**2. Materials and methods**

#### **2.1. Study design**

**1. Introduction**

66 Selected Topics in Midwifery Care

and detention in health facilities [1–4].

skilled birth services [4, 11, 12].

Worldwide, a growing body of research suggests that, many women experience poor treatment during childbirth [1–4]. While the WHO [5] continues to emphasise that every woman has the right to the highest attainable standard of health, which includes the right to dignified and respectful healthcare, many women are reported to experience disrespectful and abusive treatment during pregnancy and childbirth in health facilities worldwide [1–4]. Such mistreatment includes physical abuse, non-consented care, non-confidential care, non-dignified care including verbal abuse, discrimination based on specific attributes, abandonment of care

Mistreatment of women in health facilities during childbirth is particularly worse in many low-income countries in Africa [6, 7]. For instance, a recent study showed that the prevalence of any form of mistreatment in an exit survey among a sample of 641 women who recently delivered in healthcare facilities in Kenya was 20% [8]. Another study revealed that 15% of women who delivered in a referral hospital in Tanzania reported experiencing one or more forms of abusive and disrespectful care, and this proportion reached to 78% among women who delivered in healthcare facilities in Ethiopia [2]. A systematic review also mentions in southeastern Nigeria that mistreatment of women in a teaching hospital was almost universal such that all of the women reported at least one kind of mistreatment during childbirth [9]. Women commonly reported physical abuse (35.7%), including being "restrained or tied down during labour" (17.3%) and being "beaten, slapped, or pinched" (7.2%); while being "sexually abused by a health worker" was reported by 2.0% of the women [9]. Similarly, a qualitative study exploring mistreatment of women in rural Tanzania estimated that 19.5% of women who reported experiencing any form of mistreatment during childbirth in the facility increased to 28.2% during a follow up survey of same women within 5–10 weeks postpartum [10]. Some 18.9% of the women reported receiving non-dignified care; 13.8% reported being abused verbally; 15.5% reported being neglected; and 5.1% reported being abused physically [10]. In Ghana, previous qualitative research has also documented that mistreatment during facility-based delivery is a salient issue, that sometimes prevent women from seeking

Given the potential for mistreatment during childbirth to undermine future use of skilled birth services in health facilities, the WHO [5] has called for greater research, action, advocacy and dialogue on this important public health issue, in order to ensure safe, timely, and respectful care during childbirth for all women. Likewise, respectful care is a key component of both the mother-baby friendly birth facility initiative currently being implemented in many low-income settings, and the WHO's vision for quality of care for childbearing women and newborns [5]. To date, however, there have been few quantitative estimates of the prevalence of mistreatment of women during facility-based childbirth in Ghana and the determinants of such mistreatment [4, 13]. This knowledge gap could potentially hamper efforts to ensure that all women receive respectful and dignified care during pregnancy and childbirth in Ghana. A health facility-based retrospective cross-sectional quantitative survey was conducted. Validated survey questionnaires were used to collect data to estimate the prevalence of mistreatments women received during their most recent childbirth, and also determine the association between various exposure variables and the outcome of interest—mistreatment.

#### **2.2. Study setting**

Empirical research was conducted in Ghana, a low-income country in West Africa. Ghana is one of the countries in Africa where maternal mortality remains a challenge. For instance, out of 5247 deaths among women aged 15–49 in 2014, 12.1% (634) were pregnancy-related [4]. Low levels of health facility delivery are partly responsible for this relatively high number of maternal deaths [11, 12]. Recent data suggest that out of 794,000 live births annually in Ghana, only 76% are attended by skilled professionals [14]. Despite the fact that the Government of Ghana has implemented initiatives to increase facility-based delivery, including making antenatal care and skilled delivery free [15], giving special attention to pregnant women to easily complete the processes of the National Health Insurance Scheme (NHIS) registration and waiving enrolment fees into the NHIS, as well as scaling up safe motherhood and child survival interventions [16], many women in Ghana still give birth outside health facilities without skilled care [14]. Recent studies have suggested poor quality of maternal healthcare services and mistreatment of women as key reasons why some women in Ghana do not deliver in health facilities [4, 11, 12].

