Background: While basic coverage of maternal health services has increased in Ethiopia, progress towards reducing maternal mortality has lagged behind and the rate of deliveries attended by skilled birth attendants has remained very low, only 26% of mothers give birth in facility. Many of the indignities that women experience keep them from seeking the care they need. More than cost, more than distance from the health facility, fear of being mistreated keeps women at home.

Objective: To assess respectful maternity care and associated factors among mothers who are in immediate post-partum period in public health facilities, Addis Ababa, Ethiopia, 2018.

Method and material: Facility based cross sectional study design was conducted at Public health facilities in Addis Ababa, from March 15 to 22; 2018.The participant facilities for the study were selected by simple random sampling method. A total of 380 mothers attending immediate post-partum care were enrolled in the study. A pretested standardized questioner was used for data collection. Data was entered and checked with Epidata version 4.1 and was exported to SPSS version21. Binary and multivariate logistic regression was used to identify the association and independent predictors of respectful maternity care. Finally p-value of less than 0.05 declared the association.

Result: Three hundred eighty women were interviewed yield a response rate of 99.2%. Among interviewed women, 82.4% had received respectful care during their stay in maternity ward. Monthly income 2282.24 ETB and above AOR 1.92[95% C.I 1.048, 3.51], married mothers AOR 3.65 [95% C.I 1.59, 8.36], Mothers, who attended secondary education and higher AOR 3.86 [95% C.I 1.73, 8.62], Male health providers AOR 2.28 [95% C.I 1.281, 4.08] and giving birth by normal delivery AOR 2.368 [95%C.I 1.12, 4.99] were found to be the predictors of respectful maternity care.

Conclusion and recommendation: More than eighty two percent of the respondents in Addis Ababa public health facilities in immediate post-partum mothers have received respectful maternity care. Educational status, marital status, income, sex of provider and mode of delivery were found to associate with respectful maternity care. Training should be given by mainly focusing female providers and process monitoring of the maternal health services were recommended.

Keywords: respectful maternity, maternal health, disrespect, abuse

D & A, disrespect and abuse; EDHS, Ethiopian demographic health survey; ETB, Ethiopian birr; FMOH, federal ministry of health; IRB, institutional review board; JU, jimma university; JUSH, jimma university specialized hospital; LB, low birth; MNH, maternal and neonatal health; RMC, respectful maternity care; SBA, skilled birth attendants; SBMR©, standard based management and recognition; SPA, service provision assessment; SPSS, statistical program for social science.

Significant progress has been made globally in maternal and neonatal health (MNH) care, and both maternal and neonatal mortality rates have dropped in recent decades. Strengthened legal frameworks and effective clinical and programmatic practices have improved the quality of services provided. Despite these improvements, access to quality services is not guaranteed for many, especially in developing countries.¹ Evidence suggests that in countries with high maternal mortality, the fear of disrespect and abuse that women often encounter in facility-based maternity care is a more powerful deterrent to use of skilled care than commonly recognized barriers such as cost or distance. In Ethiopia to increase access to delivery service, governments has expanded a number of facilities, very successful Health Extension Program at community level , road access – still long way to go but has improved, ambulances was deployed to district level and maternal and neonatal health care facility services are now free. But still majority of births takes place at home with unskilled attendants and only 26% of births take place at health facility.^2,3 While many interventions aim to improve access to skilled birth care, the quality of relationships with caregivers during maternity care has received less attention.⁴

Recent studies showed that the prevalence of disrespect and abuse of mothers is worse in Sub-Saharan African countries.⁵ Studies; in Kenya, Tanzania, Ethiopia, and Nigeria analyzed women’s experiences during childbirth and estimate prevalence of disrespect and abuse care (20 %, 20–28 %, 78, and 98 %), respectively.^6,7 Many women did not have procedures or the labor process not explained to them and did not hear about the findings of exams. In Ethiopia only 16% of Women asked whether she had any questions or not.^8,9 Respectful maternity care (RMC) is a universal human right to every childbearing woman in every health system. It is not an option. It is not a luxury awarded only to women in certain geographies or demographic groups. It is a right .¹⁰ In Ethiopia most of the evidence gathered on disrespect and abuse during childbirth in health facilities are either in the form of qualitative studies or documentation of anecdotal statements. As a result, the approximate burden of disrespect and abuse occurring in facilities are not well known.¹¹ Therefore, the aim of this study is to assess respectful maternity care and associated factors among mothers in immediate post-partum period in public health facilities, in Addis Ababa.

1. General objective

The aim of the study is to assess respectful maternity care and associated factors among mothers who are in immediate postpartum period in public health facilities, Addis Ababa, Ethiopia 2018.

