Prevalence of disrespect and abuse and its determinants during delivery in rural Uttar Pradesh India

INTRODUCTION

Maternal mortality is unacceptably high. About 830 women die from pregnancy-or childbirth-related complications around the world every day. It was estimated that in 2015, roughly 303 000 women died during and following pregnancy and childbirth. Almost all of these deaths occurred in low-resource settings, and most could have been prevented.¹

In India over a decade considerable decline in MMR from 398 in year 1997-1998 to 130 in year 2014-2016. from the above figure as per SRS 2014-16 Assam is at the top in MMR i.e., 237 and Kerala at the bottom with 46 maternal deaths per 1,00,000 live births. Among the major states Bihar/ Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh/ Uttarakhand and Assam are more than the national figure which is 130 maternal deaths per 100000 live births.²

Even though substantial improvement in maternal health indicators in India over a decade the proportion of adolescent deaths (9%) during pregnancy or during childbirth to total maternal mortality is unacceptably very high.³ Recognizing the importance of maternal heath, the United Nations has main focused on improving maternal health in the millennium development goals to reduce maternal mortality ratio (MMR) by 75% during 1990-2015.⁴

In India, there has been a significant increase in institutional deliveries after the government launched its flagship programs Janani Suraksha Yojna (JSY) in 2005 and Janani Shishu Suraksha Karyakram (JSSK) in 2011 under the banner of the national rural health mission (NRHM). Despite the launch of such programs, the rate of institutional deliveries in India is still below desirable levels in many states in India.

There are many potential factors that could drag back a woman to utilize maternal health services in India. Financial and geographical hurdles and poor quality of care are some of the major barriers that found to have limited the maternal healthcare utilization among women.^5-7 The other potential factors that facilitate underutilization of maternity healthcare services are, perceived need of the care by woman and her cultural practices and beliefs.

Beside this, an important, but little understood component of underutilization of healthcare services among women is disrespectful and abusive behavior by health workers and other facility staffs in facilities.^8,9 In India, evidence suggests that women from lower caste and socioeconomically disadvantaged groups are treated in a non-dignified and non-consented manner.^10,11 This symbolizes the existence of biases in the healthcare system. There are also instances where women with certain individual characteristics are physically abused, neglected and abandoned, discriminated or asked to pay extra payment while undergoing a difficult phase like during childbirth.^12,13 As our literature search is conducted on disrespect and abuse of women by health providers during facility-based childbirth in the Varanasi district of Uttar Pradesh. According to the above study, the frequency of any abusive behavior (excluding inappropriate demands of money due to its high prevalence 90.5%) was 28.8%.¹⁴ Hence, there is a need to assess the frequency and nature of disrespect and abuse experienced in health care facilities by women, and explore possible associations, if any during labor and delivery.

METHODS

A community-based cross-sectional study was conducted in two blocks of Balrampur district, Uttar Pradesh, India. A population proportion formula was used to estimate the sample for the study. The expected level of disrespect and abuse of 28.8% (excluding inappropriate money demand due to its high prevalence was 90.5%).¹⁴ The 95% of the confidence interval, 7% precision, and 20% non-response rate were used to calculate the sample size of 384. The study included 384 women using the multistage cluster sampling who underwent facility-based childbirth during the last six months before the survey.

Ethical approval

Ethical clearance was obtained from the “ethical review committee” of the institute of medical sciences, Banaras Hind university, Varanasi. Respondents have explained the aim and the purpose of the study, and the interview began with written consent from each respondent.

Data collection tool

A pre-tested semi-structured schedule was used for data collection collect data. The questionnaire was prepared in English and Hindi both. Face to face interviews was conducted between April to September 2019.

Dependent variable

For this, the experiences of disrespect and abuse during labor and delivery based on 26 indicators are classified into 7 categories.

Physical abuse: Includes physical abuse, verbal abuse, supporting staff insulted, denied to give pain relief and doctor harsh.

Non-dignified care: Includes not speak politely by healthcare provider and make negative comment.

Neglect care: Leave patient left alone, not encourage to call when needed and not came quickly when needed.

Detention care: Includes forced to adopt family planning, not allow to leave due to factor of pay, refer to another hospital without citing reason and sked bribe, asked to stay back.

Non-confidential care: Includes physical barrier not used, discuss personal information in front of others and left record open.

Non-consented care: Includes attendant not encourage to remain with you, not obtain concern prior any procedure, force C section, not allow the position your choice, cloth and Macintosh not clean and female worker not present.

Discrimination: Includes disrespect based on any attribute and speak language not understand by women.

Independent variables

Socio-demographic characteristics (age, ethnicity, religion, education, and occupation etc.) and obstetric characteristics (parity, number of living children, and place of delivery).

Data analysis

The characteristics of the study population were summarized by computing univariate analysis. Bivariate analysis was conducted for the prevalence of D and A by the background characteristics of respondents. We also computed the Chi-square test of association to examine the relationship between D and A and independent variable. Finally, determinants of D and A was examined by performing a Binary logistic regression analysis of different background characteristics for the study population. If Yi is the dependent variable, Xi is a set of explanatory variables, and βi’s are the coefficient, then the logistic regression equation is-

Where p predicts the probability and log odds of p and (1-p) provide the odds ratios on the reference category. Data were analysed using SPSS trail version 25.

