Prevalence of Disrespectful Maternity Care and Abuse among Women Seeking Maternity Care Services at the Kenyatta National Hospital , Nairobi : A Cross-Sectional Descriptive Study

Background: Respectful Maternity Care (RMC) is a basic human right for every childbearing woman. Acts of disrespectful maternity care and abuse are commonly reported worldwide and are recognized as a powerful deterrence to facility based childbirth than the traditionally known accessibility. In Kenya, acts of disrespect and abuse are frequently reported. Objectives of the study: To assess the prevalence of disrespectful maternity care and abuse among women seeking maternity care services at the Kenyatta National Hospital, Nairobi. Methods: This study was conducted at the Kenyatta National Hospital maternity wards. A descriptive study design was employed and targeted 164 respondents. The study utilized an interviewer administered questionnaire and an observational checklist to collect required data. Participants were sampled using simple random sampling method. Data was collected between July 15 and July 3


Background
Disrespect and abuse (D & A) targeted at laboring mothers and their families during facility-based childbirth indeed are not a new phenomenon and have been reported and documented in many countries around the world for many years [1].It is described as the violation of the women's rights while they seek maternity care services.Respectful maternity care (RMC) is described as a universal human right that must be accorded every childbearing woman visiting a health facility anywhere in the world.The White Ribbon Alliance (WRA) and other World Health Organization (WHO) affiliate bodies identify seven fundamental rights due to women seeking maternity services in health facilities to include the right to dignified care, right to timely care, right to consented and confidential care, right to non-discriminatory care, right to liberty and self-determination and freedom from any form of abuse or ill treatment [2].
Acts of disrespect and abuse are not only a violation of the women's rights but they are a major deterrent in seeking health services and can cause women to drop out of care altogether [3].Indeed, fear of disrespect and abuse in facility-based maternity care is a major barrier to use of skilled birth attendants in developing countries with high maternal and neonatal mortalities than commonly recognized barriers such as cost of service or distance to the facilities [2] [4].
The problem of disrespect and abuse for women seeking maternity services is not a case of a few individuals but rather a problem that runs deep within maternity systems worldwide [5].These acts include humiliation of women, discrimination based on specific attributes such as economic status, non-consented care, non-dignified care, non-confidential care, abandonment of care, detention in health facilities and physical and verbal abuse during childbirth [4].Hence, D & A contribute to the three common delays in maternity care, which include not recognizing the signs of an emergency and seeking care, not identifying and reaching a medical facility and not receiving adequate and appropriate treatment.The delays are recognized as major contributor to the high rate of maternal and neonatal mortality and morbidity.Improving access to health facilities will not save women if they are not willing or not allowed to go to health facilities or are forced to endure disrespect and abuse in those facilities [3]  In the USA, evidence from research indicates that obstetric violence is systemic involving cases of forced, coerced and unconsented procedures like cesarean sections and episiotomies in proportions that are not fully recognized.In countries like Tanzania and South Africa, women frequently experience feeling ignored or neglected, encountering monetary demands by care givers; are discriminated against, face verbal abuse and, in rare instances, physical abuse [7].
In urban Tanzania, 15% of the women reported experiencing at least one instance of disrespect and abuse.This number was found to be dramatically higher during community follow-up interviews, in which 70% of women reported experiencing some form of disrespect and abuse during their facility-based delivery [7].In Kenya, 20% of women are reported to experience some form of disrespect and abuse whose manifestations include: non-confidential care, non-dignified care, neglect or abandonment, non-consensual care, physical abuse and detainment for non-payment of fees [8].
The main objective of this study was to assess the prevalence of disrespectful maternity care and abuse among women seeking maternity care services at the Kenyatta National Hospital.

