Obstetric Violence and its Associated Factors Among Women Attending Intrapartum Care at Public Health Facilities of Addis Ababa, 2023.

doi:10.21203/rs.3.rs-4902485/v1

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Obstetric Violence and its Associated Factors Among Women Attending Intrapartum Care at Public Health Facilities of Addis Ababa, 2023.

https://doi.org/10.21203/rs.3.rs-4902485/v1

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BACKGROUND: -Intrapartum violence and abuse create psychological distance between women and care providers and then drive women away from formal health care systems in fear of being subjected to such violence; these violence and abuses are sometimes more prominent hindrances than geographical or financial barriers to maternal health service utilization.

OBJECTIVE: This study aimed to assess the prevalence of obstetric violence and its associated factors among women receiving intrapartum care at public hospitals in Addis Ababa, Ethiopia,2023.

METHODS: An institution-based cross-sectional study was conducted at six hospitals in Addis Ababa, Ethiopia. A total of 423 postpartum mothers were included in this study. Study participants selected using systematic random sampling. An interviewer-administered questionnaire was used to obtain necessary information on the sociodemographic characteristics of the participants, health system-related factors, obstetric-related factors and intrapartum obstetric violence-related questions. To maintain data quality, a pretest was administered at another site, and the data were checked for completeness, cleaned and entered into Epi-Data version 3.1 and exported into SPSS version 25 for analysis. The descriptive part was presented in tables and figures. A bivariable binary logistic regression was used to identify potential candidate variables (p<0.25) for multivariable binary logistic regression analysis. Basic assumptions for binary logistic regression were made, and model fitness was checked before running multiple binary logistic regression analyses. To control for potential confounding variables, multiple binary logistic regression analyses were performed, and the regression results are presented as the mean odds ratio (COR) and AOR with 95% CI, with a p value less than 0.05 indicating statistical significance.

RESULTS: The magnitude of intrapartum obstetric violence was 56.5%. The findings of the study showed that age (AOR: 6.4, 95% CI (2.76, 14.89), occupation (AOR: .15895% CI (.072, 346), number of ANC visits (AOR: 7.2095% CI (2.66, 19.52), duration of hospitalization at HFs (AOR: 6.57, 95% CI (2.95, 14.64), duration of assisted delivery (AOR: .424, .227, .791), and sex of health professionals who attended (AOR: 2.14, 95% CI (1.07, 1.28)) were factors associated with intrapartum obstetric violence.

CONCLUSION AND RECOMMENDATION: The magnitude of intrapartum violence was high. Any responsible body should intervene in these factors.

Intrapartum

violence

obstetric violence

Addis Ababa

BACKGROUND

In 2014, the World Health Organization (WHO) defined obstetric violence as disrespectful and offensive treatment that represents a considerable lack of respect and includes the following: “physical abuse, profound humiliation and verbal abuse, coercive or unconsented medical procedures (including sterilization), lack of confidentiality, failure to get fully informed consent, refusal to give pain medication, gross violations of privacy, refusal of admission to health facilities, neglecting women during childbirth to suffer life-threatening, avoidable complications, and detention of women and their newborns in facilities after childbirth due to inability to pay” (1)

Obstetric violence (OV) is a form of gender-based violence (GBV) that targets pregnant and childbearing women during and beyond the intrapartum period; this violence violates human rights and evidence-based medicine and hinders the delivery of respectful maternity care (RMC) (2,3)

Violence against women is largely recognized as a major human rights abuse and a significant public health problem with multiple adverse physical, mental, sexual, and reproductive health effects(4,5). A universal human right declares that every childbearing woman in every health system around the world should practice respect and compassionate care as part of their basic human rights, including respect for women’s autonomy, dignity, feelings, and choices(6).

Obstetric violence during facility childbirth includes physical abuse, lack of consent for care, nonconfidential care, undignified care, abandonment, discrimination, and detention in facilities for failure to pay user fees (7). Disrespectful delivery care is a type of obstetric violence that threatens human rights to respectful and discrimination-free care(4). Disrespectful and abusive care has seven forms, including physical abuse, non-consented care, non-dignified care, nonconfidential care, discriminated care, abandonment, and detention in facilities (8).

The World Health Organization (WHO) defines compassionate and respectful maternal care (CRMC) as the right of every woman to attain the highest standard of health, which similarly includes the right to dignity compassionate and respectful health care to all childbearing women worldwide throughout pregnancy, childbirth, and the postnatal period(1,9).

