Mistreatment of Women in Childbirth: Time for Action on This Important Dimension of Violence against Women.

The mistreatment of women in childbirth has been documented by researchers for over three decades in all global regions. The scale of the problem is indicated by a systematic review conducted by Meghan Bohren and colleagues [1], which provides a foundation from which a typology of violence can be developed and used as a basis for developing measurement instru-ments and tools. This is a valuable complement to other work that is currently underway in this area [2]. A multicountry study on the mistreatment of women during childbirth could be extremely valuable in generating comparable information on prevalence, risk groups and facili-ties, and the health consequences (physical and mental, including future health-seeking prac-tices and expectations). It would provide the foundation needed for developing health policy, monitoring its impact, and advocating for proper resources. Mistreatment of Women in Childbirth as a Subset of Violence against Women From Bohren and colleagues ’ systematic review, it is very easy to draw parallels between the mistreatment of women in childbirth and violence against women more broadly, and these parallels may lead us to conclude that the former should indeed be viewed as a further subse

A rapid appraisal of maternal health services in South Africa

This report is a rapid appraisal of maternal health services in South Africa. It reflects the first activity in a five-year research programme, funded by DFID. The research project is a multi-country project involving researchers from the London School of Hygiene and Tropical Medicine, (UK) Manchester University (UK) and research institutions in Uganda, Bangladesh, Russia as well as South Africa. The programme aims to develop theoretical frameworks and methodologies to better understand health system functioning in developing countries, and to apply these insights to strengthening health system development. As part of this project maternal health has been identified as a possible probe or tracer to illuminate particular features of health system functioning and performance.Funded by DFI

Local level inequalities in the use of hospital-based maternal delivery in rural South Africa

BACKGROUND: There is global concern with geographical and socio-economic inequalities in access to and use of maternal delivery services. Little is known, however, on how local-level socio-economic inequalities are related to the uptake of needed maternal health care. We conducted a study of relative socio-economic inequalities in use of hospital-based maternal delivery services within two rural sub-districts of South Africa. METHODS: We used both population-based surveillance and facility-based clinical record data to examine differences in the relative distribution of socio-economic status (SES), using a household assets index to measure wealth, among those needing maternal delivery services and those using them in the Bushbuckridge sub-district, Mpumalanga, and Hlabisa sub-district, Kwa-Zulu Natal. We compared the SES distributions in households with a birth in the previous year with the household SES distributions of representative samples of women who had delivered in hospitals in these two sub-districts. RESULTS: In both sub-districts, women in the lowest SES quintile were significantly under-represented in the hospital user population, relative to need for delivery services (8% in user population vs 21% in population in need; p < 0.001 in each sub-district). Exit interviews provided additional evidence on potential barriers to access, in particular the affordability constraints associated with hospital delivery. CONCLUSIONS: The findings highlight the need for alternative strategies to make maternal delivery services accessible to the poorest women within overall poor communities and, in doing so, decrease socioeconomic inequalities in utilisation of maternal delivery services. Keywords: Maternal health, Socio-economic inequalities, Access, Maternal delivery servicesWeb of Scienc

Prevalence of emotional, physical and sexual abuse of women in three South African provinces

Introduction. There is growing recognition in the ranks of the South African government that violence against women is a serious problem facing us all. Until now data on the epidemiology of violence against women in South Africa have been scanty. This report presents the findings of the first major community-based prevalence study.Objectives. To describe the prevalence of physical, sexual, financial, and emotional abuse of women.Methods. A cross-sectional study conducted in the Eastern Cape (EC), Mpurnalanga (MP) and the orthern Province (NP). The sample included one randomly selected woman aged 18 - 49 years living in each of 2 232 households. The sample was drawn using stratified, multistage, random methods, and 1 306 questionnaires were completed, giving a,90.3% response rate after adjusting for households without an eligible woman.Results. The prevalences of ever having been physically abused by a current or ex-partner were 26.8% (EC), 28.4% (MP) and 19.1% (NP). The prevalences of abuse in the last year were 10.9% (EC), 11.9% (MP) and 4.5% (NP). The prevalences of rape were 4.5% (EC), 7.2% (MP) and 4.8% (NP). Considerable emotional and financial abuse was also reported, e.g. the prevalences of a partner having boasted about or brought home girlfriends in the previous year were 5.0% (EC), 10.4% (MP) and 7.0% (NP). The prevailences of physical abuse during a pregnancy were 9.1% (BC), 6.7% (MP) and 4.7% (NP). The proportions of abused women who were injured in the year before the survey were 34.5% (EC), 48.0% (MP) and 60% to (NP).Conclusions. This study is the first large-scale, communitybased prevalence study to be undertaken in South Africa The main findings are that emotional, financial and physical abuse are common features of relationships and that many women have been raped. Physical violence often continues during pregnancy and constitutes an important cause of reproductive morbidity. Many women are injured by their partners and considerable health sector resources are expended providing treatment for these injuries

An investigation into mistreatment of women during labour and childbirth in maternity care facilities in Uttar Pradesh, India: a mixed methods study.

