From a total of 86 women their experience observed during labour and after delivery; the majority 46 were from rural/ semi urban areas, most women were 28 were in the age group 25-29, regarding their educational status most 25 women had secondary education , 19 were illiterate and 10 had university degree (Table 1).
Table 1
Distribution of participants based on Sociodemographic characteristics.
Characteristics
|
Participants
|
Total
|
Labour
|
Postpartum
|
Number = 53
|
Number = 33
|
Number = 86
|
Address
|
|
|
|
Urban
|
27
|
13
|
40
|
Rural/Semiurban
|
26
|
20
|
46
|
Age
|
|
|
|
18-19
|
5
|
7
|
12
|
20-24
|
13
|
10
|
13
|
25-29
|
20
|
8
|
28
|
30 and above
|
15
|
8
|
23
|
Educational status
|
|
|
|
Illiterates
|
10
|
9
|
19
|
Primary
|
12
|
5
|
17
|
Junior secondary
|
9
|
6
|
15
|
Secondary
|
16
|
9
|
25
|
University Diploma degree
|
6
|
4
|
10
|
Para
|
|
|
|
Primipara
|
29
|
18
|
47
|
Multipara
|
21
|
10
|
31
|
Grand multipara
|
3
|
5
|
8
|
Themes identified from participate observation field note
Three categories of themes were identified from the analysis of participant observation field note; D&A themes, contributors themes and respectful themes. (Figure 1)
Disrespect and abusive experience of women
Themes identified as D&A included physical abuse, poor communication, non-consented care, lack of privacy, lack of confidentiality , loss of autonomy, neglected care, and lack of companion.(Figure 1).
Physical abuse
Episiotomy without local anaesthesia was identified as D&A themes under the category of physical abuse. During their admission for labour and childbirth, the women experienced painful procedure that this study categorized as physical abuse. Some procedures, such as episiotomy, were performed without local anaesthesia while the women felt and verbalized pain. The following field note indicates such an occasion.
A provider was monitoring a woman in labour, when she suddenly pushed down and the baby came at the external genitalia.... Then, the provider put on a pair of surgical gloves, took scissors from the pack of equipment, and made an episiotomy without local anaesthesia. The woman yelled, moving away from him… (Field note, Observation of labor (OBL) 02)
Poor communication
Poor communication included interactions that undermine the woman’s preference or need, such as women’s urge or need to change their position, to know discharge time, and their request for beddings and birth companions. In some observed women’s requests, the provider did not respond to the women in an acceptable manner.
A woman asked a midwife, “Please give me beddings?” The midwife laughed at the woman and she said, “No, we don’t have beddings”. (Field note, post-natal observation (PNO- 06)
Rather than explaining the reason for not allowing a companion, the provider responded to the women with inappropriate words that undermine the woman’s concern.
A woman asked a health care provider, “Please allow one attendant to assist me on baby care—I cannot take care of my baby because my hands are dirty and this intravenous fluid lines restricts my movement”. The provider replied, “Do not talk too much. I told you before, we cannot allow attendant for the women in this unit”. (Field note, PNO -11)
Non-consented care
Clinical procedures and physical examinations were performed on women without providing information to the women or asking their permission. For instance, women were not informed about the purpose, risk, and benefits of procedures such as physical examination medication, lab investigation and caesarean section. Usually, before procedures and examinations, the provider only requests the women to comply for intended procedures. As the following field note indicates, procedures were performed abruptly without notifying the women.
During the admission of a woman to the first stage room, the health care provider monitoring her labour said to her “Open your legs and uncover your lower body part”. The woman opened her legs and undressed her lower body part. He took one surgical glove from the bedside table, put it on one of his hands, and performed a vaginal examination. ((Field note, OBL-28)
Sometimes, providers performed procedures on women during labour without notifying them. Women recognized it when they felt the pain, as the following field note indicates.
A provider assisting in a woman’s delivery consistently encouraged her to push with each contraction. Suddenly, he took a scissor from the equipment set and performed an acute episiotomy incision on the woman’s perineum. She cried and moved away from him.
Some women were requested to sign written consent forms without sufficient information for caesarean sections. For instance, a provider informed a woman of his decision and immediately insisted she signed a written consent without asking for her agreement.
After performing a physical examination of a woman…..Subsequently, he said to her, “To save the life of your baby, we need to perform a surgical procedure”. Then, he attached the informed consent form to her clinical record. Addressing her, he said, “Put your signature here,” and she signed the consent form. (Field note. OBL- 16)
Lack of privacy
Women’s physical privacy was not protected during labour and delivery. For instance, in the labour ward, procedures, and examinations were performed on women in an open space. Also, women were repeatedly uncovered during physical examination in the view of others. In the case of unpredicted second stage of labour, women’s delivery was assisted without a privacy
In a shared room, a provider put on surgical gloves and said to a woman, “Lay down on your back and bend your leg”. The woman did as instructed, and the provider performed vaginal examination in the presence of other women and health care providers. (Field note OBL-01).
