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1. TO ASSESS THE PREVALENCE OF DISRESPECT AND ABUSE BY HEALTH CARE
PROVIDERS IN FACILITY-BASED CHILDBIRTH AT IKUTHA SUB COUNTY
HOSPITAL, KITUI COUNTY.
NAME: PRISCAH KITEME
STUDENT NUMBER: SHS/ MRH/3827 – 1/2020
A RESEARCH PROPOSAL SUBMITTED IN PARTIAL FULFILMENT FOR THE
AWARD OF THE BACHELOR OF SCIENCE IN MIDWIFERY OF THE AMREF
INTERNATIONAL UNIVERSITY

2. DECLARATION
AMREF INTERNATIONAL UNIVERSITY
DECLARATION OF ORIGINALITY FORM
Name of Student: Priscah Kiteme
Registration Numbers: SHS/MRH/3827-1/2020
Department: Nursing and Midwifery Sciences
School: School of Medicine
Course Name: BSc Midwifery
Declaration
1. I understand what plagiarism is and I am aware of the University’s Policy in this regard.
2. I declare that this dissertation is my original work and has not been submitted elsewhere
for examination, the award of a degree, or publication. Where other people’s work or my
own has been used, this has properly been acknowledged and referenced in accordance
with the Amref International University requirements.
3. I have not sought or used the services of any professional agencies to produce this work.
4. I have not allowed, and shall not allow anyone to copy my work to pass it off as his/ her
work.
5. I understand that a false claim in respect of this work shall result in disciplinary action,
by the university plagiarism policy.

3. Signature ……………… Date ………………………….

4. APPROVAL
This research proposal has been submitted for examination with the approval of the following
supervisors:
Internal Supervisors
Ms. Priscilla Ngunju; BSc; MPH (Environmental Health and Occupational Health)
School of Medicine
Department of Nursing and Midwifery Sciences
Amref International University
Signature: ____________________________ Date: ________________________

5. CHAPTER ONE: INTRODUCTION
1.0 Background
Worldwide women face different forms of disrespect and abuse during labor and
childbirth. Disrespect and abuse act as a barrier to dignified care and has effects on health
seeking behavior and the health outcome of the mother and baby. The overall effect of this
barrier is felt globally in addressing maternal mortality issues. Women’s experience of care in
labor and childbirth and the satisfaction of services positively or negatively impact health-
seeking behavior. This could also be the reason for the low utilization of birthing facilities. In
health facilities where women experience dissatisfaction and mistreatment, they become
reluctant to recommend the facility to others or even discourage them. Mistreatment of women
during labor childbirth violates their human rights to respectful care and disempowers them.
Afulani et al 2017 pointed out that the quality of experience comprises respectful provider-
patient communication.
Weak health system and poor leadership where there is no accountability and adherence
of health recommended policies and guidelines and ethical standards are not followed cases of
disrespect and abuse are rampant. Health system culture also tolerates abuse as a means to gain
control and compliance from perceived difficult women. Unfriendliness, poor attitude, provider
burn out and biases influence how women are treated in birth facilities. D&A is worsened by
women’s inability to pay for the services. Disrespect and abuse are maternal health problems and
contribute to suffering and discouragement and influence women’s decisions about birthing
facilities. This could further lead to seeking services of non-skilled attendants (TBA).
Childbearing is an experience with deep personal and cultural significance (USAID, 2018).

