‘I would have stayed home if I could manage it alone’; testimony of an Ethiopian mother abandoned by care providers during facility based childbirth: a case report

Background: Every woman is entitled to respectful care during pregnancy and childbirth as a basic human right. However, not all women are being treated equally well. Case presentation: This case study highlights some of the common disrespectful practices that women face. This is a testimony of a 28-year-old mother of two, narrated in her own words. The data were collected during an in-depth interview in November 2019. The interview was conducted in her house and her name has been changed to protect her identity. The interview was audio-taped by a digital voice recorder, later transcribed and translated verbatim from the local language, Amharic, to English. Conclusion: This woman’s story highlights the unfortunate reality for some women. Five themes emerged from her narrative: denial of care, non-consented care, non-dignied care, taking a sick baby home with resentment, and loss of trust of care providers. her personal experience during facility based childbirth. The interview was transcribed and translated verbatim from the local language, Amharic, to English. Both transcript and translated version of the document were cross-checked with the original interview by an experienced linguist.


Plain English Summary
Disrespect and abuse of women during facility based childbirth includes the way care providers act, behave or treat childbearing women and is against the basic human right of childbearing women.
Abandonment is among the seven categories of disrespect and abuse and is characterized by care providers denying care or neglecting the woman during labor, childbirth and/or immediately after birth.
The authors sought the opinion of a mother who had experienced abandonment, via face to face interview.
This testimony narrates her story as a victim of disrespect in a facility that resulted in her child becoming disabled following abandonment by care providers during childbirth. The respondent has signi cant loss of trust of care providers.
In conclusion, disrespectful care during facility based childbirth may lead to poor outcome for both the mother and baby and can deter women from seeking lifesaving professional maternity care.

Background
Despite progress in reducing maternal mortality, Ethiopia still has one of the highest maternal mortality ratio in the world; estimated from the most recent health survey to be 412 per 100, 000 live births (1,2).
As maternal and newborn mortality mostly occur during birth and immediate postpartum period, ensuring access to quality maternity care is a key aspect of reducing avoidable deaths. Quality maternity care requires health facilities to be adequately equipped with compassionate skilled providers, physical resources and medical supplies (3).
The third sustainable development goal is reducing maternal mortality ratio (MMR) to less than 70 per 100,000 live births in 2030. In order to achieve this, Ethiopia needs to triple its 2.3% annual maternal mortality reduction rate to 7.5% (4,5). Accordingly, the government of Ethiopia has focused considerable efforts on education of health care providers, building new and upgraded facilities; and making maternity care services cost free. As a result, primary healthcare coverage has improved (6). However, despite the progress signi cant problems remain which are re ected by the fact that only 48% of women gave birth in a health facility in 2019 (7). Improving access alone is not su cient inducement to encourage pregnant women to give birth in health facilities (8). The perception and experience of women regarding the quality of the service also in uences utilization (9). Improving the quality of care and humanizing maternity care is vital to increase service uptake (10). Recent studies have suggested that improving both access and quality of care are of vital importance to reduce the MMR (8).
Quality of care, however, is a complex phenomenon often explained through an interaction between health system structure, interpersonal and technical aspects of care provision and outcomes of care (9,11). Respectful care as a universal human right for women and babies is an important dimension of quality. The World Health Organization (WHO) has issued a statement for stakeholders on prevention and elimination of disrespect and abuse during facility based childbirth, emphasizing respectful maternity care as core indicator of quality of care (12). Nonetheless, any attempt to understand quality of care concepts should start with analysis of 'what women need and want' (13).
Respectful care is a fundamental right for every woman and baby (10). However, many women in Ethiopia are mistreated by their attendants during facility based childbirth (14)(15)(16)(17)(18)(19)(20)(21). This mistreatment is manifested by any form of uncaring behavior or inhumane treatment (22). Such encounters can potentially deter women from seeking professional maternity care (23). As a result, they may opt for birth at home, often relying on traditional birth attendants rather than quali ed health professionals. This in turn increases the risk of maternal and neonatal morbidity and mortality (14).
The White Ribbon Alliance (WRA) categorise disrespect and abuse of women during facility based childbirth in seven categories; physical abuse, non-consented care, non-con dential care, non-digni ed care, discriminatory care, abandonment or denial of care, and detention in facilities (9). Abandonment or denial of care may have negative health consequences on both the mother and her newborn (24). This may occur for a variety of reasons including; if the facility is closed when it is supposed to operate 24 hours, if it is open but no staff are available, if healthcare providers didn't encourage the woman to call if she needed them, providers made the woman feel alone or unattended, providers didn't come quickly when needed, providers denied support during labour, the woman was left unattended during birth of her baby, providers failed to intervene when medically indicated, or providers failed to grant woman's requests (25).
The aim of this case report is to record and share one woman's experience of disrespect in a facility that resulted in her child becoming disabled following abandonment by care providers during childbirth.

