring contractions (talks, discusses, performs actions during contractions), loud/harsh/cold tone, undermining efforts, nervous restless demeanour, cold or angry facial expression, criticism of woman’s behaviour, doubts expressed about woman’s ability. Absent behaviour such as no introduction, no discussion of wishes of woman, no explanations or information given, no encouragement, no expression of empathy.
Abandonment	Woman is ignored when seeks or asks for care, neglected when asks for help, left unattended, gives birth alone. Delay in receiving intervention when needed, failure to provide supplies even if supplies are available, failure to offer services when staff are adequate and on duty.
Privacy violation	Medical information shared with other patients or family members (such as HIV status shown to others, discuss issues with other clients present). Being unnecessarily uncovered during clinical examination or labour, no use of available screens or lack of attempt to provide privacy. Sharing of beds with other patients. Frequent interruptions and attendance of different staff members.
Non-consented care	No permission obtained before examination for medical procedures.

Table 5: Examples of exposure to supportive care in the current pregnancy

Name	Type of supportive care	Examples
Rory	ANC: Effective communication	Received quick services during her second ANC visit and was asked if she has any problems.
	Birth: Physical support	During admission for birth one nurse escorted her to the waiting area and helped her find a bed.
Diana	Birth: Emotional support, nursing proximity, effective communication	During birth she was attended gently and in a friendly way. Nurse came when she asked her to and she experienced the nurse to be with her at all times during the birth. Was given instructions on how to push.
Jessica	ANC: Emotional support	She was given priority when she came with her husband during her first ANC visit. She liked that she was allowed to sit on the front bench and was given services quickly. She was approached in a friendly way.
	Birth: Emotional support, physical support, effective communication	During birth she felt she got very good service. The nurses were gentle and friendly to her. She was explained what was causing her to delay giving birth and nurses directed her what to do after they ruptured the membranes. They helped her to carry her things, cleaned her and carried her baby.
Angel	ANC: Effective communication	During one ANC visit a nurse was providing health education about HIV prevention and testing, was giving explanations and involving women.
Flora	ANC: Emotional support, effective communication	During her second visit, she was given good services. It was discovered she was HIV positive. Nurses ensured they were sitting in a private place. The nurse used humour, a soft tone of voice and had regular eye contact. She was given explanations and instruction about her condition and the medication.
Jane	ANC: Emotional support, effective communication	She was happy with the services during the first ANC visit, nurses were swift in providing care and helped each other when it was busy so that she did not have to wait long. During her third visit, she was told the baby was doing fine.
	Birth: Physical support, emotional support	Upon arrival at district hospital for birth, the nurse assisted her to get on the bed and instructed her how to lie. When the nurse noticed the examination was painful, she tried to comfort Jane, told her in a soft tone of voice to try to relax and keep her bottom down on the bed.
Tara	ANC: Emotional support	The ANC clinic was closed one day when she went for a check-up outside of her scheduled visits because she was feeling sick. She was instead directed to be seen by the doctor.
	Birth: Emotional support	During birth the nurse was considerate for her HIV status and made sure the person accompanying her did not find out. Was given good services after birth. Was told to lie down to rest for a while after birth and not get up immediately. (Note: The researcher assisted this birth.)
Maria	ANC: Effective communication	During her second ANC visit, nursing students asked her for consent before performing physical examination. They were polite and friendly to her.
Bea	ANC: Effective communication, nursing proximity, emotional support	During her first ANC visit, a nurse was providing health education about HIV prevention and testing, was giving explanations and involving women. She was seen immediately by a doctor who asked her name and spoke about her problem. He looked at her while asking and expressed a friendly attitude; he was gentle and listened to her.
Pili	ANC: Emotional support	During second and third ANC visit she had positive social talk with the nurses.
Naima	ANC: Effective communication	During her second ANC visit she was told the baby was fine and that he was playing inside. Was instructed to go and see the doctor if she was having pains or other complaints.