Materials and Methods
This was a descriptive study that employed quantitative and qualitative methods.
The study employed the use structured interviewer administered questionnaire which addressed social-economic and demographic characteristics of the respondents, prevalence of disrespectful maternity care and abuse and the reactions to this kind of care.A standardized observational checklist was also used based on the seven universal rights due to women to assess prevalence of acts disrespect and abuse.
This study was conducted at the Kenyatta National Hospital general maternity wards-labor ward and antenatal/postnatal wards-targeting women seeking maternity services and are admitted for at least 24 hours.Kenyatta National Hospital records about 979 deliveries in its general maternity wards every month.All women who were in stable condition and consented to the study were sampled.However, those who came to the hospital seeking maternity services but were discharged before 24 hours or those who did not consent to the study were excluded, similar to those who were found to be critically ill or had psychological disturbances or co-morbidities.
The sample size for the study was calculated based on the target population of 979 deliveries per month and an assumed prevalence of 15% as indicated from previous studies.Using the Fisher's formula for sample size calculation, a Sample size of 164 women was targeted in the study.
The study utilized simple random sampling method targeting all mothers who were admitted to the general maternity wards of Kenyatta National Hospital.
The selection of the mothers was done by allowing the mothers admitted to the ward to select pre-marked papers indicated as "Yes" for those to be considered for the study and "No" for those not to be considered.The mothers with "yes" were then explained about the study and consent sought.In total, forty (40) papers were put out per day with 20 bearing "Yes" and another 20 bearing "No".
Consent to the study was sought and an exit interview was conducted using the interviewer administered questionnaire in a secure predetermined room with enough privacy and comfort within the wards.The coding was to ensure that the women remain anonymous for confidentiality and the secure room was to accord privacy to the women as they participated in the study.Similarly, four observations on each item were conducted as the women were received at admission and were followed through care using a non-participatory approach to assess the quality of care accorded to them based on the seven universal fundamental rights due to women in labor as collaborative tool to the questionnaire.
To achieve clarity, comprehensiveness and validity of data, study instruments were scrutinized and further pretested at the nearby Mbagathi sub-County hospital, two weeks before the commencement of data collection, targeting a population of about 10% of calculated sample size.Mbagathi hospital was chosen as it had a similar catchment and characteristics of patients as the facility where the study was to be done.The instruments were then subjected to necessary adjustments and modifications to ensure validity and reliability were achieved during the data collection process.Data was collected between July 15 th and July 30 th

Socio-demographic factors
In this study, 152 respondents were interviewed representing 93% of the targeted 164 participants.More than half of the women, 100 (66%), were aged 21 -30 years.The rest were either 20 years and below, 17 (11%) or 31 years and above, 35 (22%).Over three quarters of the women were married, and living with their husbands, 119 (78%).In terms of parity, majority of the respondents were either delivering for the first time, 56 (37%) or for the second time, 53 (35%).
In terms of level of education, all those interviewed reported to have attained some form of formal education with the majority, 68 (45%) having attained secondary education and those with tertiary education being, 51 (33%).In regard to place of previous delivery, majority, (95%) of those who had more than one child reported to have delivered in a health facility for their previous deliveries (Table 1).
Prevalence of disrespectful maternity care and abuse among women seeking maternity care services at KNH general maternity wards.
From the study, it was found out that majority of the respondents, 99 (65%) chose to come to the hospital by choice while the rest, 53 (35%), were referred from another health facility (Figure 1).Timely care It was found from those interviewed that majority, 105 (69.1%) were satisfied with the speed of attention they received at admission while the rest, 47 (30.9%) reported dissatisfaction (Table 2).
However according to the period mothers had to wait before they got attended to at admission, 64 (42%) waited for less than 30mins, 30 (19%) waited between 30 minutes and one hour while the rest, (cumulatively 39%), waited for over one hour before they could be attended to (Table 3).Of those that waited for over one hour, 29 (19%) waited over three (3) hours before they could be attended to at admission.

