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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
DECLARATION

2. 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.
Signature ……………… Date ………………………….

3. APPROVAL

4. 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. ABSTRACT
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).
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;

6. 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.
METHODS
As part of the evaluation to assess the prevalence of disrespect and abuse by health care
providers in facility-based childbirth, direct observations, interviews and questionnaires were
employed in the facility. Frequencies of disrespect and abuse items organized around the Bowser
and Hill categories of disrespect and abuse and presented in the White Ribbon Alliance’s
Universal Rights of Childbearing Women Framework were calculated. Bivariate analysis was
done to assess the association between selected client background characteristics and the place of
delivery with the disrespect and use during childbirth.

7. RESULTS
A total of 200 observations were made in Ikutha sub county hospital in kitui county. Additional
150 questionnaires were also issued and duly filled in the facility. The results showed that while
women were frequently greeted respectfully (13.9% were not), they were often not encouraged
to ask the health provider questions (73.1%), were not given privacy (58.2%) and were not
encouraged to have a support person present with them (83.2%). Results from the bivariate
analysis did not show a consistent relationship between place of delivery and D&A items, where
the odds of being shouted at was lower in a health center when compared to a hospital, while
there was a higher odds of clients not being asked if they have any concerns if they were in a
health center when compared to a hospital. Women who were HIV+ had significantly lower odds
of not having audio and visual privacy, of not being asked about her preferred delivery position
and of not being asked if she has any other problems she is concerned about.
1.8 CONCLUSION
This study is among the first to quantify the prevalence of disrespect and abuse during labor and
delivery in Kitui county through direct clinical observations. Measurement of the poor treatment
of women during childbirth is essential for understanding the scope of the problem and how to
address this vice.

8. CHAPTER ONE
INTRODUCTION
1.1 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.

9. 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.
1.2 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.

10. 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.
1.3 Significance of the study
The Population-based surveys have investigated vital information regarding
disrespect and abuse occurring in health facilities during childbirth but they
were unable to capture explanations of clients and providers about
compassionate and respectful care during maternity care. Qualitative research
will thus be conducted to complement population-based surveys to obtain an
understanding of how women and midwives perceive, interpret and consider a
number of factors affecting maternity care during delivery in this study.
Language and conduct of health practitioners during child birth will also be put
into consideration.
The study also adds to the existing body of knowledge on women and
midwives‟ perspectives of compassionate and respectful care during facility-
based delivery services. Understanding of their perspectives is essential and

11. helpful in guiding health care practitioners to design women-centered practice
guidelines that address negative perceptions of health facility-based delivery.
Ultimately, enhanced positive experiences with the delivery care could enhance
the uptake of facility delivery in the future and assist with avoiding of direct
obstetric complications and maternal death. Furthermore, the information that
will be generated through this research will be useful to other researchers as
reference material.

12. CHAPTER TWO
LITERATURE REVIEW
Recently, more information has been made available on how women have been treated during
and after labor and delivery. The information is significant in the sense that women who have
been mistreated during labor and delivery are likely not to ask for the services again in their
lifetime. In this study, we provide results about whether women were abused, mistreated or
mishandled during childbirth by midwives.
2.1. Midwives experience of provision of maternity care
2.1.1. Who is Midwife?
The International Confederation of Midwives (ICM) define a midwife as: “a
person who has completed a midwifery education program that is based on the
ICM Essential Competencies for Basic Midwifery Practice and the framework
of the ICM Global Standards for Midwifery Education and is recognized in the
country where it is located; who has acquired the requisite qualifications to be
registered and/or legally licensed to practice midwifery and use the title
„midwife‟; and who demonstrates competency in the practice of midwifery”.
Midwives have a wide-ranging and uniquely skilled place in caring for women
not only throughout pregnancy and childbirth but also in antenatal and postnatal
care; neonatal care; sexual health and fertility services in partnership with
women and their families.
2.1.2. Midwives care during child birth
Midwives are the primary professional group to provide care during childbirth
(3).an exploratory study done in Sweden showed midwives experience creating
a calm and safe environment by their caring attitude and sharing of
responsibility. A similar study done in Norway identified midwife’s first
encounter with the woman as a key opportunity for establishing rapport during
labor This study also identified being mentally present and actively developing
mutual trust as two important factors for building a relationship for laboring
mothers. Other studies done in Afghanistan reported that skilled birth attendants