Within Ghana, empirical data collection took place in the Tema General Hospital in the Tema Metropolis of the Greater Accra region. The population of the Tema Metropolis, according to the 2010 Population and Housing Census, is 292,773, representing 7.3% of the region's total population [17]. Females represent 52.2% of the total population of the metropolis. Also, nearly all of the population in the metropolis lives in urban localities [17]. The Metropolis has five government health facilities, 58 private health facilities, four quasi-government facilities and 32 community-based health planning and services (CHPS) zones [18]. The Tema General Hospital serves as the main referral Hospital in the Metropolis with regard to maternal healthcare for both private and public health facilities [18]. This is the main reason why it was chosen for this study. The maternity block of the Hospital has a total of 294-bed capacity [18]. The facility recorded 7000 deliveries in the year 2016, of which 2035 were deliveries by caesarean section and 41 maternal deaths [18].

were identified. Each of the 2357 women was then given a unique number, starting from 0001 to the last woman on the list i.e. 2357. The numbered list was then exported into a Googlebased random number generator software and the 253 respondents were randomly selected. Following this selection, a visit was made to the CWC of the Tema General Hospital to meet each selected woman on the day she was scheduled to attend the CWC. During this meeting, we explained the purpose of the study to selected women as well as how they were selected. The women were then given time (2 weeks) to decide their participation. After the 2 weeks, each woman was contacted via telephone. Where the decision was in favour of participation, a date and interview venue were agreed upon between the authors and each woman. Most women agreed to do the interview during their next visit to the CWC, which happened between May and July 2018. However, for any selected woman who did not come to the CWC in the course of the study (there were 3 such cases) or opted not to take part in the study (there were 4 such cases), such women were replaced by repeating the random selection process on

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the remainder of the women not selected in previous round/s of random selection.

Data was collected through face-to-face survey from May to July, 2018. A structured, closedended questionnaire was designed for the data collection. The questionnaire focused on collecting information on a number of issues including socio-demographic characteristics, reproductive and maternal health history, and experiences of mistreatment during childbirth. We adopted and adapted several validated questions from previous researchers [1–3, 8, 20, 21], based on Bowser and Hill's [22] typology of mistreatment. Our operational definitions of the specific components of mistreatment we were interested in are summarised in **Table 1**. The questionnaires were in English, but were asked in English and three other local dialects (*Ga*, *Twi*, and *Ewe*) depending on which one a respondent was fluent in. The second author who collected

**2.6. Data collection methods and instruments**

the data speaks all three local dialects fluently.

**Category of mistreatment Example**

Discrimination based on specific patient

**Table 1.** Type and definition of mistreatment.

attributes

Physical abuse Hitting, roughly forcing legs apart for delivery

Non-dignified care Humiliation by shouting, blaming, or degrading

delivery

Non-confidential care No privacy (spatial, visual, or auditory)

Detention in facilities Not releasing mother until bill is paid

Non-consented care No informed consent for procedures, such as when provider elects to perform unnecessary episiotomy

educational level, etc. Abandonment of care Facility closed despite being 24/7, or if open, no staff can or do attend

HIV status, ethnicity, age, marital status, language, economic status,

#### **2.3. Study population**

The study's population comprised all women who had given birth at the Tema General Hospital between November 2017 and April, 2018. However, women who had complicated births as well as women who had stillbirths were excluded. We excluded these categories of women because complicated or stillbirths may typically require additionally invasive interventions which could unduly affect women's judgement about mistreatment. Besides, women who go through complicated birth or stillbirth may experience physical and emotional stress, which could also affect their judgement about mistreatment during childbirth.

#### **2.4. Sample size estimation**

A minimum sample size of 230 was first estimated using Cochran's statistical formula for crosssectional studies [19]. The sample size estimation was based on the following assumptions:


The minimum sample size of 230 was adjusted upward by 10% to cater for possible incompleteness of data. Thus, the final sample size for the study was 253.