Consented care at admission, labor and delivery
The study examined the frequency of consented care at admission based on the procedures that the women received at admission (Figure 2).Overall, majority of the respondents, 119 (78%) reported to have consented while the rest,  33 (22%) reported that no consent was sought from them but they just complied with the procedures.
While in the ward during labor and delivery, based on various procedures of abdominal palpation, vaginal examination and augmentation of labor, majority (over 90%) of those who received these procedures reported that consent was sought from them.Majority of those who said that abdominal palpation was done on them, 125 (93%), out of the 134 who said they received the service, said they gave consent.Majority of the respondents, 125 (82%) reported that a vaginal/digital examination was done on them and of these, 7 (6%) said they did not consent to the procedure.Similarly, 65 (43%) of the mothers said their labor was augmented and of these, 7 (9%) stated that consent was not sought from them for the procedure.While only 11 (7%) of those interviewed reported that they received an episiotomy during delivery, only 6 (60%) of them consented for the episiotomy to be done while 5 (40%) did not consent to the same but just complied (Figure 3).

Dignity of care
In assessing dignity of care, aspects of orientation of the women to the ward were assessed together with if the women experienced physical or verbal abuse while they were attended during admission, labor and delivery.Majority of the respondents, 96 (63%) reported that they were given orientation to the ward setting by a nurse/midwife while 41 (27%) learnt on their own and 11 (7%) got orientation from other patients.Orientation to meal times and what to eat or what not to eat during labor majority, 99 (65%) reported to have decided on their own.While 59 (39%) of those interviewed said they learnt where the toilets and bathrooms were from the nurse/midwife, 53 (35%) learnt from the other  During labor and delivery, almost all those interviewed, 150 (99%) reported not to have experienced any form of physical abuse during labor and delivery (Figure 5).
Majority of the respondents, 147 (97%), reported not to have experienced any  scolding while 150 (99%) experienced no incident of being laughed at.23 (15%) of all the respondents reported experiences of being shouted at while 18 (12%) of all the women interviewed reported positive to episodes of being threatened with withdrawal of services (Figure 6).

Non-discriminatory care
Majority of all those that were interviewed, 138 (91%) reported that they received care just like any other patient within the ward.Similarly, 150 (99%) of all those interviewed reported that they did not receive any request from anybody to bribe them to receive a service or give any form of bribe.Majority of the respondents, 141 (93%) did not get detained in the health facility for whatever reason (Figure 7).

Confidentiality of care
During labor and delivery, Majority of the respondents, 109 (72%) reported that while receiving care their confidentiality was maintained while 43 (28%) of the respondents reported that their confidentiality was not maintained during labor and delivery (Figure 7).

Privacy of care
During labor and delivery, majority of the respondents, 103 (68%) reported that their privacy was maintained while the rest, 49 (32%) felt their privacy was not maintained (Figure 7).However, during labor and delivery, majority, 119 (78%) reported that they got the attention of the care giver when they needed it while 33 (22%) reported not to have received the attention of the caregiver when they needed it (Figure 7).

Right of information
With regard to feedback to the patient on the findings of the procedures done during labor and delivery, 131 (86%) of the women received feedback from the care giver on the findings while the rest, 21 (14%) did not receive any feedback after the procedures (Figure 8).

Observed care during admission, labor and delivery
The observed care during admission, labor and delivery was done using a standardized checklist based on the universal fundamental rights due to women in labor.
In relation to dignity of care, it was observed that most mothers were not  welcomed in a kind and gentle manner during admission (three out of four observations).However, the mothers were neither exposed to use of no-dignified language nor shouted at or harsh language used against them during admission.
But it was observed that the mothers did not receive a clean bed for themselves upon admission where by most of them shared a bed two or more mothers.
In regard to consented care, it was left undecided as observed instances of consent being sought were equal to those of when no consent was sought.In terms of confidentiality in care, it was observed that history of the patient was not taken in private in all of the observed times (four out of four observations).
Similarly, the patient's file was observed to be handled by anybody and was kept within reach of unauthorized persons within the patients' cubicle.
Aspects of privacy of the patient were also observed and it was found out that mothers were accommodated in rooms without partitions between beds and that mothers shared beds most of the time.In worst instances, it was observed that mothers were being accommodated in the corridor and on stretchers rather than beds in the cubicles.Similarly, most of the time mothers were observed not to be appropriately covered during examination in the antenatal ward and during delivery.Besides not being covered appropriately and protected from the view of others in the room, mostly there were no partitions to protect the mothers from view of others.However, after third stage of delivery, most mothers were observed to be well covered with linen.There were no observed partitions in postnatal ward and, mostly because mothers are not frequently examined in postnatal ward, it was not conclusive to say if privacy is maintained or not.
In observation of abuse in care, it was observed that most patients were not shouted at during labor and delivery.Similarly, it was observed that mothers were not exposed to any form of physical abuse (Table 4).