2. Specific objectives

1. To assess the magnitude of respectful maternity care on mothers in immediate postpartum period in public health facilities, Addis Ababa city, 2018.
2. To identify factors associated with respectful maternity care among mothers in immediate postpartum period in public health facilities, Addis Ababa city, 2018.

Study area and period
The study was conducted in Addis Ababa, capital city of Ethiopia. The town has 28 woredas with a total of 328 kebeles. The population projection of 2015/16 of the town is 2.9 million people, with total reproductive age groups of 34.4%. The city consists, a total of 13 government hospitals and 23 health centers. The study was conducted from, March 15- 22, 2018 on mothers who gave birth in Addis Ababa public hospitals and in immediate post-partum period at the time of discharge.

Study design
Facility based cross-sectional study design was conducted.

Population

Source population: All mothers who delivered in Addis Ababa public health facilities and in immediate post-partum period.

Study population: All mothers who are in immediate post-partum period in post natal care unit in public health facilities of Addis Ababa, and present during the time of data collection.

Inclusion and exclusion criteria

Inclusion criteria: All mothers in immediate post-partum period in public health facilities of Addis Ababa

Exclusion criteria: All mothers in immediate post-partum period in public health facilities of Addis Ababa who are not willing and able to respond

Sampling technique and procedure

From a total of 36 public health facilities, by taking 30%, 11 Public health facilities were selected by simple random sampling method that is, 7 health centers and 4 hospitals were involved in the study. The last six months delivery number per month was taken from the registration book the average delivery number was calculated and the sample size was proportionally allocated to the health facilities. And finally all mothers who are eligible and available during the study period and who satisfy the inclusion criteria were recruited in the study.

Data collection tools

Respectful maternity care was measured using a total of 16 questions using the seven classifications. To assess if the mother has experienced physical Abuse, 5 questions were used 1.Pushed2.Pinched or otherwise beat her, 3. Used force as a restrain during labor/ delivery/ examination and 4. Procedures were done without anesthesia or other forms of pain relief. For each items the response was scored as: 1“No” if a woman didn’t experience any of the abuse, 2 “yes” if she has experienced the any of the abuse. For consented care one question was asked, 1. Surgical or other procedures done without asking her consent and the response was scored as 1. “No” if there were procedures done without her consent and 2. “Yes” if her consent was not taken for any procedures. For dignified care, 3 questions were asked, 1. If the health care’s providers shouted at or scolded her, 2. If they made negative comments about her =3. If they threatened to withhold treatment, because she could not pay or did not have supplies, for any of the questions the response were scored as 1. ”No” if she was not dignified and 2. “Yes” if she was dignified.

1. Confidential care was assessed by 2 questions 1. If the health care’s providers discussed her private health information, in a way that others could hear and 2. If her body (private parts) was seen by other people (apart from health providers) during delivery. For each items the response was scored as: 1“No” if a woman didn’t experience any of the abuse, 2 “yes” if she has experienced the any of the abuse.
2. Discrimination was measured with 2 questions 1.If she was treated poorly because of poverty, 2. Because of her religion, her age other marital status and it was scored 1.”No” if she didn’t face any of the actions and 2. “Yes” if she has experienced the actions.
3. Abandonment of care was measured by 2 questions, 1. If the health providers ignored or abandoned her when she called for help and 2. If she delivered without any assistance. For each items the response was scored as: 1“No”, if a woman didn’t experience any abandonment, 2 “yes”, if she has experienced abandonment.
4. Detention in facilities was measured with 1 question, 1. If she was not allowed to leave the health-facility due to failure to pay .The response was scored 1. “No”, if the mother didn’t experience any of the actions and 2. “Yes”, if she has experienced the abuse or action.

Data collection techniques for quantitative data

Data was collected for one week in the selected health facilities, exit interviews were conducted to all of postpartum women in the maternity unit who have recently delivered at the selected facilities as they leave the maternity ward after giving birth. All women satisfying these inclusion criteria were recruited until the required sample sizes was reached by using structured face to face and in-depth interview questioner first prepared in English and translated in to Amharic for appropriateness and easiness in approaching the study participants and back to English by different persons to check the consistency of meaning. Non- staff member of 11 diplomas and 1 BSc Midwifery background personnel and have experience of qualitative data collection technique were recruited as data collectors and supervisor respectively.

Data collection techniques for qualitative data

For qualitative data collection; the data collectors and investigator selected the participants and organized appropriate time and comfortable place for the interview. During conducting the in-depth interview explanation and elaboration of the need to do the in-depth interview were made and the interviewees were asked for their willingness to participate in the study and the in-depth interview was conducted after the confirmation of the individuals consent.