#### **2.5. Sampling procedure**

A simple random sampling method was used to select the 253 respondents. To ensure that each qualified potential respondent in the sampling frame had equal chance of being included in the study, the register of all women who had given birth in the facility between November 2017 and April, 2018 and were attending child welfare clinic (CWC) at the Tema General Hospital was obtained from the senior nursing officer of the maternity unit. Using the inclusion and exclusion criteria outlined above, the names of all women who had live and uncomplicated births were compiled in excel spreadsheet. In all, a total of 2357 potentially qualified women were identified. Each of the 2357 women was then given a unique number, starting from 0001 to the last woman on the list i.e. 2357. The numbered list was then exported into a Googlebased random number generator software and the 253 respondents were randomly selected. Following this selection, a visit was made to the CWC of the Tema General Hospital to meet each selected woman on the day she was scheduled to attend the CWC. During this meeting, we explained the purpose of the study to selected women as well as how they were selected. The women were then given time (2 weeks) to decide their participation. After the 2 weeks, each woman was contacted via telephone. Where the decision was in favour of participation, a date and interview venue were agreed upon between the authors and each woman. Most women agreed to do the interview during their next visit to the CWC, which happened between May and July 2018. However, for any selected woman who did not come to the CWC in the course of the study (there were 3 such cases) or opted not to take part in the study (there were 4 such cases), such women were replaced by repeating the random selection process on the remainder of the women not selected in previous round/s of random selection.

#### **2.6. Data collection methods and instruments**

nearly all of the population in the metropolis lives in urban localities [17]. The Metropolis has five government health facilities, 58 private health facilities, four quasi-government facilities and 32 community-based health planning and services (CHPS) zones [18]. The Tema General Hospital serves as the main referral Hospital in the Metropolis with regard to maternal healthcare for both private and public health facilities [18]. This is the main reason why it was chosen for this study. The maternity block of the Hospital has a total of 294-bed capacity [18]. The facility recorded 7000 deliveries in the year 2016, of which 2035 were deliveries by

The study's population comprised all women who had given birth at the Tema General Hospital between November 2017 and April, 2018. However, women who had complicated births as well as women who had stillbirths were excluded. We excluded these categories of women because complicated or stillbirths may typically require additionally invasive interventions which could unduly affect women's judgement about mistreatment. Besides, women who go through complicated birth or stillbirth may experience physical and emotional stress, which could also affect their judgement about mistreatment during

A minimum sample size of 230 was first estimated using Cochran's statistical formula for crosssectional studies [19]. The sample size estimation was based on the following assumptions:

**2.** Prevalence of mistreatment of women in the sample was assumed to be 20%. This assumption was based on a recent study in Kenya which found overall prevalence of mistreatment

The minimum sample size of 230 was adjusted upward by 10% to cater for possible incom-

A simple random sampling method was used to select the 253 respondents. To ensure that each qualified potential respondent in the sampling frame had equal chance of being included in the study, the register of all women who had given birth in the facility between November 2017 and April, 2018 and were attending child welfare clinic (CWC) at the Tema General Hospital was obtained from the senior nursing officer of the maternity unit. Using the inclusion and exclusion criteria outlined above, the names of all women who had live and uncomplicated births were compiled in excel spreadsheet. In all, a total of 2357 potentially qualified women

pleteness of data. Thus, the final sample size for the study was 253.

caesarean section and 41 maternal deaths [18].

**2.3. Study population**

68 Selected Topics in Midwifery Care

**2.4. Sample size estimation**

to be 20% [8].

**1.** Confidence level was set at 95%.

**3.** Margin of error (5% = 0.05).

**2.5. Sampling procedure**

childbirth.