13. provided all necessary services to laboring mothers including checking vital
signs, use of pantograph during labor, administration of medication. And also
they provided moral support and required information about the progress of
labor.
“It is challenging to be expected to provide excellent maternity care
whilst you do not have enough midwives in a day to cover a shift let alone those
specialist midwives that we are dreaming of and we do not have. We are
extremely short-staffed in the maternity ward”
The above quote is taken from the study done in South Africa and showed the
effect of the shortage of midwives in providing quality maternity care. This
study further describes the shortage of material, Indecisive manager, poor staff
communication and lack of management support as some factor that leads to
poor provision maternity care. A study done in Amhara regional state, Ethiopia
on quality of intrapartum midwifery care reported competence of midwives,
insufficient availability of essential equipment, lack of training as barriers to
giving quality labor and delivery care.
2.2. Women experience of maternity care
2.2.1. Experience of care in health system
Experience of care is a process indicator and reflects an interpersonal aspect of
the quality of care received. This indicator broadly composed of three domains:
effective communication, respect and dignity and emotional support
(25).facility-based delivery is one chance for women to get health care
experience. Women need service to be provided respectfully but evidence
showed that women face humiliating and undignified conditions in health
facilities(26)

14. 2.2.2. Abuse and Disrespect in facility based delivery
All childbearing women need and deserve respect and protection of their
autonomy and right to self-determination during facility-based delivery however
many women across the globe experience disrespectful, abusive or neglectful
treatment during childbirth. Disrespect and abuse in childbirth defined as
interactions or facility conditions that local consensus deems to be humiliating
or undignified, and those interactions or conditions that are experienced as or
intended to be humiliating or undignified. In a 2010 landscape analysis, Bowser
and Hill described seven categories of disrespectful and abusive care during
childbirth these are physical abuse, non-consented care, non-confidential care,
non-dignified care, discrimination, abandonment of care and detention in
facilities.
A number of studies have identified the disrespectful and abusive treatment of
women during facility-based delivery. An observational study done in Kitui
reported that 94% of laboring mothers experienced disrespect and abuse. In a
study done in South Africa, 51% of women reported to have non-respectful
maternity care and teenage and young mothers, a mother with no schooling or
primary education, Mother from other country and mother with less than 20-
year residency in South Africa reported more negative experience.
Facility and community survey in rural Tanzania showed that the prevalence of
disrespect and abuse was found to be 19.5% in an exit interview and 28.2 in the
follow-up interview. The same study done in Kenya also revealed that 20% of

15. the women reported any form of disrespect and abuse. A cross-sectional study
done in southern Mozambique showed that the prevalence of disrespect and
abuse was found to be 24% in central hospital and 80% in the district hospital
and lack of confidentiality/privacy reported as the main type of disrespect and
abuse.
In Ethiopia, the rate of ranged from 67% in western Oromia, 78% in Addis
Ababa, to 99% in southern Ethiopia.
2.2.3. Midwives perspective on disrespectful and abusive maternity care
A study done in Ghana identified abusive and disrespectful care to be practiced
by both practitioner midwives and staff midwives and the reason for
disrespectful care is explained as an alternative way not to lose the life of baby
or mother. A Similar study in Nigeria reported midwives‟ belief of disrespectful
care as an appropriate measure to ensure good outcomes to mother and baby.
Similar study done in Tigray region reported the practice of disrespect and
abuse by midwives and put resource scarcity of the health facility as reason
behind the practice. Other similar study done in Ethiopia reported physical and
verbal abuse as well as non-consented care to be practice by midwives during
labor and delivery and most midwives explained these abusive care to be
unintended and are the result of weakness in the health system or from medical
necessity.

16. CHAPTER THREE
OBJECTIVES OF THE STUDY
3.1 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.
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.

17. 3.2 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?
3.3 Broad objectives
To assess the prevalence is abusive care among women who have facility-based childbirth at
Ikutha sub-county hospital.
3.3.1 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.
3.4 Variables
The proximate variables in the study were;

18. Disrespect
Abuse
Age
Religion
Level of education
Marital status
3.5 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

19. 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.

20. CHAPTER FOUR
METHODS AND MATERIALS