6. Disrespect and abuse are highest 30 minutes before delivery and 15 minutes
after, whereby women are blamed for being uncooperative and disobedient. (Eze et al, 2021;
Bohren et al, 2016). Physical abuse is associated with a good outcome, providers will agree with
women who never question them as they take charge of the entire process (Aronson 2013).
Women become disempowered and also lack autonomy, this makes women normalize disrespect
and abuse in birth facilities (Jewkes and Penn – kekana 2015; Sen et al 2018). Adverse
consequences of disrespect and abuse on women’s health include increased risk of birth
complications, post-traumatic stress disorder which may end up in postpartum psychosis
(Munthe – Kaas HM et al 2014)
Many women face barriers during childbirth in health facilities including
disrespect and abusive care, these range from medical procedures without the woman's consent,
discrimination, non-confidential care, abandonment or denial of care, detention, and physical or
verbal abuse. In many cases, disrespect and abuse occurrences are underreported or not reported
at all.
1.1 Statement of the problem
Disrespect and abuse is a common problem not only in low and middle-income
come countries but also in the developed countries. Northern Europe’s prevalence rates
range between 13 and – 28% of disrespect and abuse to women. In Sweden, Norway,
In Belgium, Estonia, Iceland, and Denmark 1 in 5 women experience one episode of D&A
In African countries, Nigeria had a prevalence of 23 – 98% a prevalence of 40% for Ghana
and Guinea. Sudan had a prevalence of 77%, Tanzania reported a prevalence rate of 15%
in Kenya, the prevalence rate ranges between 20 % and 1 in 5 women humiliation during labor.
A woman in Bungoma was awarded 2500 USD in compensation by the court for the disrespect
and mistreatment in 2013 during childbirth.

7. Disrespect and abuse cause a lot of suffering to women and their newborn babies,
the problems could be physical, psychological and emotional. With continued effects of
disrespect and abuse utilization of birthing facilities will reduce significantly despite free
maternity care. A reduced skilled birth attendant will lead to increased maternal morbidity and
mortality. Normalization of D&A during labor and childbirth in health facilities will be passed
on to young health providers.
This study will help understand the prevalence of disrespect and abuse during labor and
childbirth among women and help develop strategies that promote respectful maternity care.
1.2 Research questions
1) What are the different forms of disrespect and abuse experienced by women during
labor and childbirth?
2) What are the factors that hinder respectful maternity care?
3) What systemic factors contribute to disrespectful maternity care among health care
providers?
4) What are the factors that can enhance respectful maternity care?
1.3) Broad objectives
To assess the prevalence is abusive care among women who have facility-based childbirth at
Ikutha sub-county hospital.

8. 1.3.1 Specific objectives
1)To determine different types of disrespect and abuse experienced by women during childbirth.
2) To identify barriers to respectful maternity care.
3) To identify health system factors that contribute to disrespect and abuse during childbirth.
4) To explore strategies that can promote respectful care.
1.4) Variables
The proximate variables in the study were;
Disrespect
Abuse
Age
Religion
Level of education
Marital status

9. 1.5) Justification
Limited data documented the prevalence and disrespect and abuse during labor and
childbirth is a motivation to carry out this study There is a need to find out about women’s
experiences during labor and childbirth. The extent to which disrespect and abuse occur in health
facilities when clients seek care lacks evidence on its extent during labor and delivery. Bowser
and Hill described the categories of disrespect and abuse pointing out limited evidence about the
extent to which the categories manifest.
There are reports in the facility by clients that they have been left unattended, examined and no
feedback, others are left to deliver on their own. The facility is a BEMONC site, and clients
reports being asked to fuel an ambulance twice for referral to a CEMONC facility. More reports
by clients that they were physically and verbally abused, others being asked to pay for injectable
drugs they never received or to clear their hospital bill despite maternity services being free.
The importance of this study is to assess the experience of women during labor and childbirth,
the challenges they face, and the magnitude of the problem. The study is also important to the
facility in assessing the quality of care offered to women during labor. This study will provide
community-level insight into the normalization of disrespect and abuse in health facilities.
The findings in this study will help in understanding the prevalence of disrespect and abuse and
will be used to develop interventions to address the factors that influence disrespect and abuse.
The findings will also be used by the facility and stakeholders to develop strategies that promote
respectful maternity care and increase the utilization of skilled birth services. This will in turn
reduce maternal and neonatal morbidity and mortality.