Mariam	ANC: Effective communication	Was told everything was fine during all her ANC visits.
Paulina	ANC: Emotional support	During her third ANC visit, she was listened to with regard to her symptoms and allowed to change her HIV medication.
Helena	ANC: Emotional support, effective communication	During her first ANC visit, she was informed about the condition of the baby and given an explanation together with her husband on what to bring during birth. The nurse ensured privacy during HIV testing, closed the door and asked for consent and explained the procedure.

Table 6: Examples of exposure to non-supportive care in the current pregnancy

Name	Type of non-supportive care	Examples
Rory	ANC: Psychological abuse, non-supportive care	During her first ANC visit she decided to keep quiet when she heard nurses speak harshly towards other women. She was placed at the end of the waiting line because she did not come with her husband. She was unnecessarily sent back and forth between different rooms without receiving services. She was not welcomed, lack of communication including no information provision about the wellbeing of her baby or herself. No consent or information provision during HIV testing. Was given a return date on a national holiday.
	Birth: Physical abuse, non-supportive care, abandonment	Forced vaginal examination during birth despite protest and expressing physically and verbally that it was painful. Not welcomed upon arrival at the facility. Her card was taken from her without any communication. No information provision after examination other than “later”, meaning she needed to go to the waiting area because birth was not imminent. Nevertheless, she gave birth 30 min later. Despite calling repeatedly for the nurse to help her, the nurse remained at a distance only to come closer when the head was crowning.
Diana	ANC: Non-supportive care	During her first ANC visit she had to wait unnecessarily long, was sent back and forth and left to wait uninformed until she was told to come back tomorrow without explanation why and for what. General lack of communication during other clinic visits without information on the wellbeing of her baby and herself.
	Birth: Non-supportive care	Other than being told birth was not until “later” she remained both at the waiting area and labour ward for a long time (total 24 h) without information about the progress of labour or condition of the baby or herself despite her own expressed worries about the amount of blood she had lost.
Jessica	ANC: Non-supportive care, privacy violation, non-consented care, psychological abuse	During her first ANC visit she was not given explanation of the findings of laboratory investigation. Was ignored when she informed the nurse about her complaints (stomach ache). She was given a return date on a Sunday. During physical examination at her first visit, there were many interruptions by students coming in and out. Was reprimanded for coming too late to her second clinic visit and threatened she would not receive services. HIV test was performed without counselling or asking for consent.
Angel	ANC: Non-supportive care	During her first ANC visit she was not provided with the ANC card and therefore had to buy and bring a notebook. She had been seen for ANC the morning of the day that she delivered a stillbirth. During this visit her stomach ache was dismissed as being part of normal pregnancy symptoms, she was not informed about her condition or that of the baby.
Flora	ANC: Abandonment, non – supportive care	For her first attempt to visit the ANC clinic she was refused services because she did not come with her husband During her actual first visit she was not welcomed, no explanations were given about the service received, no safe space to express her symptoms of pain and cough.
	Birth: Psychological abuse, abandonment, non-supportive care	Upon arrival at the facility for birth, the nurse responded annoyed and aggressive upon arrival at the facility, wanted to send her to another hospital for unclear reason. The nurse was angry at her for having squatted above the basin and said that she would have lost her job if the baby had been born in the basin. She was told to clean up after birth and was threatened not to get back ANC card or would not be allowed to go home if her sheets were not washed. Was not taken seriously when she told the nurse she felt to push. Was left alone for 4 hours without any check-up. Eventually, the head was born without nurse present.
Jane	ANC: Non supportive care, abandonment.	During her first ANC visit she was not believed when she told the nurse her last normal menstrual period. Her information was dismissed and the nurse gave her an estimated date of birth two months beyond what Jane believed to be true. No education or information provision on measurements or what to expect during pregnancy and birth despite it being her first pregnancy. Was refused services at her second clinic visit because this day was not for her village.
