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“I felt like I should have delivered at home” – how mistreatment can discourage women from giving birth in a health facility

A study looking into respectful maternity care in Northeast Nigeria
Three healthcare professionals at entrance to maternity ward, Gombe State Nigeria. Credit: IDEAS

The Northeast of Nigeria has some of the highest rates of maternal and newborn deaths in the world. Drastically reducing this number of preventable deaths is therefore seen as a top priority for the health sector. Evidence from around the world has shown that encouraging mothers to deliver their babies in a health facility with the support of a skilled birth attendant is key to better health outcomes for women and babies. The available data from Northeast Nigeria however continue to show a low rate of institutional delivery, women are reluctant to deliver in a health facility. One of the possible reasons for this may be the quality of care they receive and the prevalence of mistreatment and even abuse they may face in a hospital.

Nasir Umar, working on the IDEAS project at the London School of Hygiene & Tropical Medicine and his colleagues have therefore undertaken a study to investigate the prevalence and manifestations of mistreatment during institutional birth in Gombe State.

Combining a mix of quantitative and qualitative methods, the study found that two-thirds of women reported at least one dimension of mistreatment when questioned after giving birth in a health facility. Half of women spoke about mistreatment related to health system conditions and restraints, such as being unclear about the fee structure and health workers making unreasonable requests. This meant that, for example, women felt they were being asked to pay more user fee for facility delivery services or to supply more delivery items than was necessary. One woman, who participated in a focus group discussion, described her experience:

“The doctor prescribed some medicine for me, he calculated the money more than five times, he will calculate and calculate again with his calculator from 700 to 1500 and another 250 Naira, from there I know there was a problem...”

One in four women also reported a shortage of staff and the poor physical condition of health facilities.

The second most prevalent form of mistreatment mentioned by women leaving a facility was related to the poor communication and relationship between health care providers and women. This could mean that mothers were denied a birth companion or felt they didn’t receive the supportive care they expected from health workers and that some health care workers lacked empathy and didn’t help the delivery process,

“I will get up and squat, and they will say no, I should lie down, I will get up again and sit down and she [birth attendant] will say no, lie down. I did not know how they give birth in a facility [my first time] …I have never heard of it, I swear I have never heard of giving birth lying down.”

Moreover, women spoke about incidences where staff failed to meet their professional standards of care, undertaking procedures without informed consent given by the mothers or even being absent at the time of delivery as this participant in a focus group discussion describes:

“It had happened to me during my first delivery before the nurse came, the cleaner did everything to me [conducted the delivery].”   

The prevalence of physical abuse reported by women was relatively low, reported by three percent of women.  Verbal abuse, on the other hand, was reported by about one in ten women. Commonly health workers would be unfriendly, shout at or scold women or blame women for poor childbirth outcomes, all in the name of facilitating childbirth.

Many study participants questioned the value of delivering in a health facility and reported that they would opt to have their next baby at home.

This study is the first of its kind to look at mistreatment during institutional delivery in Gombe State and it provides evidence that mistreatment deters women from giving birth at a health facility, preferring instead the higher risk of a home birth. The study points to the importance of making sure that respectful care, including effective communication, is integrated in training for health care providers. Addressing the health system constraints, such as poor infrastructure, lack of space and supplies will be key to encouraging more women to use maternal and newborn health services.

You can read the paper here: https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0837-z