10. CHAPTER TWO: LITERATURE REVIEW
2.0 Introduction
Disrespectful treatment of pregnant women in health facilities is a global
problem more common in middle and low-income countries. The experience during
antenatal, labor and delivery, and postpartum period may discourage or cause a delay
in seeking care in health facilities leading to increased maternal and neonatal morbidity
and mortality. The World Health Organization defines respectful maternity care (RMC)
as care organized for and provided to all women in a manner that maintains their
dignity, privacy, and confidentiality, ensures freedom from harm and mistreatment, and
enables informed choice and continued support during labor and childbirth. Facility-
based childbirth lacks interpersonal and emotional care and is sometimes full of
disrespect and mistreatment. Mistreatment of women during delivery at a health facility
is a common problem in low-income countries like Kenya, Tanzania, Nigeria, Ethiopia,
and many other sub-Saharan countries (Freedman and Kruk, 2014; Afulani et al.,
2019).
Many women face many obstacles during labor and childbirth including poverty,
socio-cultural factors, accessibility to health facilities, lack of food at home and health
facilities, lack of supplies, drugs, and basic infrastructure at health facilities, poor
quality of care at health facilities, lack of participation in planning for health services
and availability of traditional birth attendants (Wilunda et al., 2014,). Medicalization
of childbirth practices has led to increased cases of women mistreatment during labor
and delivery. Women feel that they are no longer active participants in the birth
process and decision is made by service providers.

11. Often disrespect and abuse occur indirectly like lack of information to
consent for cesarean section, dismissing birth plans, and threats about delivering a
disabled child on account of non-compliance. Many service providers defend their
abusive actions by labeling women as uncooperative, disobedient, or the life of the
baby is at risk. Women have been found to accept mistreatment by health workers in
scenarios where they perceive such actions as necessary to save both mother and baby
(Balde MD et al 2017). Disrespect and abuse towards women during childbirth deters
the efforts towards achieving SDGs. This is also violating women’s right to respectful
care. Disrespect and abusive care has many consequences on the health and wellbeing
of the women including the risk of birth complication, posttraumatic stress disorder,
and reluctance to use health facilities (Munthe-Kaas HM et al, 2014). Other
consequences experienced later in life are related to sexuality, future pregnancies, and
mode of delivery (Kjaergaard H, 2013).
2.1 factor 1
Women especially in the rural settings do not know their rights and therefore they
suffer a lot during labor and childbirth. Disrespect and abuse is normalized during childbirth or
justified as necessary to save the mother and baby (Balde MD et al 2017). Many women suffer in
silence due to fear of victimization or they do not know what they can do, thus disrespect and
abuse go unreported. Browser and Hill 2010 suggested seven categories of disrespect and abuse,
these include physical abuse, non-consented care, non-dignified care, non-confidential care,
abandonment, lack of privacy, and detention. During labor and childbirth, a woman may
experience one or more forms of disrespect and abuse. Physical and verbal abuse is the

12. commonest form of disrespect and abuse. Physical abuse can be in form of slapping, hitting,
kicking, or pinching the women while verbal abuse takes the form of shouting and scolding
(Respectful Maternity Care, 2013). Physical and verbal abuse is at its peak 30 minutes before
birth up to 15 minutes after birth, at these times women are threatened that they may lose their
babies if won’t cooperate, and abdominal pressure is applied to deliver the baby which is more
painful than labor pain (Eze, I.I. et al. 2021). Nurses and midwives tend to be abusive when
dealing with anger or frustration with a non-compliant woman (Bohren et al. 2015). The Health
system authorizes service providers to have control over women believing that their practice has
a safer and better outcome (Bohren et al. 2016). Young and single with no education or little
education are more likely to experience verbal abuse than fellow women who are older and
educated (Eze, I.I. et al.2021)
Adolescents and unmarried women experience insensitive comments since pregnancy and
childbirth is viewed as appropriate in marital relationship, they are often discriminated against or
treated differently from married clients. Women with disabilities are also treated with
discrimination since they are not able to attend to themselves (Bohren et al. 2015). In some
settings, it has been reported that some women clean up themselves following their childbirth
even cleaning the floor after it has been messed with liquor, urine, blood, or feces while their
counterparts are cleaned and their linen changed (Moyer et al. 2016).
During labor and childbirth, women do not receive adequate information about the medical
procedures, providers do not take informed consent from patients regarding procedures like
cesarean sections, episiotomies, hysterectomies, and blood transfusions, sterilization, or
augmentation of labor. Informed consent promotes a woman’s autonomy and enables her to
choose what suits her (Shimoda k, et al 2018, Burrowes,s et al 2017). Medicalization of