	Birth: Psychological abuse, physical abuse, non-supportive care, abandonment, non-consented care	Upon arrival for birth she was not welcomed at the health centre, instead she was ridiculed by the nurse because she was not adequately responding to the nurse’s comments. The nurse had told her firmly not to drop her clothes on the floor. Was told her son almost died because she was not pushing well. Was told firmly to stop crying without attention for the reason why she was crying. Vaginal examination and interventions were done without consent and forced while restraining her if she resisted. She was told she was not relaxing, she was not doing what she was supposed to do. Received directions on what to do in a firm way “keep arm straight”, “don’t move”, but no explanation on what was going on, why she received interventions and no consideration for her pains or her fear. Was refused to drink water as this was thought to reduce contractions. Was ignored when she arrived at the health centre until her family member provided the necessary gloves to the nurse. Vaginal examination and interventions including fundal expression and episiotomy without consent.
Tara	ANC: Non supportive care	During her second ANC visit, the nurse was ranting about her working conditions while performing services and scolded another woman because she said she could not hear her well.
Maria	ANC: Psychological abuse, non supportive care, privacy violation	During her first ANC visit she received belittling comments when she was unable to answer all the questions related to danger signs. During her second visit, other women who came with their husbands were prioritised and she was told to go back in line. Nurses laughed at women complaining about long waiting time. Asked the researchers to change her return date on her ANC card after she had not shown up, she feared she would be scolded if she would go next time. No explanation given on findings, no follow-up provided despite being diagnosed with low haemoglobin level. Interruptions when other students walked in and out during physical examination.
Bea	ANC: Non-supportive care, abandonment	Nurses refused to give her an estimated date of delivery because she could not remember her last menstrual period; however, this was complicated because of her use of contraceptive method. Was refused care during her expected fourth visit because the nurses expected to receive training.
Pili	ANC: Psychological abuse, abandonment, privacy violation, non-supportive care	Threatening language during health education. The nurse was informing people what to bring for birth, explaining that women will get HIV if they don’t bring their own sheet and that they will be refused if they don’t bring everything. Pili felt this was normal and good health education because some women don’t know how to behave. No explanation about medication which was given or tests which were performed. Refusal of service for her first visit because they only see women for their first visit on Mondays. Also refused services during her fourth visit because the nurse who was doing the clinic had to escort a woman in labour to the district hospital. Frequent interruptions during the clinic visit.
Naima	ANC: Psychological abuse, non-supportive care, privacy violation	Naima felt she was not allowed to be seen during her second ANC visit. Nurse told all waiting women that “if you do not have a husband with you, there is no checking at the clinic”. During the visit her cues of being sick were ignored, not asked about. For her third ANC visit, other women were prioritised which caused her to wait for a long time, she was not feeling well and had a crying toddler with her, she could not cope and left without being attended. Interruptions by other health provider during physical examination looking for supplies.
Mariam	ANC: Non supportive care	She said the nurse was harsh during the first ANC visit, performing her work angrily. Was not taken seriously in relation to her own expectation of when she thought she would give birth.
Paulina	ANC: Non supportive care:	Had to go to another clinic several times to collect her HIV card number. Was getting severe side effects of her new HIV medication but was not taken seriously at the ANC clinic which resulted in her stopping taking her ARVs, despite going back to the ANC clinic outside of her scheduled visits. She explained the nurse did not inform her about the condition of the baby or herself.
Helena	ANC: Non-supportive care, abandonment	Was refused services during her first visit because she had not brought her husband with her. During ANC she was told she was wrong about the length of her pregnancy. Received a return date on a national holiday. Received another vaccination for tetanus even though she had finished it, was not believed and given the injection anyway. Nurse was annoyed she came late for her third ANC visit, was reprimanded and threatened not to receive services. Was refused services during her 1st visit because she had not brought her husband with her.