Disrespectful Maternity Care Experiences Negatively Influence Future Intention to Use Institutional Delivery in Northern Ethiopia

Background Ethiopia has successfully increased antenatal care coverage substantially, but deliveries attended by skilled providers are still low. Disrespectful and abusive maternity care practices are believed to be among the factors deterring institutional delivery services. However, information on the relationship between women’s experience of disrespect and abuse (DA 95% CI: 30.082, 117.359). Conclusion Disrespectful and abusive experiences strongly deterred future use of maternal health services. In order to achieve the desired level of institutional delivery coverage in low- and middle-income countries, attention must be given to improve the manner in which services are offered. Keywords: Intention to deliver at a health facility, Respectful maternity care, Disrespect and abuse, Tigray, Ethiopia DOI: 10.7176/JHMN/72-01 Publication date: March 31 st 2020

the women whether they intend to deliver again in a health facility or not. Responses were categorized into two after excluding those who reported having no intention to give birth again because they already have the desired number of children. Those who intend to go to the health facility for delivery were categorized as 'having intention to deliver in health facility in the future, and the remaining were categorized as 'no intention to deliver in a health facility in the future'. The latter includes preference to deliver at home and seeking assistance from traditional birth attendants. The content validity of the tools was determined by submitting the tool to five experts. The experts were selected from public health, obstetric, sociology, law and psychology departments of Mekelle University. The selection of experts depended on the closeness of the study, experience and interest of the experts towards the study. The content was validated by the experts on a judgment basis. They were given the option of "agree" or "disagree" for each item in terms of relevance, accuracy, and appropriateness in relation to the problem of the study, objective and purpose of the study. For the option of "disagreement" or "agreement" a column of suggestion was given that would be for modification or radical change of the items.
Data were kept in a safe place for storage and processing. Data were entered using Epidata version 3.1, Data were cleaned and then transferred to SPSS version 20. The electronic data were password protected and shared only to the study team. As the outcome was dichotomous, we used logistic regression model to assess the associations between the outcome and the predictor variables, and an association was considered statistically significant at alpha 0.05 levels with 95% confidence interval. The goodness of fit of the model was checked using Hosmer and Lemeshow test and found to be good. Variables were included in multivariable logistic regression model if their p-value were either found to be less than 0.25 in bivariable logistic regression or important variable of the study.
The study subjects were given information about the objective of the study and their permission was sought. Women who visited maternity units for services were informed about the nature of the study. And informed consent was obtained from each participant before proceeding further. Talks with the village head, chief or community leaders of the villages were held to create smooth working relations in those villages. The study was scheduled and arranged as much as possible to not interfere with daily activities or invade the privacy of the participants in any way. A written contract in Tigrigna was required for verification; for those who were illiterate, a thumbprint was used for signing.

Results
Out of 1,031 women interviewed, the majority (80.2 %) of the women were between the age of 20 and 34 years of age. About 63% of them were rural residents, and 34% had no formal education. About 17% of women reported generating their own income (Table 1).
Of the total 1,031 women, 864 (84%) of them reported that a health centre was the nearest health facility for birthing, and 96 (9.3%) of them considered distance as a potential barrier to utilize delivery services. Additionally, almost 6% of them felt not at ease using a health facility for giving birth. Out of the total study subjects, 931 (90.5%) spent less than 12 hours in labour in the maternity ward of the health facility (Table 2).
Of women utilizing labour and delivery care services, 11% of them reported that, they were shouted at, about 10% of them were scolded/insulted, and 7.3% of them reported that their requests for help were ignored. About 7% of the women reported that health care providers did not share necessary information related to the procedure they were receiving. Six percent of the study subjects reported that they were left alone unattended while they were in labour and delivery, and 5.9% of the women reported that health care providers had performed procedures without informing them adequately. About 5% of women reported that they were discouraged or care providers became negative towards them. A few women (4%) reported that they were lay in an unhygienic bed/couch, and 3.7% reported that their movement was restricted for a long time. Around 2% of women reported that they felt shame for being exposed naked to others unnecessarily.
Fifteen percent of the study participants reported more than one types of D&A during their most recent experience of giving birth at a facility. Out of the total, one in ten women expressed having no intention to use a health facility for future deliveries (Table 2). Multivariable logistic regression model was used to examine the factors associated with women's future intention of using health facilities for delivery. Table 3 shows the results of multivariable analysis. In this analysis, residence, feeling at ease to visit health facilities, duration of labour at health facility, level of D&A experienced during labour and delivery were significantly associated with intention of future usage of institutional delivery.
Urban dwellers and women who reported that they felt not at ease to visit health facilities were about four times more likely to intend not to use health facility to give birth in the future than their counterparts respectively (Fig.1). Women who spent 12 hours or more in labour in the health facility were about 4 times more likely not to intend to go to health facilities for future delivery than those who spent less than 12 hours in labour. Experiences of D&A were strongly associated with intention not to use a health facility for a future delivery. Women who were abused were almost 60 times more likely not to intend to go to a health facility for future delivery than those women who were not abused ( Fig.1; Table 3).