Case Presentation
This is a testimony of a 28-year-old mother of two, narrated in her own words. The data were collected during an in-depth interview in November 2019 in Fitche town, north of Addis Ababa. The interview was audio-taped using a digital voice recorder. The woman was invited to share her personal experience during facility based childbirth. The interview was transcribed and translated verbatim from the local language, Amharic, to English. Both transcript and translated version of the document were crosschecked with the original interview by an experienced linguist.
This interview was conducted as part of project examining disrespect and abuse of women during facility based childbirth in Ethiopia. While conducting a focus group and discussing the issue of abandonment or denial of care, I noticed some of the participants gave one another a surprise glance. On further enquiry, they told me that their neighbor is a woman with a traumatic experience of care. In fact, they said "her life was never the same since the incident. We can see the sorrow in her eyes you know." Following the focus group, I invited the participants to speak to their neighbor and ask if she would like to share her story with me for the project. I was invited to her house the following day. She was recruited in line with the ethical approval.
Abandonment or denial of care Upon our meeting, Aisha (name changed) welcomed me to her house and started narrating her story in a deep sorrowful voice after taking a deep breath. "I have fresh memory of it. It was afternoon when I arrived at the hospital, they (care providers) kept me in the waiting room without any checkup till the night shift workers came. The night shift checked me only once as I spent the whole night laboring. Early morning, as I felt the urge to push down the baby, the doctor left me with interns, instructing them to attend me. The baby was coming out but the doctor didn't wait, he abandoned me. I screamed out of helplessness and overwhelming pain, nobody cared. The interns neither helped me nor did they call for help. They denied my very basic right, the care I came for." Non-consented care "A couple of hours later, the reckless doctor came back very relaxed after I was exhausted by the prolonged labor. I was worn out and couldn't push anymore; he noticed a problem and rushed to a procedure. He cut my genitalia (episiotomy) without any explanation while I was in the waiting room. He was not careful when he cut my body without my consent. Then, two men hold my legs and other two my arms and took me to the delivery room. They put me on the delivery couch like a trash. What are they going to lose if they give me a tiny respect and took me on stretcher? They didn't utter a word all this time, they just did what they think was right and took the baby out. After all who can question them? I gave birth about 24 hours after my admission." Aisha went silent for a while "…The baby didn't cry at birth and I thought I lost him. The doctor dashed to the bed at the corner. He was pumping something to my baby's mouth and one of the interns was compressing his chest. Seeing my rst born like this traumatized me. Still now, thinking of that moment gives me stab on the chest. I laid on that couch naked in humiliating way and bleeding till one of them came remove the placenta and stitch the tear they made down there, as if he was sewing a piece of cloth. The suturing was no more less than a labor, they didn't gave me any anesthesia. The wound took more than two months to heal. For a couple of weeks sitting was impossible. I turn from one side to the other on bed with so much pain. I was having less amount of meals than I should thinking of the misery during defecation. During that period only Allah knows what I went through. I have to ask my mom traditional wound care practices to prevent infection because they neither advised nor gave me antibiotics on my discharge." Non-digni ed care "They transferred me to the postnatal room and kept my child behind. Though I was drained by the prolonged labor I couldn't rest because of my child's circumstance. None of this could have happened to me if that devil doctor was around. He could have shortened my suffering. I knew my baby was in trouble but nobody, nobody said a word to me, let alone reassuring me. They even yelled at me for crying out loud "don't make our work di cult already, act like a grown woman". My husband and family who were waiting outside the ward the whole time heard my cry and interfered. Only then, one of the interns told them that the baby was suffocated (asphyxiated) and is on oxygen (being resuscitated).
"After a long resuscitation, my baby cried and they gave it to me. They didn't tell me how to proceed with nursing or any precaution with the illness that my baby had. They just told me I am ready to go off within 3 hours. I wonder how many lives went wrong in their reckless hands. They are accountable for my darkened life. The baby was not breathing well, let alone sucking breast when I left the hospital and they didn't care at all, they just wanted me to get out of their sight. The doctor said 'your child is ok and will start sucking breast any time soon'. He was not sorry that he abandoned me at that critical moment with students who were supposed to work under his supervision and now he rushed me to leave the hospital. I don't know what I did to him to deserve this, he just watched me when I took home a sick baby. I believe someday Allah will punish him the way he deserves. He made me hate all care providers and the entire health care system." Aisha couldn't talk any longer, and started crying. I gave her as much time as she desired to recover.