Lack of confidentiality
Providers unintentionally violated women’s confidentiality during labour and delivery. The health care providers discussed women’s health status, including HIV status, in a shared ward with their co-workers, as the following field note indicates.
One of the health care providers said to his co-workers, “She is an RVI case; take care of yourself”, while referring to a woman admitted to the labour ward. After 45 minutes, a midwife came from another room and asked the providers, “Which one of these women is reactive?” One of the residents showed the midwife the bed to which the woman had been admitted. (Field note. OBL-30)
Loss of autonomy
Women were not involved in decision-making for procedures during labour and delivery. For instance, they did not request a provider’s explanation about procedures. However, they responded to all instructions when providers asked them to adopt a position for subsequent procedures. Sometimes, the women’s concerns about mobility were ignored.
After a woman was transferred to the delivery bed, a provider awaiting the birth of her baby for one hour said to his co-worker, “I need forceps to assist her”, referring to the woman. Then, said to her, “I am going to assist you”. The woman did not respond to him before he subsequently applied his forceps and assisted her delivery. (Field note. OBL-29)
Neglected care
Women’s need for supportive care during labour and delivery was neglected. Specifically, women’s comfort, hygiene, post-partum care, and postoperative care were neglected. The following field observation note of recovery rooms indicates the neglect of women’s intravenous fluid lines after caesarean sections. For instance, intravenous fluid tubes were left open while connected to empty fluid bags.
A woman’s attendant in a recovery room said to a health care provider, “Please change this intravenous fluid bag”, pointing to an empty fluid bag. However, the provider left the room without responding to the attendant’s concern. (Field note, recovery room observation (RRO) 01)
Further, post-operative clinical care of the women was neglected, including laboratory investigations that needed immediate clinical intervention.
A woman’s attendant said to a health care provider, “My daughter is Rhesus negative. She has medications to take after she receives the result of her baby’s laboratory test results. However, a blood sample was not taken from her baby.” The provider responded, “Inform another health care provider”, and left the room. (Field note, RRO -02)
Women’s comfort after delivery was neglected for clinical monitoring. For example, some women stayed on the delivery bed for more than two hours for observation.
A postnatal mother said to a health care provider, “Please transfer me to another room”. Again, she said, “You see I cannot extend my leg on this bed and did not sleep throughout last night because of the cry of other women in labour”. The provider did not respond to her concerns. (Feld note, PNO -01)
Lack of companion
Birth companions were not allowed in the labour and delivery room. For instance, women’s attendants were told to stay outside the labour room until the women were transferred to postnatal rooms.
When a woman reached the labour room, a provider told her to lie down on her back, pointing to a bed in the labour room. He then told the woman’s companion to stay outside, and immediately, the companion left the room. (Field note, OBL 47).
Contributors to D&A
Contributors to D&A during childbirth were classified into three main categories: provider-related factors, health facility-related factors, and women-related factors. (Additional file 1)
Provider-related contributor
Provider-related contributors include lack of respect and lack of collaboration among health care providers working on the same women.
Lack of respect among providers
Health care providers did not respect each other while they were in the same unit and working for the same women. For instance, residents did not use midwife assessment findings for women care. Sometimes, while the midwife monitored labour, residents interrupted them without asking for an excuse to interrupt. Similarly, sometimes the midwife ignored the resident’s verbal orders.
While a midwife was monitoring a woman in labour, a medical resident came in and told the woman to lie down in her back. The woman laid down in her back and the midwife left the place for the resident. Subsequently, the resident performed a physical examination of the woman. (Field Note, OBL-03)
Lack of communication and collaboration
There were no formal communications between the midwives and the residents about the women’s clinical condition. For instance, a midwife was not involved in clinical communications about diagnosis, obstetric decisions and case handover. Such practice of providers contributing to D&A included unnecessary examinations and neglected care.
The resident performed an examination of a woman who cried due to labour pain in a shared labour ward and moved to another woman. After 10 minutes of his examination, a midwife came to the same woman. She performed the same examination and left the room. (Field note OBL 10).
Health system-related contributors
Health system-related contributor themes included poor human resource management, scarcity of equipment and supplies, and wastage of supplies.
Poor human resource management
Subthemes included a lack of recognition of professional skills, overburdened responsibility, lack of supportive supervision and inconsistent supervision of trainees.
