**4. Discussion**

As shown in **Table 4**, many women experienced multiple forms of mistreatment during their most recent health facility delivery. The majority of women (25.7%) suffered from two types of mistreatment; 17.4% suffered three types of mistreatment; 11.1% suffered four different types of mistreatment; and 5.5% suffered five types of mistreatment. Only 0.8% of the women suffered six types of mistreatment, with no respondent reporting suffering all the seven types

**Table 5** presents information on bivariate analysis investigating the association between socio-demographic factors and mistreatment based on chi-square test of independence. Age of mother (p = 0.046), mother's level of education (p = 0.048), mother's monthly income (p = 0.045), and husband's monthly income (p = 0.002) were statistically significantly associated with mistreatment of women during their most recent childbirth in the Tema General Hospital. In addition to the socio-demographic factors, other maternal and health system factors were assessed. The results are shown in **Table 6**. A woman's HIV status (p = 0.009), as well as type of birth attendant during childbirth (p < 0.01) were statistically associated with

In total, six (6) factors showed statistical association with mistreatment at the bivariate level. These were pulled into a logistic regression model in a second round of analysis. A simple logistic regression analyses model, followed by a multiple logistic regression analyses model, were then performed on the six variables. The results are shown in **Table 7**. After adjusting

**Table 7.** Predictors of mistreatment during childbirth (logistic regression analysis). \*p < 0.05

of mistreatment studied.

78 Selected Topics in Midwifery Care

mistreatment.

**3.3. Factors associated with mistreatment**

This study is among the first in Ghana to quantitatively estimate the prevalence of mistreatment of women during health facility-based childbirth and associated factors. Findings suggest that, the overall prevalence of mistreatment of women during their most recent childbirth in the Tema General Hospital was high (83%), with most of the mothers experiencing detention (43.1%) due to lack of fee payment, non-confidential care (39.5%), neglect/abandonment (31.8%), verbal abuse (25.3%), discrimination (21.3%), physical abuse (14.2%), and non-consented care (13.3%). Many women also experienced multiple forms of mistreatment. The main factors that significantly predicted mistreatment were being HIV positive, being attended by a midwife rather than an obstetrician/gyneacologist, and a woman's husband earning lower monthly income.

A number of our findings above deserves further commentary. Compared to other previous studies in Africa [8, 9], the 83% prevalence of mistreatment in this study is relatively high. It is however not surprising as evidence from a recent systematic review suggests that mistreatment is increasing in many low-income settings especially in urban areas [13]. With increasing population in many urban areas in SSA amid declining human and financial resources for health as well as deteriorating health infrastructure, there are suggestions that congestion in maternity wards, under-staffing, and over working of health staff, may be compromising quality of maternity care, including mistreatment of women during childbirth [21, 24–26]. It is also possible that mistreatment may not be increasing per se; just that many urban women are becoming increasingly aware of their rights as patients partly because of improvements in formal education. This is more likely in the present study given that the majority of women had some formal education. Be that as it may, the relatively high prevalence of mistreatment in this study is a cause for concern. Mistreatment of women in health facilities during childbirth does not only violate the rights of women to respectful care, but can also threaten women's rights to life, health, bodily integrity, and freedom from institutional violence [5]. Thus, not only is mistreatment a public health issue but it also becomes a human rights and an equity issue [10]. As a number of studies have shown, women who experience mistreatment from midwives or other maternity care providers in a health facility setting are often less likely to go to a health facility again in subsequent childbirth [4, 11, 12]. This suggests a need for interventions to raise awareness among maternity care providers about the potential adverse effect mistreatment of women could have on utilisation of skilled birth services in the future, and the need to treat women with respect and dignity during childbirth.

and SSA are attended by midwives, our finding here is very concerning. Lack of cultural competency, limited training on patient-centred care as well as low staffing numbers and work overload among midwives are possible factors that could contribute to midwives inadvertently mistreating women during childbirth. This would again suggest a need to further strengthen the core training curriculum of midwives to emphasise patient-centred care and interpersonal communication and relationships in addition to increasing the staffing numbers and expanding infrastructure to enhance the interaction between midwives and women during childbirth. Regular on-the-job training of midwives to improve the cultural competency skills alongside improved supervision and greater accountability in the labour wards could

Mistreatment of Women in Health Facilities by Midwives during Childbirth in Ghana: Prevalence…

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Although findings from this study would provide useful information that could guide policy and practice to reduce mistreatment of women in health facilities during childbirth, the study has some limitations. A major limitation is the cross-sectional retrospective survey design that was used, which did not offer opportunities for observational and longitudinal analysis to be done. Observing the interactions between women and maternity care givers would particularly have provided important nuances and as well introduce validation mechanisms into the data collection process. Also, there could be recall bias as respondents were made to recall events that happened in the past 6 months prior to this study. These limitations aside, we believe important lessons could be learnt from our study. Also, our findings could form the basis for a large-scale, more elaborate study using both qualitative and quantitative methods along with health facility audits, to determine the scale of mistreatment of women during childbirth in both urban and rural health facility contexts, and the drivers of