Taking sick baby home with resentment After a while Aisha took a breath and continued "I left the hospital three hours after giving birth as per his (the doctor) decision though the baby was still unable to suck breast. We waited till next morning and even tried canned milk but he couldn't take it. We returned to the hospital after 24 hours when the baby's breathing di culty got worse. Another team of care providers received us and told us that the baby was not breathing well and shouldn't have left the hospital on the rst place. They checked and admitted him (to neonatal intensive care unit) for ten days. They were even planning to refer him to Addis Ababa but later changed their mind and kept him. Nobody updated me about my child's circumstance. Imagine staying in hospital separated from your sick newborn baby that long, thinking they will hand me over his body sooner or later. As a mother that was the worst time of my life." "We went home after 10 days, my baby was on spoon feeding still unable to suck breast. They told me that was the maximum they can do. As I was told, I tried to breast fed him, but didn't succeed. My life changed from that day on, he cries day and night. I have to carry him at all times, I can't take rest during the day or sleep at night. I have visited referral hospitals in Addis Ababa and got nothing except wasting my time and money. Finally, one specialist told me his brain was irreversibly damaged because of the prolonged labor without intervention/help. He told me the poor prognosis of my child: that he may encounter developmental delay, speech problems, not dressing by himself…soooo many disabilities. He is ve years old now and still looks like a newborn, couldn't sit and feed himself. I have to change his position as he can't move his head. He take only milk (bottle feeding) and I have to widen the opening of the bottle because he can't suck. I have tried to diversify his food but he couldn't take them. As to his friends he was in kindergarten but he never left the bed by himself. They disabled my child and took away his future" Aisha is still very angry towards her care providers "This problem could not have happened to my baby if that doctor has some humanity in him. I feel bad when I think of hospitals now, I have a negative memory. He considered my cry as a joke and abandoned me. My families believe the baby is disabled because of my abandonment during labor. Nobody anticipated this to happen to my child. Since it was my rst pregnancy I was curious and had full antenatal care follow up. I had payed attention to every detail they (care providers) told me. I have never been said my pregnancy has a problem. My relatives and neighbors were all preparing to celebrate Allah's gift with my family. Now, some people say it was a bad luck but, I will always say he (the doctor) put an end to my child's life before it even started. What is the fate of my child, till when he is going to stay in bed? She became very emotional and cried but continued to tell her story. "I always live with a grief when I see my child in bed unable to talk and feed himself. He follows me with his eyes in the room and this breaks my heart most. My life turned upside down, I can't sleep at night or leave home during the day." Aisha cried again. "I am hopeless creature. What did I sin to get such a punishment?" She wiped her tears and continued after a long sigh, "…First, it is a job they are paid for and above all it is a matter of life and death for us. If they don't like the profession they should change it, otherwise it is not decent to play with our lives. Why are they in a white coat if they are not keen to help others? I would have stayed home if I could manage it alone; it broke my heart when they abandoned me." Loss of trust on care providers "When I gave birth to my second child six months ago, I carefully chose the facility where my relative works and she took good care of me. If not for her, I would have given birth at home. I didn't allowed any staff came near me except her. How can I trust care providers and give birth in their hands after all what they did to me? Look, I am an educated urban woman and understand well the risks of home birth. Likewise, I had bad experience in hospital; the care providers were very mean to me. Their bad attitude deters women from seeking skilled attendants at birth. How can you go there knowing they will degrade you from humanity? They treat you with respect only if they know you. So, it is not wise to visit a random health facility for a childbirth or else, you may regret it. I advise women of my community to visit health facilities where they have a relative or at least a friend."