Lack of recognition of professional skills
Lack of recognition of professional competencies of some health care providers contributed to D&A. Health care professionals from different disciplines were assigned to the same labour ward; however, some of them worked below their professional scope of practice. For instance, midwifes were not regularly involved in monitoring labour, conducting delivery, or in shift handovers. They were more engaged in equipment preparation and discharge procedures, even during high case load time. This culture of the facility caused midwives to ignore the women’s obstetric care needs and focus on other tasks, as in the following field note:
While a medical student was monitoring a woman in labour, spontaneously, the woman pushed down and delivered on her bed. He did not anticipate the imminent birth and was not prepared for it. At the same time, four midwives were preparing gauze in a room that linked with the labour ward. (Field note, OBL-02)
Some of the midwives focused more on equipment preparation than clinical care. For instance, a midwife could postpone medication time to prepare delivery equipment. This included medications for preventing convulsion.
A resident asked a midwife to administer MgSO4 to a mother; the midwife replied affirmative, although she continued with her equipment preparation. After 40 minutes of the verbal order, another resident asked if MgSO4 had been given to the mother. “Who gave her the medication? By whom and when?” The first resident replied, “Sr. X has given to her”, referring to the midwife. But the medication had not been given to the woman. The midwife returned after she was finished with the equipment preparation to administer the MgSO4 to the mother. (Field note, PNO-21)
Overloaded responsibility
Some health care providers took part in most of the tasks carried out in the labour room. For instance, the residents evaluated women at admission, monitored, and conducted all types of delivery. Thus, the work burden on them contribute to non-consented care, neglected care and rushed procedures.
Four medical residents were assigned to a labour room. Two of them worked in the operation theatre on a woman with obstetric complications. One of the residents assisted another woman in delivery. The last resident alone monitored five women admitted to the first stage room. (Field note, OBL- O6)
Inconsistent supervision of trainees
Trainee assignments with inadequate supervision contribute to D&A. When residents were occupied with other emergency tasks, students monitored women in labour with full responsibility and subsequently failed to detect imminent birth. Therefore, they performed episiotomy without local anaesthesia and conducted delivery without physical privacy.
While a medical student monitored a woman’s labour, she pushed downward spontaneously and the baby’s head became visible. However, the student did not anticipate imminent delivery and was not prepared for it. Afterward, he put on surgical glove, performed episiotomy without local anaesthesia, and assisted the delivery without privacy curtains. (Field note, OBL-02)
Lack of supportive supervision
Lack of supervision contributed to D&A. Some health care providers were not present at their assigned workplace, and available providers were overstretched to cover an entire unit’s tasks. As a result of their high workload, the available health care providers ignored some of the women.
A resident was assigned to monitor women labour admitted to two labour rooms. He came to a woman in one of the labour rooms and checked foetal heart rate. At the same time, a test tube was placed on her bed for a routine blood tests; however, he could not take the sample from the woman. (Field note, OBL-17)
Some health care providers intentionally reported wrong diagnoses to postpone their responsibility for the next shift provider. Such practice of providers resulted in unexpected delivery without privacy and dignity in which women’s bodies were exposed to other women admitted to the same room and health care providers.
During a shift handover, a woman’s labour had been reported as latent first stage of labour. However, after 15 minutes of the handover, she delivered her baby on her bed in a shared room in the presence of other women (Field note, OBL-24).
Scarcity of equipment
Scarcity of equipment resulted in D&A in the form of abandonment of timely care, lack of hygienic care, and unnecessary procedures. For instance, a shortage of sterile surgical equipment and operating theatre tables frequently delayed emergency caesarean sections for 15–30 minutes. Scarcity of vital sign equipment affected regular monitoring after delivery. Sometimes woman insisted on leaving her own bed for another woman in advanced labour after her admission. When she refused, the providers talked to her rudely, insisting she complied. In the following field note, shortage of maternity operation theatre table and scarcity of sterile equipment delayed emergency caesarean section and resulted in a fatal consequence
A resident identified that the cord was blocking a second twin after he assisted a woman’s first twin. He immediately instructed the woman to adopt the knee-chest position. His co-worker informed the operation theatre team about an emergency case that required an urgent caesarean section. However, the maternity operation theatre table was occupied by another woman. To expedite access, the health care providers informed the major operation theatre unit responsible person of the mother’s situation, who, unfortunately, responded that sterile equipment was not ready. (Field note - OBL 31)
Scarcity of equipment used in assisting delivery, such as obstetric forceps and vacuum extractors, resulted in unnecessary caesarean section. Sometimes the essential equipment was not ready for use, and providers became aware of the unavailability of the particular equipment when he/she wanted to use it, as demonstrated in the following field note.