OBJECTIVES: To investigate the nature and context of mistreatment during labour and childbirth at public and private sector maternity facilities in Uttar Pradesh, India. METHODS: This study analyses mixed-methods data obtained through systematic clinical observations and open-ended comments recorded by the observers to describe care provision for 275 mothers and their newborns at 26 hospitals in three districts of Uttar Pradesh from 26 May to 8 July 2015. We conducted a bivariate descriptive analysis of the quantitative data and used a thematic approach to analyse qualitative data. FINDINGS: All women in the study encountered at least one indicator of mistreatment. There was a high prevalence of not offering birthing position choice (92%) and routine manual exploration of the uterus (80%) in facilities in both sectors. Private sector facilities performed worse than the public sector for not allowing birth companions (p = 0.02) and for perineal shaving (p = < 0.001), whereas the public sector performed worse for not ensuring adequate privacy (p = < 0.001), not informing women prior to a vaginal examination (p = 0.01) and for physical violence (p = 0.04). Prepared comments by observers provide further contextual insights into the quantitative data, and additional themes of mistreatment, such as deficiencies in infection prevention, lack of analgesia for episiotomy, informal payments and poor hygiene standards at maternity facilities were identified. CONCLUSIONS: Mistreatment of women frequently occurs in both private and public sector facilities. This paper contributes to the literature on mistreatment of women during labour and childbirth at maternity facilities in India by articulating new constructs of overtreatment and under-treatment. There are five key implications of this study. First, a systematic and context-specific effort to measure mistreatment in public and private sector facilities in high burden states in India is required. Second, a training initiative to orient all maternity care personnel to the principles of respectful maternity care would be useful. Third, innovative mechanisms to improve accountability towards respectful maternity care are required. Fourth, participatory community and health system interventions to support respectful maternity care would be useful. Lastly, we note that there needs to be a long-term, sustained investment in health systems so that supportive and enabling work-environments are available to front- line health workers

Nursing staff dynamics and implications for maternal health provision in public health facilities in the context of HIV/AIDS

This study, carried out in Limpopo, KwaZulu-Natal, and Mpumalanga provinces in South Africa, aimed to document nursing staff dynamics in maternal health services, and to explore the factors associated with these dynamics. The study found that a high percentage of nursing staff working in public facilities were demotivated, burnt out, and were considering leaving the facility where they were working. A range of factors, both financial and nonfinancial, were associated with nurses considering going overseas: inadequate pay, poor promotion, feeling unsupported by management, and having bad relationships at work were all associated with lack of organizational commitment. As a result of high numbers of nurses feeling demoralized, there is not a conducive environment for policy interventions. Policymakers need to pay more attention to how policies are implemented and the impact of policies on the relationships between nurses, and nurses and managers in facilities

A systematic review of the profile and density of the maternal and child health workforce in China.

BACKGROUND: To track progress in maternal and child health (MCH), understanding the health workforce is important. This study seeks to systematically review evidence on the profile and density of MCH workers in China. METHODS: We searched 6 English and 2 Chinese databases for studies published between 1 October 1949 and 20 July 2020. We included studies that reported on the level of education or the certification status of all the MCH workers in one or more health facilities and studies reporting the density of MCH workers per 100 000 population or per 1000 births. MCH workers were defined as those who provided MCH services in mainland China and had been trained formally or informally. RESULTS: Meta-analysis of 35 studies found that only two-thirds of obstetricians and paediatricians (67%, 95% CI: 59.6-74.3%) had a bachelor or higher degree. This proportion was lower in primary-level facilities (28% (1.5-53.9%)). For nurses involved in MCH care the proportions with a bachelor or higher degree were lower (20.0% (12.0-30.0%) in any health facility and 1% (0.0-5.0%) in primary care facilities). Based on 18 studies, the average density of MCH doctors and nurses was 11.8 (95% CI: 7.5-16.2) and 11.4 (7.6-15.2) per 100 000 population, respectively. The average density of obstetricians was 9.0 (7.9-10.2) per 1000 births and that of obstetric nurses 16.0 (14.8-17.2) per 1000 births. The density of MCH workers is much higher than what has been recommended internationally (three doctors and 20 midwives per 3600 births). CONCLUSIONS: Our review suggests that the high density of MCH workers in China is achieved through a mix of workers with high and low educational profiles. Many workers labelled as "obstetricians" or "paediatrician" have lower qualifications than expected. China compensates for these low educational levels through task-shifting, in-service training and supervision