STATEMENT OF THE PROBLEM

During childbirth, many women face rude and harsh treatment at facilities worldwide. Such treatment not only violates women's rights to respectful care but also puts their lives, health, physical integrity, and freedom from discrimination at jeopardy. On this crucial public health and human rights issue, this statement urges more action, dialog, study, and advocacy(1).

Obstetric violence and abuse during childbirth are worldwide issues, but they are especially prevalent in low-income countries such as Sub-Saharan Africa(10–14). Increased STIs, preterm labor, vaginal bleeding, placental abruption, cesarean delivery, hemorrhage, and infection have all been linked to maternal physical health outcomes throughout pregnancy and delivery(15).

Obstetric violence during the intrapartum period is difficult to notice because of its gendered, structural, and institutional nature, as well as its pervasive normalization and embedding in health systems and sociocultural norms(16). The World Health Organization (WHO) reported that the majority of women are mistreated by their birth attendants (1). Obstetric violence seems to be widespread throughout the world, with reports ranging from 18.3% (17)to 75.1% (18). A systematic review conducted in Ethiopia showed that 50% of mothers were disrespected while giving birth at public institutions(19), ranging from 98.9% to 21.6% in Ethiopia(20).

Intrapartum violence and abuses create a psychological barrier between women and care providers, driving women away from formal health care systems in fear of being subjected to such violence; they are sometimes more significant impediments to maternal health service utilization than geographic or financial barriers(21,22). Maternal mortality and morbidity are serious public health concerns that have devastating impacts on children, families, and communities worldwide(23–25).

Sustainable Development Goals 3 aim to reduce maternal mortality to less than 70 per 100,000 live births. However, this ambitious goal cannot be achieved unless the quality of the services is improved (26,27). In July 2019, the United Nations General Assembly issued an important report that noted the situation of violence against women in reproductive health care services, which particularly emphasized attention at childbirth and OV, and this report emphasized the mobilization that is taking place in many countries against such abusive practices. It proposes adopting a human rights-based approach to the various forms of abuse that women have suffered in the context of childbirth by insisting not only on violating women's rights to live a life free from violence but also jeopardizing their right to life, health and women's health. Their physical integrity, intimacy, independence and right to nondiscrimination.(17)

The Ethiopian Federal Minister of Health has adopted a new compassionate and respectful care (CRC) approach and started providing in-service training to all health care providers(8). The five-year progression plan, called the Health sector transformation plan, involved personalizing a compassionate respectful care initiative and offering sector-wide training for health care providers, including addressing the issue of respectful maternity care(28,29). The WHO intrapartum care guideline recommends respectful maternity care for all women, which is care that maintains “dignity, privacy, and confidentiality; ensures freedom from harm and mistreatment; and enables informed choice and continuous support during labor and childbirth(30). In Ethiopia, interventions such as maternal waiting homes in health facilities, free services and transportation, pregnant women conferences, and media advocacy campaigns were introduced to increase the quality of delivery. Despite the intervention, 26% of the delivered women indicated problems with the quality of care(31).

The presence of obstetric violence has been associated with factors and determinants such as marital status, age, educational level, socioeconomic level, employment status, race, parity, history of miscarriage, sex and professional category of the person attending the birth, type of delivery, and the public or private nature of the childbirth center(32–37). Additionally, different clinical practices, such as giving birth on the delivery table in the lithotomy position, performing an episiotomy without the woman's consent, pressureing on the uterine fundus, or carrying out vaginal examinations without the woman's permission, are associated with a greater perception of obstetric violence (36). Therefore, this study aimed to assess the prevalence and associated factors of OV among intrapartum women in public health hospitals in Addis Ababa, Ethiopia.

SIGNIFICANCE OF THE STUDY

Intrapartum violence during childbirth is common and has adverse health consequences for women and potentially for their fetus; however, very few studies have examined such abuse in developing countries, including Ethiopia. Despite its importance in fighting violence, there are fewer evidence-based documents on violence against child birth women in the county, and these reports are produced by policy planners, decision makers and nongovernmental organizations. Considering the importance of this topic, this study contributes to providing insight into the effects of intrapartum violence during childbirth. This approach will help individuals to contribute to their own profit and provide insight into the effect of intrapartum violence on adverse delivery outcomes, and it will also be used as a baseline for further studies.