A resident had decided to assist a woman labour with obstetric forceps and asked the mid wife to retrieve them. She responded that the forceps were sent to another unit for sterilization. The midwife left the room to bring the forceps from the autoclave that was located in the major operation theatre. She came back after a few minutes and told the resident the equipment was not ready for use. He then requested a vacuum extractor in place of the forceps. The midwife brought him a vacuum extractor, which, when subsequently applied, was not functional. Finally, he decided to assist the delivery with a caesarean section. (Field note, OBL 48)
Scarcity of supplies
Scarcity of supplies caused women to stay in unhygienic and non-dignified conditions of labour rooms. Most women in the labour ward stayed without beddings, sometimes undressed, or with their soiled clothes, and in some rare circumstances, admitted to the bare floor. The majority of the women were admitted without bedding in the labour and postnatal wards, as the following field note indicates.
A health care provider instructed a woman to lie down in her back on some bed. The bed was without beddings, and its mattress was covered with a plastic sheet. (Field note, OBL- 01)
Wastage of supplies
Wastage of supplies resulted in shortage and subsequently contributed to D&A. For instance, new bed sheets were cut into small pieces to pack equipment, and after a single use, they were used to wipe blood from the floor. Stained and difficult to reuse, such patterns created wastage of bedding in the labour wards. The following field note indicates this practice.
A cleaner placed some gowns and bed sheets to cover some blood splashed on the floor, and she stood on it. Subsequently, she wiped blood from the bed with pieces of the bed sheet. (Field note, OBL-14)
Women-related contributors
Passivity
Women were passive participants in the care they received during labour and delivery. Most of the women did not ask providers for information about examinations and procedures. The providers simply instructed them to adopt certain positions for each subsequent procedure without informing them.
A health care provider told a woman to uncover her abdomen and flex her leg. The woman uncovered her abdomen as she was instructed. He examined her abdomen and listened for foetal heart rate with a fetoscope. Then, he put on surgical gloves and asked the woman to open her legs, which she did as he proceeded to a vaginal examination. (Field note, OBL 02).
Respectful care
Some provider practice and facility culture were considered as respectful care, such as being with the women during labour, timely clinical care at admission, supportive care, and provider collaboration in obstetric emergency. Respectful facility culture includes birth companion after deliver and free maternity service.
Being with the women
At least one health care provider—a medical intern or resident—are often assigned to a woman in labour. In most cases, at least one trainee monitored the women throughout their labour. Thus, women were not left alone during their labour and delivery.
He [health care provider] sat on a chair close to a labouring woman’s bed, placed his hand on her abdomen and counted uterine contractions. He repeated the same examination at regular intervals. (Field note. OBL- 03)
Timely clinical care
Women receive timely clinical care throughout their stay in the labour ward. In majority of women provider evaluate their clinical condition throughout their labour and provide clinical care according to women need without delay unless constraints beyond provider was present during women admission.
Supportive care
Some women received supportive care from the health care providers after delivery. For instance, some health care providers brought clothes, food, and fluid from the women’s attendants at the reception and accompanied the women during transfer from the labour room to the postnatal room.
When a day shift midwife came close to the postnatal mother, the mother requested, “Please bring me clothes from my relatives waiting at the reception. The provider went to the labour ward entrance, collected some clothes from the woman’s attendant, and brought them to her. (Field note. PNO-14)
Teamwork in emergency
In emergency situations, women receive collaborative care from health care providers. Such practice was common in emergency cases such as uterine rupture. Residents collaborated with midwives and nurses to save the lives of the women.
The physician who was assigned to the room immediately transferred the woman from a stretcher to a bed. One health care provider took the obstetric history of the woman and another measured vital signs. Subsequently, other health care providers opened two intravenous lines through her arms and initiated the fluid. (Field note. OBL- 26)
Respectful facility culture
Respectful facility culture includes birth companion after deliver and free maternity service.
Postnatal companion
For women admitted for delivery, a birth companion was allowed after they were transferred to the postnatal ward.
After a woman changed her soiled clothes, the midwife transferred her to the normal postnatal room and called for one birth companion from the woman’s relatives to stay and assist her. (Field note. PNO - 10).
Free maternity service
Women did not have to pay for maternal health services such as spontaneous delivery, caesarean section, instrumental delivery, or medications. Therefore, women were not detained for lack of payments. Usually, at discharge, they were given a letter of clearance that allowed them to leave the facility without receipt showing payment.
A midwife provided a letter to all postnatal mothers at discharge that authorised them to go home without payment for the received service.