This study aimed to examine the prevalence of mistreatment of women during childbirth in health facilities in Ghana, and the factors associated with such mistreatment. Results revealed the prevalence (83%) of mistreatment of women during childbirth in the Tema General Hospital to be high. The specific types of mistreatments varied from woman to woman, but the most prevalent forms were detention, physical mistreatment (hitting, slapping, pinching, legs held and forced apart), and verbal abuse (shouted at, insulted, and reprimanded). A number of factors have been identified to be statistically related to mistreatment, including husbands' monthly income, being HIV positive, and being attended in childbirth by a mid-

Taken together, the results and discussions in this study add to a growing body of evidence across Africa including in Nigeria [1], Tunisia [2], Ethiopia [7, 20, 25], Kenya [8, 24], and Guinea [21] that suggests mistreatment of women during childbirth as an important public health and human rights issue. Our study, together with evidence from previous research within Africa, gives an indication of the factors that may be contributing to mistreatment of women during childbirth. We think the widespread nature of the phenomena of mistreatment of women

all help lessen mistreatment.

mistreatment.

**5. Conclusion**

wife as against an obstetrician/gynaecologist.

This study also indicated that 43% of women who were detained after delivery were as a result of non-payment of medical bills. This is an important factor especially in SSA where women are not as economically empowered as men, and one would therefore expect to find many women with very low monthly income. This seems to be the case in this study where women appeared to earn far lower monthly incomes than their husbands, and where husbands' monthly income was a significant determinant of mistreatment. Indeed, in an Ethiopian study, women with higher monthly incomes were less likely to experience mistreatment as compared to those with a lower monthly income [7]. In countries that still have a user-fee system, poor women may be detained in hospitals after delivery for failure to pay the required bills. A recent study in Ghana indicated that 22% of the women in the sample were detained in health facilities after delivery for nonpayment of fees [9]. Our finding in relation to the relatively high detention rate of women after birth is however surprising given that Ghana has since 2005 implemented a user-fee exemption policy for skilled delivery services. It could be the case that there are other informal charges not covered under the user-fee exemption policy. This is more likely given that previous research in Ghana has reported the existence of informal charges in many health facilities despite the existence of the NHIS and the user-fee exemption policy for delivery services. Our findings here would suggest a need to relook at the user-fee exemption policy for maternal healthcare services to ensure that services are truly free for women. Also, ensuring timely enrolment of all pregnant women on the NHIS through the user-fee exemption policy could lessen the financial burden mothers and families may go through during childbirth.

Again, non-consented care (no informed consent before procedures), non-confidential care, performing vaginal examination in the presence of other people, including patients, as well as disclosure of medical history without consent were other forms of mistreatment mothers went through during delivery. These findings could be due to under-staffing, lack of resources and smaller size of the labour ward and delivery rooms in the hospital. The findings here imply that, expanding the staffing numbers and labour ward and partitioning the rooms with lowcost curtains may have a great bearing on ensuring privacy and respectful maternity care.

Another important finding relates to the fact that women who were HIV positive were more likely to report being mistreated compared to those who were HIV negative. This is not so surprising given that HIV/AIDS is still largely a highly moralising and stigmatising disease in many contexts in Africa. Our result here however does suggest a need for maternity care providers to be less judgmental and discriminatory when dealing with HIV positive mothers. Rather, compassionate and dignified care needs to be emphasised in the care delivery process.

Finally, women whose births were attended by obstetricians/gyneacologists were also significantly less likely to report mistreatment compared to those whose births were attended by midwives. Given that majority of births in this study, and indeed in most parts of Ghana and SSA are attended by midwives, our finding here is very concerning. Lack of cultural competency, limited training on patient-centred care as well as low staffing numbers and work overload among midwives are possible factors that could contribute to midwives inadvertently mistreating women during childbirth. This would again suggest a need to further strengthen the core training curriculum of midwives to emphasise patient-centred care and interpersonal communication and relationships in addition to increasing the staffing numbers and expanding infrastructure to enhance the interaction between midwives and women during childbirth. Regular on-the-job training of midwives to improve the cultural competency skills alongside improved supervision and greater accountability in the labour wards could all help lessen mistreatment.

Although findings from this study would provide useful information that could guide policy and practice to reduce mistreatment of women in health facilities during childbirth, the study has some limitations. A major limitation is the cross-sectional retrospective survey design that was used, which did not offer opportunities for observational and longitudinal analysis to be done. Observing the interactions between women and maternity care givers would particularly have provided important nuances and as well introduce validation mechanisms into the data collection process. Also, there could be recall bias as respondents were made to recall events that happened in the past 6 months prior to this study. These limitations aside, we believe important lessons could be learnt from our study. Also, our findings could form the basis for a large-scale, more elaborate study using both qualitative and quantitative methods along with health facility audits, to determine the scale of mistreatment of women during childbirth in both urban and rural health facility contexts, and the drivers of mistreatment.