OBJECTIVES

GENERAL OBJECTIVE

To assess the prevalence of obstetric violence and its associated factors among women attending intrapartumcare at public hospitals in Addis Ababa, Ethiopia, 2023

SPECIFIC OBJECTIVES

To determine the prevalence of obstetric violence among women attending intrapartum care at public hospitals in Addis Ababa, Ethiopia,2023

To identify the factors affecting obstetric violence among women receiving intrapartum care at public hospitals in Addis Ababa, Ethiopia, 2021

STUDY AREA AND PERIOD

The study was conducted from May to June 2023 in Addis Ababa, Ethiopia. Addis Ababa is geographically located at 9°2' North and 38°42 East. As a capital city of the Federal Democratic Republic of Ethiopia, it is located almost at the center of the country. The Addis Ababa City Administration is divided into Eleven subcities: Addis Ketema, Akaki-Kaliti, Arada, Bole, Gulelle, Kirkos, Kolfie-Keraniyo, Lideta, Nefas Silk-Lafto, Yeka and Lamikura Subcity. Seven hospitals owned by the Addis Ababa Health Bureau, 5 by the Federal Ministry of Health, 1 by Addis Ababa University, 3 by the nongovernmental organization, 3 by the defense force and police and 34 by private owners were included. There was an average delivery of 3338 deliveries per month in Addis Ababa city administration public hospitals.

STIMY DESIGN

A facility-based cross-sectional study was also conducted.

POPULATION

SOURCE POPULATION

All intrapartum women seeking service in public hospitals in Addis Ababa

STUDY POPULATION

All women who gave birth in selected public hospitals in Addis Ababa fulfilled the

The inclusion criteriafor individuals in the year 2023 were as follows:

ELIGIBILITY CRITERIA

INCLUSION CRITERIA

All pregnant mothers who were admitted to the hospitals for labor and delivery services during the data collection period

EXCLUSION CRITERIA

Those mothers who were critically ill and unable to complete the interview

SAMPLE-SIZE DETERMINATION AND SAMPLING TECHNIQUE

SAMPLE-SIZE DETERMINATION

The sample size was determined using a single population proportion formula by considering 50% prevalence because there was no similar study on intrapartum violence among the laboratory mothers, and the assumption of a 95% two-sided confidence interval and 5% margin of error was used to determine the sample size. Therefore, the above assumptions were entered into the formula:

Were

P = proportion of intrapartum violence, 0.50

d = Margin of sampling error - 5%

A (Z a/2) = Critical value at 95% confidence interval of certainty (1.96)

By adding a nonresponse rate of 10%, the sample size was reduced to 423.

The final sample size for this study was 423.

SAMPLING TECHNIQUES/PROCEDURE/

To obtain the required information from the study subjects, a systematic random sampling technique was used. All public hospitals in the Addis Ababa city Administration were included. The study participants were allocated proportionally based on the number of last month deliveries (March, 2023) in each hospital. Finally, the study subjects were selected by systematic random sampling based on the card number of the women by using the registration book as the sampling frame. Dividing the total duration of delivery by the sample size (3338/423) gives a sampling fraction (K) of 8. Therefore, laboratory mothers were interviewed every 8 times until a total sample size of 423 was reached. The primary study subject was selected using lottery methods by preparing random numbers from 1 to 8.

STUDY VARIABLES

DEPENDENT VARIABLE

Intrapartum obstetric violence

INDEPENDENT VARIABLES

Sociodemographic and economic variables of the family
Age of the mother, Marital status, Religion, Ethnicity, Education attendance, Occupation, Family monthly income, Residence
Obstetric characteristics of participants
ANC follow-up, place of ANC, ANC received from, number of ANC visits, gravidity, parity, history of previous institutional delivery, route/type of current delivery, preferred birth position, labor was augmented/induced, time of delivery, and number of days spent at the hospital before delivery
Health care provider-related factors
Number of birth attendants, main birth attendants, sex of the main birth attendant, profession of birth attendants, type of health facility, and provider experiences

