Multi-stakeholder Perspectives on the Maternal, Provider, Institutional, Community, and Policy Drivers of Disrespectful Maternity Care in South-East Nigeria

Figures & data

Table 1 Socio-Demographic Characteristics of the Respondents in the Quantitative Survey (n=156)

Variables	Frequency	Percent (%)
Age (Mean ±SD)	31.97 ±6.82
Gender
Male	100	64.1
Female	56	35.9
Marital status
Unmarried	83	53.2
Married	68	43.6
Divorced	1	0.6
Separated	1	0.6
Widowed	3	1.9
Religion
Christian	156	100
Job designation
Midwife	40	25.6
Doctor	116	74.4
Average monthly income
<N50000 (<$140)	4	2.6
N50000-100,000 ($140-$278)	29	18.6
N101,000–200,000 ($279-$556)	82	52.6
N201,000–300,000 ($557-$833)	17	10.9
301,000–400,000 ($834-$1111)	14	9.0
>400,000 (>$1111)	10	6.4
Ever had a child
No	93	59.6
Yes	63	40.4

Note: $1=N357.40 as at time of study.

Table 2 Drivers of Disrespectful Maternity Care at Patient, Provider, Facility, Health Systems and Community Levels

Parameters	Frequency	Percent (%)
Patient factors
Non-cooperation during childbirth	125	80.1
Non-provision of essential birthing items	65	41.7
Poor antenatal attendance/Unbooked clients	64	41.0
Illiteracy	51	32.7
Disrespectful patients/relatives	50	32.1
Poverty	44	28.2
Poor awareness of rights	30	19.2
HIV/HBV status	28	17.9
Disrespect and abuse during childbirth assumed to be normal	7	4.5
Others*	2	1.3
Health provider factors
Work overload	80	51.3
Personality type	69	44.2
Poor respectful maternity care training	67	42.9
Pressure to achieve good obstetric outcomes or else be blamed	47	30.1
Qualification (doctor, midwife etc.)	31	19.9
Lack of incentives/rewards	30	19.2
Poor remuneration	23	14.7
Cadre (Senior/Junior)	21	13.5
Others*	1	0.6
Facility factors
Poor design of Labor wards for privacy	85	54.5
Inadequate work equipment	73	46.8
Facility type (public/private)	61	39.1
Lack of basic amenities such as light, water	52	33.3
Lack of monitoring and supervision	51	32.7
Training gaps for providers at facility-level	45	28.8
Lack of facility-level policies on respectful maternity care	41	26.3
Lack of redress and sanctions for offenders	42	26.9
Administrative and management issues	35	22.4
Others*	2	1.3
Health system/policy factors
Lack of focused training for health workers on respectful maternity care at systemic level	86	55.1
Lack of health system policies and/or enforcement	78	50.0
High cost of health care	62	39.7
Community factors
Poor awareness of fundamental rights and redress mechanisms	71	45.5
Lack of autonomy and empowerment of women	66	42.3
Disrespect and abuse during childbirth treated as normal	63	40.4
Gender inequalities	48	30.8
Ideology of patient inferiority	42	26.9
Lack of community engagement/oversight	36	23.1
Others*	1	0.6

Note: *Refers to other drivers not captured in the questionnaire.

Table 3 Recommendations for Mitigating Disrespectful Maternity Care by the Respondents

Parameter	Frequency	Percent (%)
Three (3) major strategies recommend for reducing disrespect and abuse
Training/Retraining for providers	118	75.6
Policies/Enforcement of policies	81	51.9
Provision of good work equipment/environment	81	51.9
Community/patient education	73	46.8
Sanctions	56	35.9
Accountability/redress mechanisms	39	25.0
Subsidized/free cost of care	30	19.2

Table 4 Summary of Qualitative Findings on Drivers of Mistreatment During Childbirth

Theme	Subtheme	Categories
Maternal-level drivers
	Obstetric-related factors	Poor antenatal care clinic attendance, lack of previous birth experience, non-provision of birthing materials
	Behavioral factors	Dishonesty with clinical history, poor personal hygiene, poor pain management and low pain thresholds,
	Socio-economic factors	Poverty, Illiteracy
Provider-level drivers
	Work-related factors	Work stress and overload, poor remuneration and appreciation by hospital, inadequate manpower and lapses in duty
	Knowledge/skill-related factors	Inadequate training and retraining on RMC at both undergraduate and postgraduate
	Behavioral/emotional factors	Hostile personality, personal problems at home, desire to save the life of the baby
	Provider-client interactions	Unbalanced power relations
Facility-level drivers
	Work environment, equipment and supplies	Inadequate work equipment, supplies and basic amenities, lack of RMC enhancing institutional structures and birthing environment such as Labor wards with privacy, stressful hospital protocols and bottlenecks, lack of synergy among workers
	Institutional cost and redress arrangements	High cost of services, inadequate institutional redress mechanisms
Community-level drivers
	Normalization of D&A during childbirth	D&A normalized to save the baby’s life
Policy-level drivers
	Lack of local policies and policy enforcement structures on RMC	Insufficient policy content on RMC and local activity to prevent D&A during childbirth, lack of capacity, work equipment and other resources to support adherence to RMC in health facilities

Abbreviations: D&A, disrespect and abuse; RMC, respectful maternity care.