13. childbirth is more technical and tends to control knowledge about what is happening by use of
medical terms. Decision-making is done by service providers rather than women themselves
(Bradley et al., 2016, Dzomeku et al., 2020). Young and unmarried women are more likely to
suffer from non-consented care, unlike married and older women.
Confidentiality and dignity is not a priority among women, providers are aware of how
important it is to treat a woman with dignity but they never care. Many women have limited
knowledge about their rights, although they are not uncomfortable being seen by others they feel
powerless (Mgawadere, F.et al.2018). Maintaining privacy and confidentiality sometimes is
challenging due to the open nature of the labor wards or the small space for the number of
women in labor. This is worsened by the lack of privacy screens or curtains (Afulani, et al 2020)
Maintaining women’s privacy and confidentiality at times is challenging because of the open
nature of the labor wards or too small for the number of women in labor. This is due to the lack
of privacy screens and curtains (Afulani, et al 2020)
Women and their babies at times are detained in health facilities when they are not able
to pay, this is a violation of human rights and denies them access to essential health services
(Karen D, et al 2020). Detention in health facilities increases the chance for nosocomial infection
due to unsanitary conditions in health facilities. Women with financial hardship may get
discouraged and may opt not to seek care in health facilities.
2.2 Factor 2

14. Poor communication creates a barrier between the client and service provider, leaving the client
in the dark during the decision-making process. When this happens women feel taken for granted
and health decision is taken on personal interests rather than the safety of the mother and unborn
baby. Poor communication makes it difficult to manage labor as women do not know what they
are supposed to do, either with no communication or poorly done. The situation is worsened by
health workers perceiving women as difficult to deal with and threatening to leave them alone or
verbally abuse them (Balde M D et al 2017). Insufficient information makes it difficult to
understand the procedures, rendering the women hopeless and helpless. Sometimes information
is withheld on grounds that women won’t understand and explaining to them would be fruitless.
Poor communication is also common during shift change, this is between the service providers
themselves and between the service provider and the clients.
Labor is stressful and requires emotional and psychological support. The support can be
from a health worker or birth companion to encourage and reassure her and assist with mobility
throughout the labor process. Due to limited space in birthing units or facility policy, a
companion may not be allowed. The woman is left at the mercy of a service provider who is
supposed to be very supportive and may choose to ignore patient needs and call for help, no
reassurance, emotional support, or motivation all a woman receives are insults and threats. This
leaves the woman emotionally and psychologically traumatized (Kyaddondo D et al 2017).
Mistreatment by health providers is psychologically traumatizing and makes the labor process
difficult for women as they are deprived of their autonomy (McMahon S A et al 2014). For labor
to progress, well women need emotional, physical, and psychological support, this makes them
feel safe and promotes positive experience (Balde M D et al 2017).