OPERATIONAL DEFINITIONS AND TERMS

Obstetric violence during facility childbirth includes physical abuse, lack of consent for care, nonconfidential care, undignified care, abandonment, discrimination, and detention in facilities for failure to pay user fees (7)
Intrapartum obstetric violence (IOV): Women who replied ‘yes’ to at least one form of OV from seven forms, such as physical abuse, nonconsented care, nonconfidential care, nondignified care, discriminated care, neglected care and detention in the health facility, were labeled as having IOV(18).
Verbal abuse: Use of harsh language and threat and blaming, such as Provider, use harsh/rude language—judgmental or accusatory comment—threaten or blamed(50).
Physical abuse: The presence of at least one of the following activities by the care provider on the client: beating, threatening with beating, slapping, pinching, restraining or tying down during labor, cutting or suturing of episiotomy cuts or perineal tears without the use of anesthesia and the use of fundal pressure to fasten the delivery of the baby. A woman who answered ‘yes’ to at least one of the criteria was considered to be physically abused at the time of labor and delivery(18,50,51).
Nonconsented care: The presence of at least one of the following: providers not giving women or her relatives proper information about medical procedures; not asking for women’s permission to conduct medical procedures such as cesarean sections, episiotomies, hysterectomies, blood transfusions, tubal ligation, or augmentation of labor; or coercing into medical procedures such as cesarean section. A woman who answered ‘yes’ to at least one of the criteria was considered to be abused in nonconsented care at the time of labor and delivery.(18)
Nonconfidential care: The presence of at least one of the following: giving birth in a public view without privacy barriers such as curtains or having healthcare providers share sensitive client information, such as HIV status, age, marital status, and medical history, in such a way that other people who are not involved in their care can hear. A woman who replied ‘yes’ to at least one of the criteria was considered to be abused in nonconfidential care at the time of labor and delivery(18).
Nondignified care: A report by the client about at least one of the following: intentional humiliation, blaming, rough treatment, scolding, shouting at, women not allowed to bring companion to the labor ward, or ordering to stop crying while they are in labor pain. A woman who replied ‘yes’ to at least one of the criteria was considered to be abused in nondignified care at the time of labor and delivery(18).
Discrimination: Discrimination based on specific client attributes such as race, age, HIV/AIDS status, traditional beliefs and preferences, economic status, or educational background. A woman who answered “yes” to at least one of the criteria was considered to be abused in discriminated care at the time of labor and delivery(51).
Neglected care: Fif there were any of the following practices: leaving the laboring woman alone, giving birth by themselves at health facilities, or failing to monitor women in labor and intervene in life-threatening conditions. A woman who answered ‘yes’ to at least one of the criteria was considered to be abused in neglected care at the time of labor and delivery(51).
Detention in facilities: Deteriorating mothers in health facilities because of bills or damage to the property of the health care facility. If a woman answered ‘yes’ to at least two of the criteria, then she was considered to be abused at the time of labor and delivery(18).

DATA COLLECTION TOOL AND PROCEDURE

DATA COLLECTION TOOL

The data collection tool was adapted by reviewing different studies(18,50,52). The questionnaire is divided into four parts. Part one included sociodemographic variables (9 items), part two included obstetric characteristic-related factors (13 items), part three included health service system-related factors (6 items), and part four included intrapartum obstetric violence-related questions. The scale internal reliability was checked by Cronbach’s alpha.

DATA COLLECTION PROCEDURE.

The data were collected by using structured questionnaires administered by an interviewer via three diploma nurses under the supervision of one BSc nurse who spoke the local language (Amharic). The data were obtained at the institutional level through face-to-face interviews. The mothers were tolled of all the details of the study before providing their consent to participate. The participants who were willing to integrate and sign the informed consent document were then interviewed in a quiet and spacious space.

DATA QUALITY ASSURANCE

To ensure the quality of the data, first, the data collection tool was prepared in English, translated into Amharic, and then returned to English to check its consistency. Then, training of the data collectors and their supervisors was undertaken for one day by the principal investigator on the objectives, relevance of the study, methods of data collection, confidentiality of the information and informed consent. Pretests were performed by taking 5% of mothers postpartum at other nonselected hospitals before the actual data collection work to determine the accuracy of the responses and to estimate the time needed, and the questionnaire was adjusted accordingly. The validity and reliability of the questionnaire were checked. The supervisor checked the data collection process on a daily basis. The investigator also makes corrective efforts to boost the validity of the conclusion by reviewing and cross-checking the questionnaires or data for completeness, accuracy, and consistency every day after completion of the daily data collection process.