Envisioning, Evaluating and Co-Enacting Performance in Global Health Interventions

The notion of performance has become dominant in health programming, whether being embodied through pay-for-performance schemes or through other incentive-based interventions. In this article, we seek to unpack the idea of performance and performing in a dialogical fashion between field-based evaluation findings and methodological considerations. We draw on episodes where methodological reflections on performing ethnography in the field of global health intersect with findings from the everyday practices of working under performance-based contracts in the Senegalese supply chain for family planning. While process evaluations can be used to understand contextual factors influencing the implementation of an intervention, we as anthropologists in and of contemporary global health have an imperative to explore and challenge categories of knowledge and practice. Making room for new spaces of possibilities to emerge means locating anthropology within qualitative global health research.</jats:p

Understanding the implementation of maternity waiting homes in low- and middle-income countries: a qualitative thematic synthesis.

BACKGROUND: Maternity waiting homes (MWHs) are accommodations located near a health facility where women can stay towards the end of pregnancy and/or after birth to enable timely access to essential childbirth care or care for complications. Although MWHs have been implemented for over four decades, different operational models exist. This secondary thematic +analysis explores factors related to their implementation. METHODS: A qualitative thematic analysis was conducted using 29 studies across 17 countries. The papers were identified through an existing Cochrane review and a mapping of the maternal health literature. The Supporting the Use of Research Evidence framework (SURE) guided the thematic analysis to explore the perceptions of various stakeholders and barriers and facilitators for implementation. The influence of contextual factors, the design of the MWHs, and the conditions under which they operated were examined. RESULTS: Key problems of MWH implementation included challenges in MWH maintenance and utilization by pregnant women. Poor utilization was due to lack of knowledge and acceptance of the MWH among women and communities, long distances to reach the MWH, and culturally inappropriate care. Poor MWH structures were identified by almost all studies as a major barrier, and included poor toilets and kitchens, and a lack of space for family and companions. Facilitators included reduced or removal of costs associated with using a MWH, community involvement in the design and upkeep of the MWHs, activities to raise awareness and acceptance among family and community members, and integrating culturally-appropriate practices into the provision of maternal and newborn care at the MWHs and the health facilities to which they are linked. CONCLUSION: MWHs should not be designed as an isolated intervention but using a health systems perspective, taking account of women and community perspectives, the quality of the MWH structure and the care provided at the health facility. Careful tailoring of the MWH to women's accommodation, social and dietary needs; low direct and indirect costs; and a functioning health system are key considerations when implementing MWH. Improved and harmonized documentation of implementation experiences would provide a better understanding of the factors that impact on successful implementation

Exploring inequalities in access to and use of maternal health services in South Africa

BACKGROUND: South Africa's maternal mortality rate (625 deaths/100,000 live births) is high for a middle-income country, although over 90% of pregnant women utilize maternal health services. Alongside HIV/AIDS, barriers to Comprehensive Emergency Obstetric Care currently impede the country's Millenium Development Goals (MDGs) of reducing child mortality and improving maternal health. While health system barriers to obstetric care have been well documented, "patient-oriented" barriers have been neglected. This article explores affordability, availability and acceptability barriers to obstetric care in South Africa from the perspectives of women who had recently used, or attempted to use, these services. METHODS: A mixed-method study design combined 1,231 quantitative exit interviews with sixteen qualitative in-depth interviews with women (over 18) in two urban and two rural health sub-districts in South Africa. Between June 2008 and September 2009, information was collected on use of, and access to, obstetric services, and socioeconomic and demographic details. Regression analysis was used to test associations between descriptors of the affordability, availability and acceptability of services, and demographic and socioeconomic predictor variables. Qualitative interviews were coded deductively and inductively using ATLAS ti.6. Quantitative and qualitative data were integrated into an analysis of access to obstetric services and related barriers. RESULTS: Access to obstetric services was impeded by affordability, availability and acceptability barriers. These were unequally distributed, with differences between socioeconomic groups and geographic areas being most important. Rural women faced the greatest barriers, including longest travel times, highest costs associated with delivery, and lowest levels of service acceptability, relative to urban residents. Negative provider-patient interactions, including staff inattentiveness, turning away women in early-labour, shouting at patients, and insensitivity towards those who had experienced stillbirths, also inhibited access and compromised quality of care. CONCLUSIONS: To move towards achieving its MDGs, South Africa cannot just focus on increasing levels of obstetric coverage, but must systematically address the access constraints facing women during pregnancy and delivery. More needs to be done to respond to these "patient-oriented" barriers by improving how and where services are provided, particularly in rural areas and for poor women, as well as altering the attitudes and actions of health care providers