Discussion
Women in the study experienced at disrespect and abuse in maternity services at the hospital.31% of all the women interviewed reported to have been dissatisfied with waiting time at admission.During labor and delivery, 22% reported to have been abandoned by the caregiver.Similarly, it was found in this study that 22% of the women experienced loss of autonomy in the sense that the care they received was non-consented during labor and delivery.In aspects of confidentiality of care, 28% of the women reported that their confidentiality was breached while 32% reported that their privacy was not maintained.The findings were a bit lower when it came to discrimination of care where only 9% reported that they were discriminated against while they sought care.14% of those interviewed reported they were denied information on their care and progress and as such loss of autonomy.These findings are similar to those by Abuya et al. who found out that 20% of Kenyan women experience some form of disrespect and abuse while seeking maternity care services in health facilities [8] and in urban Tanzania where 15% of the women reported experiencing some form of disrespect and abuse in a 2014 study [7].
In the country context, disrespect in maternity care should be a thing of the past because the Kenyan constitution 2010 outlines the rights of every Kenyan.
The low levels of awareness and literacy inhibits women from raising their voices against disrespect.Health systems are over stretched which contributes to lack of privacy and personalized care as reported by many women in this study.A lot needs to be done to empower health workers to embrace respect and care amidst a heavy workload.

Conclusions
The study found that the prevalence of disrespect and abuse among women seeking maternity services at the Kenyatta National Hospital maternity wards is high (up to 32%).Concerning aspects of care that were measured, only discrimination of care was found to be low at 9% compared to breach of privacy 32%, long waiting time 31%, non-confidential care 28%, abandonment of care 22%, non-consented care 22% and 14% for lack of autonomy as manifested by lack of feedback on care and progress.
The policy makers of the ministry of health, hospital management and ward managers should work towards reducing these aspects of disrespect and help increase confidence in the utilization of facility based maternity services and skilled birth attendance.

Limitations of the Study
The study was conducted with strict time lines and limited funding making it difficult to follow-up on focused group discussions as part of the study to yield qualitative data.
Similarly, the research was conducted in one facility and as such caution should be taken not to generalize with other facilities which might have different aspects of their shortcomings.
2017 and was entered into the computer, cleaned and analyzed using descriptive and inferential statistics by computer program SPSS version 20.The results were presented in figures, graphs and tables.The research followed laid down procedures of approval by the University of Nairobi/Kenyatta National Hospital Research and Ethical Committee (UoN/KNH REC).Once the approvals were obtained, permission to collect data was sought from the KNH administration.The participants' informed consent to participate in the study was obtained from the participants after a clear explanation on the purpose of the study, its objectives and intended benefits.All participants participated in the study voluntarily and were allowed to opt out of the study at any time without preconditions or any victimization.

Figure 2 .
Figure 2. Procedures done at admission and prevalence of consented care.

Figure 3 .
Figure 3. Procedures done during labor and delivery and consent given.

Figure 5 .
Figure 5. Physical abuse in labor and delivery.

Figure 6 .
Figure 6.Prevalence of verbal abuse during labor and delivery.

Figure 7 .
Figure 7. Experiences during labor and delivery.

Figure 8 .
Figure 8. Feedback from caregiver on findings.

Table 1 .
Socio-demographic factors of the respondents admitted to KNH general maternity wards.
Unemployed Open Journal of Obstetrics and Gynecology

Table 2 .
Satisfaction to waiting time at admission.

Table 3 .
Waiting time at admission.