DATA PROCESSING AND ANALYSIS

The data were checked for completeness and consistency before being entered into the computer. The data were subsequently coded, and the results were double verified using EPI-DATA 3.1 software. The data were subsequently entered into SPSS version 25 for analysis. Descriptive statistics were used to summarize the data, and the results are presented as frequency tables and graphs. Factors associated with the dependent variable were assessed using binary logistic regression. Basic assumptions for binary logistic regression were made, and model fitness was checked before running multiple logistic regression analysis. Initially, bivariable logistic regression was performed to evaluate the associations between the dependent variable and the independent variables. Variables with a p value ≤ 0.25 were considered to be significant candidate variables for multivariable logistic regression analysis to control for confounders. The degree of association between the dependent and independent variables was measured using an adjusted odds ratio (adjusted odds ratio) with a 95% confidence interval (CI) at a significance level ≤ 0.05.

SOCIO-DEMOGRAPHIC CHARACTERISTICS

A total of 423 eligible mothers were approached in this study, and 418 mothers agreed to participate, for a response rate of 98.8%. Regarding the age category, 179 (42.8%) were found between the 25th and 29th age groups, and 242 (57.9%) of them were religious fellows. Of the 418 mothers, only 65 (15.6%) were married. Regarding educational and occupational status, the majority of the participants (183 [43.8%] had completed secondary education, and more than 185 [44.3%] were housewives. Among those mothers, 418,273 (65.3%) had a monthly income less than 5000 birrs per month (Table 1).

Table 1

Sociodemographic characteristics of mothers delivered in Addis Ababa, Ethiopia, 2023
Variables	Category	Frequency	Percent
Age	19–24	102	24.4
	25–29	179	42.8
	Above 30	137	32.8
Residence	Urban	324	77.5
Residence	Rural	94	22.5
education level	Illiterate	75	17.9
	primary education	160	38.3
	secondary and above	183	43.8
marital status	Married	353	84.4
marital status	Others	65	15.6
Religion	Orthodox	242	57.9
	Muslim	118	28.2
	protestant and others	58	13.9
Occupation	Housewife	185	44.3
	Government	119	28.5
	Others	114	27.3
Income	< 5000	273	65.3
Income	> 5000	145	34.7

OBSTETRIC CHARACTERISTICS OF THE STUDY PARTICIPANTS

Out of 418 mothers, 332 (79.4%) had a history of ANC follow-up, but only 104 (24.9%) had completed the 4th week, and 228 (54.5%) had delivered at night. Regarding the mode of delivery, 202 (48.2%) mothers delivered by C/S. Among the respondents, 226 (54.1%) had a duration longer than 24 hrs. Furthermore, 206 (49.3%) patients had complications, either on their infants or on their infants, but only 32 (10%) of them were dissatisfied with the overall care. (Table 2)

Table 2

Obstetric characteristics of mothers in Addis Ababa, 2023
Variables	Category	Frequency	Percent
number of delivery	less than 3	251	60.0
number of delivery	above 3	167	40.0
ANC follow up	Yes	332	79.4
ANC follow up	No	86	20.6
number of ANC visit	1st visit	88	21.05
	2nd visit	110	26.3
	3rd visit	61	14.6
	4th visit	159	38.04
place of ANC	health center	256	61.2
	hospitals	143	34.2
	Others	19	4.5
ever had delivery at current health facility	Yes	161	38.5
ever had delivery at current health facility	No	257	61.5
who refer you to current HF	Self	122	29.2
	from HC	277	66.3
	from clinic and others	19	4.5
time of birth of the current delivery	Day	190	45.5
time of birth of the current delivery	Night	228	54.5
mode of delivery	SVD	190	45.5
	C/S	202	48.3
	Assisted	26	6.2
time stayed at HF	< 24 hr	192	45.9
time stayed at HF	> 24 hr	226	54.1
Complication in infant and mothers	Yes	206	49.3
Complication in infant and mothers	No	212	50.7
satisfaction in overall care	strongly satisfied	140	33.5
	satisfied	201	48.1
	neutral	35	8.4
	dissatisfied	28	6.7
	strongly dissatisfied	14	3.3

HEALTH SYSTEM CHARACTERISTICS

Among the health system characteristics, the majority 234 (56. %) of the pregnant mothers were followed up at health centers, and 54.1% of them were visited by two health professionals; however, at the time, their delivery was given by doctors. The majority (n = 219; 52.4%) of the health professionals were male. (Table 3).