RESULT

Table 1 shows the characteristics of 384 postpartum women. The majority of women 59.38%, were the in-age group 15 to 34 years, 86% were married after the legal age of marriage that is 18 above years, 73% had not having a formal education, and 64% were housewife. More than half of the women were multiparous. Over three-quarters had been delivered in the same facility previously. Thirty-two percent had reported 4 and more ANC visit during last pregnancy. The 94% were reported less than 24 hours of hospital stay during the ng last delivery and 53% reported place of delivery is community health-centered.

Table 2 describes elements of D and A that women reported experiencing during their facility stay. Utmost every woman (98.5%) experienced any kind of disrespect or abuse during institutional delivery. However, 92% of women experienced non-consent care in which women were neither informed nor their verbal or written consent was taken before any medical procedures in the labor room. The 73.4% of women were detained during childbirth. While 44% (169) of women were traumatized by the experience of physical abuse during institutional delivery, which includes physical violence, verbal abuse, and insult.

Logistic regression analysis determined the association between various possible predictors of D and A and the categories of experience. Women with less than 4 ANC visits were less likely to experience physical abuse compared to women having 4 and more ANC visits during last delivery; OR: [0.4% CI (0.4, 0.7); p=0.001]. Women in the age group 25 to 34 years less likely to experience nonconfidential abuse as compared to women in age group 15 to 24 years OR: [0.38% CI (0.15, 0.92); p=0.033]. Women living in nuclear families, were 2 times more likely to face the incidence of non-confidential abuse as compared to women living in joint families; OR: [2.4 (1.3,4.8); p=0.008]. Women who delivered the last three or four deliveries in public facility ten times more likely to face consent abuse as compared to the women who delivered the last one or two deliveries in health facilities; 10.21 (1.71,60.9); p=0.011. Women who were married after age 18 and above years are more likely to face neglected care as compared to the women who were married before 18 years; OR: [2.7 (1.04,7.2); p=0.04] (Table 3).

Women from other religion 2.5 times more likely to get dignified abuse as compared to women of Hindu religion OR: [2.5 (1.29, 4.49); p=0.007], 32 (0.13, 0.69) p=0.005, (Table 4).

Women who were married after age 18 and above years are less likely to face discrimination as compared to the women who were married before 18 years; OR: [0.32 (0.13, 0.69); p=0.005]. Women in the age group 25 to 34 years are less likely to experience detention as compared to women in the age group 15 to 24 years OR: [0.39% CI (0.18, 0.87); p=0.023]. Women with less than 4 ANC visits were more likely to experience detention compared to women having 4 and more ANC visits during the last delivery; OR: [1.95% CI (1.1, 3.47); p=0.022].

*Denotes a statistically finding a p<0.05.** Reference category and NA -refers to cases where statistical analysis could not performed.

*Denotes a statistically finding a p<0.05. **Reference category and NA -refers to cases where statistical analysis could not performed.

DISCUSSION

Increasing institutional delivery and providing respectful maternity care is one of the main focuses of the maternal health program of the Indian government. Encouraging respectful maternity care during childbirth is a vehicle to utilize maternity services and also prevent maternal morbidity and maternal mortality rate. Throughout the world various study documented the incident of abuse and disrespect during maternity services utilization. Making respectful maternity care is global agenda. This study aimed to find out the prevalence of disrespectful and abusive behavior during institutional delivery.

In this study, the prevalence of disrespectful maternity care during facility based child birth is very high in the study population. Utmost every woman (98.5%) experiences any kind of disrespect or abuse during institutional delivery. Similar to the studies was conducted in Pakistan and Nigeria also found that almost all women (99.7% and 98%, respectively) experienced at least one type of abusive behavior or disrespect during delivery.^15,16 However, the overall disrespect and abuse reported during facility-based childbirth was 29% in a study conducted in Uttar Pradesh, India.¹⁴

However, 92% of women experienced non consent care in which women were neither informed and nor their verbal or written consent were taken before any medical procedures in the labor room. which was similar to a study conducted in Gujrat, Pakistan in which it is mentioned that the most commonly experienced disrespect and abuse was non-consented care and lack of informed choice (99.7).¹⁷ 73.4 % of women were detained during child birth. While 44% (169) of women were traumatized by experience of physical abuse during institutional delivery, which includes physical violence, verbal abuse, insult etc.

Disrespect and abuse during labor and delivery were significantly associated with age group, religion, level of education, age at marriage, place of delivery, No. of ANC visit etc. The finding was consistent with studies conducted in Kenya and in which age group, and parity were the predictors of disrespect and abuse.¹⁸

However, there are limited studies related to women related to disrespect and abuse during childbirth in India. The findings of the study might be the basis for intervention to enhance respectful maternity services. The findings of the study might

be useful to maternity care providers. The limitations of this study are respondents who received maternity healthcare services in the health facilities in the last six months were requested to report any disrespectful and abusive healthcare, so there could be a possibility of a loss of memory of respondents about the eventualities during childbirth.

CONCLUSION

Our study shows that the occurrence of disrespect and abuse during childbirth was very high. almost every woman reported at least on the incidence of abuse and disrespect during delivery. The effort made by civil society, government and other international organizations are yet not sufficient to restricted the abuse and disrespect during delivery. There is a normalization of the issue under study in the community. Thus, efforts have to be put in place using the mass media forum to educate women about the rights that are compelled during childbirth and Alike citizen charter, respectful maternal care charter may be installed in health facilities to educate women and the community about the components of respectful maternity care.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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