Data collector training manual was prepared. One day training was given for supervisor and data collectors on the basic techniques of data collection, approaches and on the issue of confidentiality and privacy by the principal investigator and collaborators.
Then questionnaire was pre-tested on 5% (19 mothers) in Alemgena health center and necessary modifications were made specifically on the understandability of specific item. All steps in data collection were closely monitored by the principal investigator.
The filled questionnaires were also checked carefully on the spot and daily basis for their completeness, accuracy, and clarity. Any error, ambiguity, incompleteness, or other problem encountered were early identified communicated, discussed, and solved before starting next day activities.

Data processing & analysis

After data collection, each questionnaire was checked for completeness, consistency and clarity and was coded and entered in to Epidata manager 4.1 and was exported to SPSS version 21. Data was cleaned and explored for outliers, missed values and any inconsistencies and it was analyzed using SPSS version 21. Descriptive statistics like frequency tables, graphs and descriptive summaries was used to describe the study variables. An odds ratio (95% confidence intervals) and Binary Logistic regression analysis was used to assess the association of different variables with respectful maternal care and p value < 0.25 were candidates for multivariate logistic regression and P value <0.05 were considered statistically significant in all tests of significance. Whereas: for the qualitative data 11 health professionals were interviewed then, and it was written in narrative forms and supplemented with the notes taken during the discussion. And finally the findings from these different data collection methods were complemented.

Ethical clearance to conduct the study was obtained from IRB (institutional review board) of Jimma University institute of health sciences and letter of cooperation was obtained and sent to selected public health facilities and to the non-selected health institution for pretest. Confidentiality of the information was ensured by not asking the name of the client or other identifiers (Table 1).

Socio-demographic characteristics of the mothers

Three hundred eighty women were interviewed with a response rate of 99.2%. The mean (+ SD) age of the women was 26.12 (+ 4.253) years. Most of respondents 223(58.7%) were Orthodox Christian followers. Almost half of respondents199 (49.7%) were attended primary education. Majority of them are married 345 (90.1%) and 239 (62.9%) of them have only one child (Table 2).

Socio-economic factors

Regarding to their socio-economic status majority of them 162(42.3%) were government employees and the mean value of the overall monthly income of the mothers are 212 (55.8%) (Table 3).

Obstetric factors

Majority of delivery took place during the night time 215 (56.6%).More than half (58.4%) of birth are by spontaneous vaginal delivery. Regarding to previous birth place majority of mothers 292 (76.8%) gave birth on current facility(Table 4).

Provider factor

Majority of delivery was attended by medical doctor 233 (60.8%) and male providers (58.7%). Regarding to age group of provider most of delivery attended by young age group (55.5%) (Table 5).

Magnitude of respectful care

Majority of mothers about 82.4% were reported as they gate respectful care from facilities (Figure 1).

Figure 1 Prevalence of respectful maternity care among mothers in immediate post-partum period in Addis Ababa public health facilities march 2018.

Classifications of RMC

Regarding to type of respectful care, the highest (89.75%) and lowest (18.2%) reported by mothers were no discrimination and dignified care respectively (Figure 2).

Figure 2 Type of RMC among mothers in immediate post-partum period in Addis Ababa public health facilities march 2018.

Predictors of respectful maternity care in public health facilities

In bivariate logistic regression analysis, each explanatory variable with outcome variable (respectful maternity care) was assessed for its association and the observed associations were reassessed by multivariate analysis to identify adjusted association with the probability of receiving respectful care. And these variables which give P-value >0.25 were considered as not significant, so that they cannot be candidate to multiple logistic Regression for farther analysis. Variables such as income level, marital status, previous use of the facility, sex of the provider. Educational status of the mothers, age group of the provider, and mode of delivery and profession of the provider were associated with respectful maternity care in bivariate logistic regression analysis (Table6). But in multivariate logistic regression after adjusting for potential confounders, having higher monthly income, being married, attending formal education, delivery attended by male provider and giving birth by normal delivery were found to be predictors of respectful maternity care.

In the analysis having monthly income 2282.24 ETB and above were about twice (AOR 1.92[95% C.I 1.048, 3.51]) more likely to receive respectful maternity care. Being married were more than three times AOR 3.65 [95% C.I 1.59, 8.36]) more likely to receive respectful maternity care than their counterparts (Table 7). Mothers, who attended secondary education and higher, tend to receive almost four times AOR 3.86 [95% C.I 1.73, 8.62] better respectful maternity care, Male health providers who attended deliveries give more than two times AOR2.28 [95% C.I 1.281, 4.08] and giving birth by normal delivery or spontaneous vaginal delivery is more than two times 2.368 [95%C.I 1.12, 4.99] likely to receive respectful maternity care than their counterparts (Table 7).