Table 3

Health system characteristics of Addis Abeba, Ethiopia, in 2023
Variables	Category	Frequency	Percent
place of ANC for last pregnancy	Hospital	154	36.8
	health centers	234	56.0
	Others	30	7.2
who assist you	mid-wife	173	41.4
	Doctors	210	50.2
	nurse and others	35	8.4
number of health professionals involved	One	157	37.6
	Two	226	54.1
	Three	26	6.2
	more than 3	9	2.2
sex of hp who attend	Female	199	47.6
sex of hp who attend	Male	219	52.4

PROPORTION OF IPOV AND ITS COMPONENTS AMONG MOTHERS IN THE ADDIS ABABA

Regarding the dimension of intrapartum obstetric violence from physical violence, health professionals who never use physical force agreed with the majority, while those who did not deny food or fluid to women in the labor item disagreed. On the woman’s right to information and informed consent-related items, Allows woman to assume the position of choice during birth was agreed upon, but Introduces self to woman and her companion were not agreed upon by the majority. Concerning confidentiality and privacy, the majority of mothers agreed that the use of drapes or coverage is appropriate for protecting women's privacy. In general, according to the IPOV-related dimension, confidentiality and privacy-related items were agreed upon by the majority of mothers, while women who were detained or confined against their will were not agreed upon by the majority of mothers.

Table 4

The prevalence of intrapartum obstetric violence and its components among mothers who delivered in Addis Ababa, Ethiopia, in 2023
Variables	Yes	No
The woman is protected from physical harm or ill treatment	295(70.9%)	123(29.4%)
Never uses physical force or abrasive behavior	326(78%)	92(22%)
Never physically restrains woman	321(76.8%)	97(23.2%)
Provides comfort/pain-relief as necessary	313(74.9%)	105(25.1%)
Does not deny food or fluid to women in labor	272(65.1%)	146(34.9%)
The woman’s right to information and informed consent	269(64.4%)	149(35.6%)
Introduces self to woman and her companion	183(43.8%)	235(56.2%)
Encourages companion to remain with woman whenever possible	215(51.4%)	203(48.6%)
Encourages woman and her companion to ask questions	307(73.4%)	111(26.6%)
Does the provider actively listen you	332(79.4%)	86(20.6%)
Gives periodic updates on status and progress of labor	313(74.9%)	105(25.1%)
Allows the woman to move about during labor	317(75.8%)	101(24.2%)
Allows woman to assume position of choice during birth	372(89%)	46(11%)
Obtains consent or permission prior to any procedure	349(83.5%0	69(16.5%)
Confidentiality and privacy is protected	336(80.4%)	82(19.6%)
Uses curtains or other visual barrier to protect woman during exams, birth	357(85.4%)	61(14.6%)
Uses drapes or covering appropriate to protect woman's privacy	360(86.1%)	58(13.9%
The woman is treated with dignity and respect.	281(67.2%0	137(32.8%)
Speaks politely to woman and companion	326(78%)	92(22%)
Never makes insults, intimidation, threats, or coerces woman or her companion	305(73%)	113(27%)
The woman receives equitable care, free of discrimination.	173(41.4%0	245(58.6%)
Speaks to the woman in a language and at a language-level that she understand	308(73.7%)	110(26.3%)
Does not show disrespect to women based on any specific attribute	210(50.2%)	208(49.8%)
The woman is never left without care	215(51.4%0	203(48.6%)
Encourages woman to call if needed	170(40.7%)	248(59.3%)
Never leaves woman alone or unattended	101(24.2%)	317(75.8%)
The woman is detained or confined against her will	115(27.5%)	303(72.5%)

PREVALENCE OF INTRA-PARTUM OBSTETRIC VIOLENCE

The picture below shows that 56.5% (95% CI 51.9%, 61.2%) of the participants agreed that intrapartum obstetric violence was present.

FACTORS ASSOCIATED WITH INTRA-PARTUM OBSTETRIC VIOLENCE IN MULTIPLE REGRESSION MODELS

Those variables that had a statistically significant association with intrapartum obstetric violence according to binary logistic regression were entered into the multivariable logistic regression after checking for multicollinearity (VIF and tolerance) and normality and for what extent the model was well fitted (hosmer-Lemishow goodness of fit). Factors with p < = 0.05 were considered to have a significant association with intrapartum obstetric violence, as shown in Table 7.