Discussion
Every woman has the right to receive respectful care during childbirth. Nevertheless, not all women are being treated in this way. This case report provides insight from a testimony provided by a woman using her own words. She clearly describes what it is like to feel abandoned by health care providers during facility based childbirth, and the devastating ongoing consequences of this. The main themes that arose through her story were denial of care, non-consented care, non-digni ed care, taking sick baby home with resentment and loss of trust of care providers.
Interpersonal quality of care, disrespect and abuse during facility based childbirth has garnered increased attention. Studies from a range of cultural contexts have recently reported care providers' lack of empathy, rudeness, uninformed decision making and denial of care (14,26). Such abusive language and practices violate the basic right of women to be treated with respect for their dignity (9) and can signi cantly impact women's willingness to seek life-saving maternity care (12,14,23). Because the healthcare providers treated Aisha in a disrespectful way and failed to appropriately assess her, the outcome was suboptimal. She was abandoned during labor and her baby did not receive appropriate treatment after birth.
Every woman is entitled to an explanation of any proposed procedures in a language and at a level she can comprehend, so she can knowingly consent to or refuse a procedure (9). The universal de nition of non-consented care includes (a) provider did not introduce herself/himself, (b) provider did not encourage the woman to ask questions, (c) provider didn't respond politely, truthfully and promptly, (d) provider didn't explain procedure and explained expectations, (e) provider didn't give periodic updates on status and progress, (f) provider didn't allow the woman to move during labor, (g) provider didn't allow the woman to assume position of choice, (h) no informed consent for procedures. Non-consented care violates women's right to information, informed consent and refusal, and respect for choices and preferences, including companionship during maternity care (27).
Care providers must ensure client's comfort during procedures. Every woman seeking care is a person of value and has the right to be treated with respect and dignity (12). A laboring mother should be encouraged to express her views freely, even when they differ from service providers' views (27). Nondigni ed care is characterized by (a) humiliation by shouting, blaming, or degrading, (b) provider didn't speak politely, (c) provider used abusive language (d) provider made insults or threats. In this case study the woman was also left naked and bleeding and was carried by her arms and legs.
Disrespect and abuse in facilities are among the biggest barriers to women seeking maternal health services globally (23) and is perceived differently (or even normalized) depending on the speci c setting (19). Therefore, a human rights approach to maternity care is vital in efforts to reduce maternal mortality. Incorporating fundamental human rights into legal and medical frameworks and translating them into measurable actions and outcomes is critical (28). Every laboring woman should feel valued, respected, and appreciated by her attendants (27).

Conclusion
In this case, abandonment of the mother by care providers during labor and lack of appropriate care for the baby led to neonatal cerebral palsy and signi cant loss of trust of care providers. Disrespectful care during facility based childbirth deter women from seeking lifesaving professional maternity care. Ethics approval and consent to participate Ethical approval was obtained from the University of Adelaide human research ethics committee H-2019-153 and Salale University College of health sciences research ethics review committee A/G/H/S/C/768/11. The participant was informed about the purpose, bene t, risk, con dentiality of the information and the voluntary nature of participation. Original name of the mother was changed due to the sensitivity of the issue. The interview was conducted in participant's house and she was accompanied by person of her choice. Data were collected only after informed written consent was obtained.

Consent for publication
Not applicable

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

Funding
This project is funded by a PhD scholarship to YMA from The University of Adelaide.
Authors' contributions YMA conceived the proposal and collected, transcribed, and translated the data and wrote the manuscript. HH, AM and JK approved the proposal with some revisions, reviewed subsequent drafts of the manuscript for their scienti c content. All authors read and approved the nal manuscript.