15. Medicalization of childbirth renders women inactive participants and no longer
decision-makers in the childbirth process. Some interventions are unnecessary and dehumanizing
to women, only taken to benefit the service provider and not for the safety of the mother and
unborn baby. Many birthing positions favor service providers and not parturient women. Women
who demand information about intervention or refuse some birthing positions are forced to
comply or threatened to be neglected, insulted or physically abused (Bohren M A et al 2014,
Beck C T et al 2018). Unnecessary intervention without medical indication should be avoided to
prevent harm to the mother and baby (Meridi M et al 2020).
2.3 Factor 3
Inadequate supplies and insufficient staffing cause a lot of stress in health facilities. Staff
shortage leads to long waiting times and neglect of patients as a result the quality of care is
compromised. Exhausted staff usually transfer their aggression to clients they serve. Staffing
constraints also contribute to a negative attitude and poor motivation among the staff. Sometimes
facilities lack essential supplies including drugs. In such a situation patients are the ones to buy
their medication and other supplies, if a client is not able to provide the required items, care is
delayed until she provides them. Poor women will be neglected and discriminated against in such
situations. Many facilities have limited space in maternity units which leads to overcrowding, in
addition, there are limited delivery beds forcing women to even deliver on the floor. The
situation is worse in the postnatal ward whereby mothers and their newborns share beds.
(Mgwadere F, et al 2019, Balde M D et al 2017). A poor working environment has a higher
contribution to poor interpersonal communication, and lack of equipment hinders client
assessment and care, hence disrespect and abuse (Lusambili A, et al 2020).

16. Health workers hand over patients’ care at the end of their shift, it is expected that different
teams will be caring for clients during their hospitalization period. In many facilities no
structured way to hand over, at times health workers will talk among themselves in a language
that clients do not understand and it is minimal or no client involvement. Continuity of care is
often interrupted after handing over whereby the new team will not address the client’s problem
and needs or may decide to reassess the clients or re-examine clients and some procedures are
uncomfortable and painful. This will lead to unnecessary delay, wrong decisions, or
interventions. In some facilities health providers will not attend to the clients unless they receive
the report, this leaves the patient vulnerable to complications (Kaye, Dan K et al 2015)
During an emergency or a complication that often occurs in labor and childbirth reliable
referral system is very important in facilities where a mother has to be referred. This will include
a functional ambulance and fuel available all the time. In such facilities, women suffer a lot
because they have to organize their means of transport or fuel the ambulance which might be
costly. (Mgwadere F et al 2019)
2.4 Factor 4
Good reception at the maternity unit is very important as it creates a first impression of what
subsequent care will be like. The warm welcome of clients without being judgmental or rude
assures the client quality and respectful care. (Kumban, I C et al 2012). Reception starts at the
point of entry to a health facility, where the gatekeeper welcomes and directs the client to where
she is going.
Provision of information is vital and promotes clients’ confidence and autonomy during care.
Health workers should give feedback after examination rather they keep it to themselves.

17. Information about the progress of labor, condition of the unborn baby, labor coping mechanism,
and her role in childbirth help reduce anxiety. During the labor process intervention may be
necessary to ensure a safe birth process, clear information will ensure active participation in
decision making by the client. (Miltenburg A G et al 2016). First-time mothers are always not
familiar with the hospital setup and organization of maternity units; they need to be directed on
where to get help when need be. During history taking health workers tend to ask questions to
complete medical records and never explain to the clients how the information would be used in
their care. Health workers do not like being asked questions, they take such women as stubborn.
Effective communication should be provided in cases where the mother and baby have to be
separated. The mother should know the condition of the baby and why the baby is being taken to
a newborn unit (David K et al 2017, Kaye Dan k et al 2015)
Once labor starts the woman becomes anxious and will want to get to a hospital as soon as
possible, any delay in receiving care makes her worried. Sometimes delay starts at the gate if the
woman goes to the hospital at night, the gatekeepers take long to let her in, and here she gets a
clue on what subsequent care will be like. Upon arrival a woman is directed to the next service
point and attended to promptly, this boosts her confidence with service providers, and she can
cope with the labor process (Ndirima Z et al 2018, Afulani P A et al 2017)