Table 5

Multiple regression table on intrapartum obstetric violence among mothers in Addis Ababa, Ethiopia, 2023
Independent variables	IPOV			COR	CI		P value	AOR	CI		P value
Independent variables		Yes	No	COR	CI		P value	AOR	CI		P value
Age	19–24	39	63	3.303	1.934	5.641	.000	6.405	2.755	14.893	.000*
	25–29	105	74	1.441	.906	2.292	.123	2.230	1.015	4.902	.046*
	Above 30	92	45	1				1
residence	urban	174	150
residence	rural	62	32	.599	.371	.967	.036	.571	.268	1.220	.148
occupation	housewife	81	104	1				1
	government	92	27	.229	.136	.384	.000	.158	.072	.346	.000*
	others	63	51	.630	.394	1.009	.054	.394	.192	.811	.011*
number of delivery	less than 3	136	115	1				1
number of delivery	above 3	100	67	.792	.533	1.178	.250	.843	.370	1.922	.684
number of ANC visit	1st visit	67	76	3.995	2.264	7.048	.000	7.201	2.657	19.520	.000*
	2nd visit	50	60	4.226	2.328	7.670	.000	8.230	2.930	23.116	.000*
	3rd visit	38	23	2.132	1.064	4.270	.033	3.252	1.009	10.481	.048*
	4th visit	81	23	1				1
time of birth of the current delivery	day	128	62	1				1
time of birth of the current delivery	night	108	120	2.294	1.539	3.420	.000	1.646	.913	2.968	.097
mode of delivery	SVD	114	76	.767	.520	1.133	.183	1.552	.777	3.101	.213
mode of delivery	C/S and others	122	106	1				1
time stayed at HF	< 24 hr	126	66	1				1
time stayed at HF	> 24 hr	110	116	2.013	1.355	2.991	.001	6.566	2.946	14.636	.000*
Complication in infant and mothers	Yes	134	72	.498	.336	.738	.001	.784	.405	1.518	.471
Complication in infant and mothers	No	102	110	1				1
Who assist you	Midwife	91	82	1				1
Who assist you	others	145	100	.765	.517	1.133	.182	.424	.227	.791	.007*
number of HP	1–2	209	174	.182	1.245	6.343	.013	1.664	.355	7.814	.518
number of HP	above 2	27	8	1				1
sex of health professionals who attend	Female	134	65	2.365	1.589	3.520	.000	2.139	1.069	1.281	.000*
sex of health professionals who attend	Male	102	117	1				1
provider experience	< 5years	129	143	3.041	1.964	4.709	.000	.229	.104	.502	.000*
provider experience	> 5years	107	39	1				1

This study revealed that the overall incidence of intrapartum obstetric violence was 56.5%, which is lower than that reported in other studies. These findings were lower than those of studies performed among postnatal women in a specialized comprehensive hospital in the Amhara Region, Northwest Ethiopia.

75.1%(18). The possible reasons may include the availability of infrastructure, shortage of trained human power and compliance of health professionals with the standard guidelines.

The sociodemographic age and occupation of mothers were significantly associated with intrapartum obstetric violence. When we compared late childbearing age (above 30), participants in the early childbearing age group (19-24) were approximately 6.4 times more likely to experience intrapartam obstetric violence. AOR=6.4 (95% CI=2.76, 14.89). This might be because those in the early childbearing age group were less experienced in the delivery process and may be unwilling to undergo any procedure; therefore, health professionals may have passed unnecessary words to them.

Occupation was another significant factor that was associated with intrapartum obstetric violence. Those mothers who were employed and working in different activities were less likely to have intrapartum obstetric violence (AOR: .15895% CI: .072, .346; AOR: .39, 95% CI: .192, .811). This might be because mothers who were housewives were less likely to be aware of and afraid of expressing their feelings.

Among the obstetric characteristics, ANC visit and time spent at a health facility were significantly associated with intrapartum obstetric violence. When we compared mothers who had a 4^th ANC visit with others, those who had one visit were more likely to have intrapartum obstetric violence (AOR: 7.2095% CI (2.66, 19.52). The reason might be that mothers who had visited only were not able to adapt very well to the environment; even if they were confused, they were likely to go so that they were at risk of violence.

With respect to the length of hospital stay, mothers whose length of stay was greater than 24 hr were included. At hospitals, there was a 6.6-fold greater risk of intrapartum obstetric violence than mothers who stayed for less than 24 hours (AOR=6.57, 95% CI=2.95, 14.64). This might be because as time elapses, the likelihood of gating different health professionals increases since humans have different behaviors, and the likelihood of being exposed to these types of violence also increases.