Discussion
In our study, women's future intention to deliver at a health facility is associated significantly with experience of D&A during maternity service utilization. In addition, significant associations were found between residence, not feeling at ease to go to a health facility, duration of labour, and women's intention of future usage of institutional delivery.
About 10% of the study participants had reported no future intention to use health facilities for giving birth, perhaps due to D&A as reported by Bohren (24). According to Zahourek, intention is purposeful (25) and prompts action. If a woman does not intend to utilize a health facility for a future delivery that creates a challenge in promoting the skilled care services. Merely making health services accessible does not sustain increased usage of institutional deliveries, as accessibility does not fully guarantee service utilization (26). Service accessibility may attract and enroll new users but might not be sufficient to retain women as continuous users of the service. Several studies have shown that even women who are aware of the benefits of institutional delivery refrain from using health facilities for delivery because of perceived or experienced low quality services, including non-dignified maternity care (27)(28)(29). Such practice could be substantiated by a theory of planned behavior as it is reflected in its basic assumption that performing a certain behavior depends on the intention to perform that behavior (30), and similarly intention is influenced by other factors and either by negative or positive experience or perception.
In this study, women's intentions of not to use institutional delivery service in the future was significantly higher among women subjected to disrespectful and abusive care. When women experience D&A during labour and delivery, they may consider alternatives that can help them minimize or avoid such distressful encounters (15). Mistreatment of a woman contradicts the principle of Safe Motherhood to render woman and newborn friendly childbirth services (31). In addition, women's intention not to go to health facilities for childbirth is significantly high among urban dwellers, and women who did not feel at ease to go to the health facility. It is believed that women with education and urban dwellers know their rights and expressed their feelings more freely and may take action intentionally. It is known that women refuse care from health providers who treat them poorly, even if these providers are capable of preventing or managing obstetric or newborn complications (26). Globally, lack of friendly and culturally sensitive health services has curtailed service use, although accessibility has improved substantially by constructing new health facilities (32,33).
Furthermore, women who experienced longer labour duration (more than 12 hours) in the labour ward tends not to utilize institutional delivery in the future. As duration of labour increases, so does the length and frequency of contact between the woman and care provider/s, which could be stressful for both parties (34). Hence the level of D&A by stressed care providers may increase, or a woman experiencing stress could have a decreased tolerance to such events. Experience of D&A could be influenced from the individual (professional or woman) or from the system/environment (35). An incident of D&A may be perceived by women differently at different times. Women who encountered care providers that were not kind and understanding also reported dissatisfaction with the care they received (36,37). In this study, the quantity of incidents of disrespect and abuse during labour and delivery is similar to other study findings conducted in Kenya, Ethiopia and Tanzania (16,38,39), but it is very low Journal of Health, Medicine and Nursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.72, 2020 5 compared to other findings from Nigeria (98%) (18). Asefa and his colleagues in Ethiopia found 16% of selfreported D&A (20). D&A becomes a common practice because of the lack of local accountability of services and lack of action taken against professionals who commit the malpractice (40). The study indicated that interventions focusing on increasing service accessibility or coverage alone would not necessarily help to reach maternal and newborn mortality reduction targets (26).
As respectful maternity care (RMC) is the main essence of quality maternity care not icing on the cake, strategies ensuring practices RMC in a woman's whole care or all the time during the care. This could be done with emphasizing to prevent any incident of D & A: 1)understanding the individual woman's need/s or preference/s through small scale quantitative and qualitative researches 2)creating mechanisms to handle and manage women's complaint/s if they have any experience of mistreatment/s 3)redressing mechanism to those who are affected emotionally/psychologically/physically due to providers' treatment 4)in-service training on the needs of RMC as a core area of providers' practice 5)incorporating RMC in curricula of health science students as part of pre-service training Strengths This community-based study included participants interviewed outside heath facilities at household level and this gave them more freedom to express their feelings and report positive and negative experiences without fear. It also helped to eliminate social desirability bias (41).

Limitations
We acknowledge recall bias as a possible limitation. Though we limited the recall period to one year, this might still be considered too long to recall details of incidents of disrespect and abuse. Though the tool was developed and considered all the domains of D&A reported by Bowser and Hill (42), and contextualized to the area and study subjects, it was not validated. The study did not also consider the immediate adverse outcomes and consequences of disrespectful and abusive experiences either to the women or their babies.

Conclusions
In conclusion, future intention to use institutional delivery services is significantly influenced by the women's experience of D&A. Efforts to increase institutional delivery in low-and middle income countries need to promote respectful maternity care in all maternity related services and it is important to establish and strengthen accountability mechanisms where women can report if they experience D&A during their use of the health services. Declarations Ethics approval and consent to participate Ethical clearance was obtained from Mekelle University IRB (Institutional Review Board). The study subjects provided written consent to participate in the study after receiving information about the purpose of the study, risks and benefits, and their rights. Study subjects were also assured of privacy during the interview and confidentiality of information. Consent for publication Not applicable. Availability of data and materials IRB does not allow authors to transfer data to third party.

Competing interests
The authors declare that they have no competing interests.