Women want a positive childbirth experience that fulfills or exceeds their prior personal and sociocultural beliefs and expectations. This includes giving birth to a healthy baby in a clinically and psychologically safe environment with continuity of practical and emotional support from birth companion(s) and kind, technically competent clinical staff.

This study indicates that about 82.4% of mother reported that they have received respectful maternity care, this result is consistent with study done in Kenya 80%, Tanzania 85%, Zanzibar 88.3%.¹² And it’s greater than studies conducted in Nigeria 2% this difference might be due to, time variation related with currently accelerated RH promotion activities and women friendly programs, different supportive trainings in some health institutions of the study area.^10,13 The finding of this study revealed that average monthly income was found to be significantly associated with receiving respectful maternity care which is those who earn above the mean value that is >2282.24 ETB (65.7%) of the mothers receive better respectful maternity care (p-value= 0.035) is consistent with a study done in one public health facility and three adjacent health centers in Addis Ababa, respondents monthly income was significantly associated with a different level of disrespect and abuse (89.5% among those with a monthly income of <713 birr and 70.3% among those with monthly income of > 713 birr; p = 0.006).¹⁰

Being married were more than three times AOR 3.65 [95% C.I 1.59, 8.36]) more likely to receive respectful maternity care when compared with those who are not in marital union. This finding may be as a result of attitudinal problem resulted from having over confidence by their companion, which might have led to miscommunication with the health providers trying to keep the health facilities rule. A study done in Nigeria Mothers who are Married 420, 9 (2.1%) of them received respectful maternity care, while out of 26 Single/widowed mothers only 1 (3.8%) claimed to receive respectful maternity care.¹³

According to this study, mothers, who attended secondary education and higher, tend to receive almost four times AOR 3.86 [95% C.I 1.73, 8.62] better respectful maternity care than those who have no formal education, this is in line with studies done in Enugu, southeastern Nigeria, educational status of mothers were significantly associated, respondents who are secondary education and above were 1.5 times receive respectful maternity care than no education.¹³ this is may be related with women empowerment educated people always practice their right better than non-educated people. Male health providers who attended deliveries give more than two times AOR 2.28 [95% C.I 1.281, 4.08]better respectful maternity care than female health providers, this result is consistent with a study done in Sub-Saharan African countries, especially urban Tanzania higher likelihood of performing respectful maternity care was found among male providers in facilities. And also the same to national study implementing a quality improvement approach among laboring women accompanied by a companion indicate that male providers were more practice RMC more frequently than female providers. A clue from a study of nurses’ abuse of patients in South Africa concluded that female nurses deployed violence against patients in their work as a means of creating social distance and maintaining fantasies of identity and power in their continuous struggle to assert their professional and middle class identity again this is may be due to bad attitudes mothers have on female providers related with female providers have low competency than male provider, so they prefer to be cared by male provider what is always been observed in our facility.

Mothers gave birth by normal delivery or spontaneous vaginal delivery were twice more likely 2.368 [95%C.I 1.12, 4.99] received respectful maternity care than those who deliver by instrumental delivery (vacuum extraction or forceps delivery), this might be because of the pain and suffering the mother faces till the child is born due to this reason she might not be able to do what the health providers ask her to do, so the providers might have used force or other unnecessary actions to offend her.

Strength of the study

Because the study was done in immediate post-partum period in maternity ward, there was no problem concerning recall bias during data collection.

Limitation of the study

Not using Observational study even though it’s best to study respectful maternity care Excluding primary health facility and rural areas, because most of the problem of respectful maternal care is in rural area that results in relation to cultural, religious and social taboos and shortage of skilled provider Some variables were missed like social desirability

More than eighty two percent of the respondents or mothers in Addis Ababa public health facilities in immediate post-partum period receive respectful maternity care. Maternal income level, marital status, educational status, their mode of delivery and the sex of the provider were the independent predictors of respectful maternity care.

We would like to express our deepest gratitude to Jimma University institute of public health for giving us this opportunity to do on this area of interest. Our appreciation also goes to our data collectors, supervisors and study participants for their valuable contribution in the realization of this study.

Author contributions

MT: conceptualized, designed the study, collect, analyses and interpretation the data and also drafted the manuscript. MK: conceptualized, designed the study, collect, analyses and interpretation the data and also drafted the manuscript.

There no financial and non-financial competing interests and there was no any funding source for this study. There have been no reimbursements, fees, funding, nor salary from any organization that depends on or influence the results of this study. The authors do not hold any stocks or shares in an organization that may in any way might be affected by this publication.

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