Regarding health system characteristics, the health professionals who assist in the delivery and the sex of health professionals were found to be factors associated with intrapartum obstetric violence. Those mothers who were assisted by other health professionals were less likely to have violence than mothers who were assisted by midwives were (AOR:.424(.227, .791). This might be because those midwives usually pass their time by assisting many mothers so that they may adapt to pain due to delivery and become careless.

This study also revealed a significant and positive association between the sex of health professionals who attended and antepartum obstetric violence. Patients who were not assisted by female health professionals were almost 2 times more likely to have unintentional obstetric violence than were those who were assisted by males (AOR: 2.14, 95% CI (1.07, 1.28)). Discipancy might be due to the responsibilities of women, such as child care and home activity, which can lead women to stress and make it difficult for them to understand the pain experienced by the mother.

From these findings, it was concluded that the prevalence of intrapartum obstetric violence was high. Age, occupation, number of ANC visits, duration of hospitalization, who assisted in delivery, and sex were factors associated with intrapartum obstetric violence. Based on the study findings, the following recommendations have been proposed for the bodies of interest:

RECOMMENDATION

As a recommendation, every responsible body starting from the ministry of health to a local health facility should work hand by hand with other stakeholders to avert intrapartum obstetric violence.

For FMOH

Should prepare policy and should act strictly on that obstacle.

For subcities

Design of a family health education strategy for those housewives

For hospitals

Training on CRC patients for health purposes
Using a flexi-time strategy for women’s health professionals

For health professionals

Respecting client
Give advice
Home-to-home health education for those housewives

For researcher

Should support by a qualitative study

English consent form

Enough information about the study is explained to me. The objective of this study was to assess obstetric violence. I have been told that the study will improve the quality of maternal health services and provide a deep understanding of the issue to the concernedbody.

I understand that participation in this study was entirely voluntary. I have been told that my answers to the questions will not be given anyone else and that no reports of this study ever identify me in any way. Therefore, I am ready and willing to participate in this study.

If the respondent does not agree to be interviewed thanks her and goes to the next respondent, if the respondent says yes, continue

ETHICAL CONSIDERATION

Ethical clearance was obtained from the Addis Ababa Public Health Research and Emergency Management Directorate and then from the selected hospitals. The data were collected after the purpose or objective of the study was presented to each participant, and written informed consent was obtained by following the COVID-19 protocol, such as keeping away or using masks and sanitizers. Any personal identifying variables of each participant were kept confidential. To assure confidentiality, a code number was assigned to the study participants without mentioning the name.

No any organization funded our work.

Author Contribution

"E.G. Wrote the main manuscript text and prepare figures and D.A. prepared figures and tables. All authors reviewed the manuscript."

Acknowledgement

We would like to forward deepest gratitude to our research advisor Zebenay Workeneh for his guidance and support in preparing this paper. On top of this, we would like to express our heartfelt thanks to SPHMMC for the chance it has given us to conduct this study.

Data Availability

yes, whatever needed I will email it.

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No competing interests reported.

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Obstetric Violence and its Associated Factors Among Women Attending Intrapartum Care at Public Health Facilities of Addis Ababa, 2023.

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Abstract

Figures

INTRODUCTION

METHODOLOGY AND MATERIALS

STUDY AREA AND PERIOD

STIMY DESIGN

POPULATION

ELIGIBILITY CRITERIA

SAMPLE-SIZE DETERMINATION AND SAMPLING TECHNIQUE

STUDY VARIABLES

OPERATIONAL DEFINITIONS AND TERMS

DATA COLLECTION TOOL AND PROCEDURE

DATA QUALITY ASSURANCE

DATA PROCESSING AND ANALYSIS

RESULTS

SOCIO-DEMOGRAPHIC CHARACTERISTICS

OBSTETRIC CHARACTERISTICS OF THE STUDY PARTICIPANTS

HEALTH SYSTEM CHARACTERISTICS

PROPORTION OF IPOV AND ITS COMPONENTS AMONG MOTHERS IN THE ADDIS ABABA

PREVALENCE OF INTRA-PARTUM OBSTETRIC VIOLENCE

FACTORS ASSOCIATED WITH INTRA-PARTUM OBSTETRIC VIOLENCE IN MULTIPLE REGRESSION MODELS

DISCUSSION

CONCLUSION AND RECOMMENDATIONS

Declarations

ETHICAL CONSIDERATION

Author Contribution

Acknowledgement

Data Availability

References

Additional Declarations

Status:

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