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

Figures & data

Figure 1. Defining disrespect and abuse of women in childbirth

Note: Reprinted from The Lancet, vol. 384, Freedman LP, Kruk ME. Disrespect and abuse of women in childbirth: challenging the global quality and accountability agendas. page e43. 2014, with permission from Elsevier.

Table 1. Disrespect and abuse categories and actions included in observation and exit interview questionnaire

Categories	Disrespect and abuse questions
Non-confidential care	Patient’s body seen by other people (aside from health provider) during delivery
Non-dignified care	Health providers shouting at or scolding patient
	Health providers threatening to withhold treatment because patient could not pay or did not have supplies
	Health providers threatening patient for any reason or making negative or disparaging comments about the patient
Neglect	Health providers ignoring or abandoning patient when in need or when she called for help
	Delivered without any assistance
Non-consented care	Tubal ligation (tying of fallopian tubes) without patient's permission
	Hysterectomy (getting your uterus removed) without patient or her relatives’ permission
	Caesarean section without patient or her relatives’ permission
Physical abuse	Hitting, slapping, pushing, pinching or otherwise beating the patient
	Health providers sexually harassing patients or making sexual advances (for example, inappropriate touching or sexual comments that make you feel uncomfortable)
	Rape (being forced to have intercourse or perform any other sexual acts against your will)
Inappropriate demands for payment	Woman or baby not allowed to leave the hospital due to failure to pay
	Health providers suggesting or asking for a bribe or informal payment for better care

Table 2. Characteristics of participants at baseline (2012) and endline (2015) in two health faciliites in Tanga Region, Tanzania

	Baseline (N = 232)		Endline (N = 237)		Chi-sq
Demographics	N	%	N	%
Age, mean	25.38	0.40	26.01	0.40	0.27
Age categories
15–19	43	18.53	37	15.61	0.27
20–34	167	71.98	167	70.46
35–50	22	9.48	33	13.92
Parity
1st birth	94	40.52	101	42.62	0.54
2–3 births	77	33.18	84	35.44
4 or more births	61	26.29	52	21.94
Attended secondary education or greater	57	24.57	61	25.74	0.77
Married	174	75.00	198	83.54	0.02
Poor	94	41.41	99	42.13	0.88
Reported low mood or depression in last 12 months	73	31.47	74	31.22	0.96
Reported ever being physically abused or raped	6	2.59	7	2.95	0.81
Delivery care experience
Caesarean section	14	6.03	12	5.06	0.65
Reported any complications during childbirth^a	115	49.57	94	39.66	0.03
Length of stay for delivery ≤ 1 day	79	34.35	93	39.24	0.27
Came directly to facility for childbirth	188	81.03	200	84.39	0.34

^aComplications include extreme pain, high blood pressure, seizures, blurred vision, severe headaches, swelling in hands/feet, baby was in distress or too large, long labour (≥ 12 hours), excessive bleeding, and infection/fever.

Table 3. Comparison of reports of disrespect and abuse on observation and self-report at baseline (2012) and at endline (2015) in two health facilities in Tanga Region, Tanzania

	Reported on observation		Self-report		Ratio of observation/self-report	D&A reported on either measure		Concordant D&A responses (among those who reported D&A on either measure)
	N	%	N	%		N	%	N	%
	Baseline (N = 232)
Any disrespect and abuse	162	69.83	23	9.91	7.05	170	73.28	15	8.82
Physical privacy	25	10.78	3	1.29	8.36	27	11.64	1	3.70
Shouting or scolding	107	46.12	14	6.03	7.65	113	48.71	8	7.08
Threaten to withhold treatment	12	5.17	3	1.29	4.01	15	6.47	0	0.00
Threatening or negative comments	101	43.53	6	2.59	16.81	105	45.26	2	1.90
Ignoring	42	18.10	8	3.45	5.25	47	20.26	3	6.38
Hitting, slapping, pushing, pinching	32	13.79	2	0.86	16.03	32	13.79	2	6.25
	Endline (N = 237)
Any disrespect and abuse	78	32.91	18	7.59	4.34	85	35.86	11	12.94
Physical privacy	3	1.27	2	0.84	1.51	5	2.11	0	0.00
Shouting or scolding	34	14.35	13	5.49	2.61	42	17.72	5	11.90
Threaten to withhold treatment	3	1.27	0	0	–	3	1.27	0	0.00
Threatening or negative comments	15	6.33	7	2.95	2.15	22	9.28	0	0.00
Ignoring	30	12.66	11	4.64	2.73	39	16.46	2	5.13
Hitting, slapping, pushing, pinching	24	10.13	5	2.11	4.80	26	10.97	3	11.54

Figure 2. Concordance between self-report and observation