‘They treat you like you are not a human being’: Maltreatment during labour and delivery in rural northern Ghana
Introduction
Every year in low- and middle-income countries, 275,000 women die due to pregnancy-related causes, and 3 million babies die in first 4 weeks of life (The Lancet, 2005, Oestergaard et al., 2011, WHO, UNICEF, UNFPA, World Bank, 2012). Facility-based delivery – or births that occur outside the home in any health-care setting – has been identified by the World Health Organization as a critical strategy for reducing these deaths (WHO, 2004). Nonetheless, many things prevent women from giving birth in a health facility, including logistical factors such as cost (Spangler and Bloom, 2010), distance to facilities (De Allegri et al., 2011, Gabrysch et al., 2011), and unexpected, rapid, or ill-timed onset of labour (Galaa and Daare, 2008). Social factors, such as the need to seek permission from others before going to a health facility (Mills and Bertrand, 2005, Bazzano et al., 2008, Moyer et al., 2013), can also prevent women from giving birth anywhere but at home.
One important factor that is not well-documented but can have profound effects on women's choices regarding where to give birth is maltreatment at the hands of providers at a health facility. Maltreatment has been described or alluded to as part of larger studies in Ghana (D’Ambruoso et al., 2005, Mills and Bertrand, 2005, Bazzano et al., 2008), Nigeria (Asuquo et al., 2000, Ejembi et al., 2004, Onah et al., 2006), Swaziland (Uyirwoth et al., 1996, Thwala et al., 2011), Tanzania (Kruk et al., 2009, Spangler and Bloom, 2010), and Uganda (Kyomuhendo, 2003). There is no uniform definition of maltreatment, and there is no standardised instrument to measure its prevalence. Maltreatment has been conceptualised as general abusive treatment towards women (Asuquo et al., 2000), negative or unfriendly staff attitudes (Asuquo et al., 2000, D’Ambruoso et al., 2005, Mills and Bertrand, 2005), verbal abuse (Mills and Bertrand, 2005), or sexual abuse (d’Oliveira et al., 2002). Maltreatment has also been described as encompassing neglect, detention at facilities if women are unable to pay for services, non-consented care, discrimination based on patient attributes, and health-care workers delivering services in exchange for bribes (FIDA-Kenya (Federation of Women Lawyers, Kenya), 2007, Bowser, 2010, Human Rights Watch, 2011).
The drivers of maltreatment, which is most often discussed in the context of midwife or nurse interactions with pregnant or labouring women, are not well understood. In many developing countries, nurses in the public sector are working long hours in harsh conditions, and there are extreme power differentials between them and their predominantly poor, illiterate patients (Jewkes et al., 1998). ‘In these situations nurses have been reported to employ humiliation, verbal coercion, and even physical violence to assert their authority and control patient behavior’ (Jewkes et al., 1998, p. 1781). Anecdotal reports from midwives in rural Ghana suggest that they will do whatever it takes to help a woman give birth to a healthy baby—even if that means hitting her to help her focus on pushing during delivery.
In 2011, the advocacy organisation The White Ribbon Alliance for Safe Motherhood published a charter to formally recognise seven fundamental rights of childbearing women, which map to seven categories of disrespect originally put forth by Bowser and Hill (Bowser, 2010). These include: physical abuse, non-consented care, non-confidential care, non-dignified care (including verbal abuse), discrimination based on specific patient attributes, abandonment of care, and detention in facilities (Respectful Care Advisory Council, 2011). Notably, these categories are not meant to be mutually exclusive as many types of maltreatment encompass multiple categories.
This study sought to explore the issue of maltreatment in rural northern Ghana using a broad cross-section of community respondents. The study included the following aims: (1) to determine whether maltreatment was mentioned by community members without prompting when discussing issues surrounding childbirth, (2) to determine the types of maltreatment reported to be occurring in facilities in rural northern Ghana, and (3) to compare the categories of maltreatment described in the existing literature against those identified in this region of Ghana.
Section snippets
Methods
This study grew out of the Stillbirth And Neonatal Death Study (SANDS) in northern Ghana from July through October 2010 (Aborigo et al., 2012, Engmann et al., 2012, Moyer et al., 2012, Moyer et al., 2013). This study focuses on cross-sectional interview and focus group data spanning the antenatal and perinatal period and excludes interactions solely focused on an infant’s first seven days of life. The cross-sectional nature of the study design allowed for a broad exploration of the issue of
Findings
Table 1 illustrates the number and type of respondents included in this study, including 128 community members (mothers with newborn infants, grandmothers, household heads, compound heads, traditional healers, traditional birth attendants, and community leaders) and 13 formally trained health-care providers. Seven focus groups and 43 individual interviews were conducted with community members, and 13 individual interviews were conducted with health-care providers.
Pursuant to Aim 1 (identifying
Discussion
We found that women delivering in facilities in rural northern Ghana experienced physical abuse, verbal abuse, neglect, discrimination, and denial of traditional customs. Such occurrences are not ubiquitous, and many women report receiving excellent care in facilities. Nonetheless, we found a consistent undercurrent of fear of maltreatment.
These results are consistent with the limited published research literature on maltreatment. Verbal abuse, ‘abusive treatment’, and negative and unfriendly
Conflict of interest
The authors have no conflict of interest, financial or otherwise, to disclose.
Acknowledgements
The authors would like to express our gratitude to the Navrongo Health Research Centre, the African Social Research Initiative and Global REACH at the University of Michigan, the Department of Pediatrics at the University of North Carolina and to the many people involved in the collection and coding of data. This includes Gideon Logonia, Gideon Affah, John Richardson, Sarah Rominski, Mira Gupta, Elizabeth Hill, and Rebecca Hess. In addition, we would like to express our thanks to the people of
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