Data was collected through face-to-face survey from May to July, 2018. A structured, closedended questionnaire was designed for the data collection. The questionnaire focused on collecting information on a number of issues including socio-demographic characteristics, reproductive and maternal health history, and experiences of mistreatment during childbirth. We adopted and adapted several validated questions from previous researchers [1–3, 8, 20, 21], based on Bowser and Hill's [22] typology of mistreatment. Our operational definitions of the specific components of mistreatment we were interested in are summarised in **Table 1**. The questionnaires were in English, but were asked in English and three other local dialects (*Ga*, *Twi*, and *Ewe*) depending on which one a respondent was fluent in. The second author who collected the data speaks all three local dialects fluently.


**Table 1.** Type and definition of mistreatment.

#### **2.7. Pre-test and quality assurance**

The questionnaires were pre-tested in the CWC of another public health facility in the Tema Metropolis using 20 randomly selected mothers who gave birth between November 2017 and April 2018. The pretest enabled ambiguities in the wording of some questions to be corrected. The pretest also enabled us estimate the average time required to complete each questionnaire. In addition to the pretesting, other quality assurance measures were implemented. Data collected by the second author were checked every day by the first author to ensure accuracy and completeness. Errors that were detected were discussed and where needed, follow up interviews were made to correct any such errors.

Hospital. Participation in the study was entirely voluntary, and this was communicated to all selected respondents. Before interviews were conducted, each participant signed or thumb printed an informed consent form to confirm their voluntary consent to participate in the study. However, respondents were told that they could withdraw consent and discontinue their participation in the study without any adverse consequences. Also, as some aspects of the mistreatment some women received were emotionally traumatising for them to recount during our study, we ensured that all such women were referred to a clinical psychologist based at the same health facility for counselling. However, this process was entirely voluntary, and no woman was referred if she did not want to see the psychologist. In addition, interviews were conducted in a private room where maximum anonymity and confidentiality were ensured. No direct compensation or benefits were paid to respondents. However, each respondent received age and sex-appropriate toy for their baby worth only GHȻ5 (\$1).

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Questionnaires were successfully completed for all the 253 respondents. **Table 2** shows the background characteristics of respondents. The mean age was 28.1 years (SD = ± 6.0). The majority (34.4%) were aged 24–29 years. The majority (32.4%) also attained secondary school education, while only 9.9% had no formal education. Also, 69.6% were heterosexually married, and most marriages (65.7%) were monogamous. Christians were in the majority (87.4%).

In terms of parity, majority (86.2%) of the respondents had between 1 and 3 children.

**Characteristics Frequency Percent (%)**

15–19 13 5.15 20–24 63 24.90 25–29 87 34.39 30–34 49 19.37 35–39 26 10.28 40–44 15 5.93

No formal education 25 9.88 Primary 36 14.23 JHS 81 32.02 Secondary 82 32.41 Tertiary 29 11.46

Married 176 69.57 Separated 14 5.53

**3. Results**

*Age*

*Level of education*

*Marital status*

**3.1. Socio-demographic characteristics of respondents**

#### **2.8. Data processing and analysis**

#### *2.8.1. Data entry and processing*

The completed questionnaires were hand-coded and entered into Microsoft Excel. The data were then exported to Stata 15 version software for further cleaning. Cleaning of the data was done by running frequencies on each variable. This checked inconsistently coded data. Inconsistently coded data were double checked with raw data from the questionnaire, and all inconsistencies and errors were resolved.

#### *2.8.2. Variables*

The dependent variable in this study is mistreatment of women during childbirth. Mistreatment was defined as specific behaviours of providers, which are related to any of the seven categories of mistreatment listed in **Table 1**, and expressed towards mothers in ways that are disrespectful or humiliating [23]. Questions on mistreatments were measured as dichotomous, such that any respondent who reported experiencing any of the seven categories of mistreatment in **Table 1** was considered mistreated.

A number of independent variables expected to influence mistreatment were also measured. These included socio-demographic characteristics such as age, marital status, income level, educational level and religion. Other maternal and health system factors included mode of delivery, type of birth attendant, HIV status and antenatal care (ANC) attendance during pregnancy.

#### *2.8.3. Statistical analysis*

Descriptive statistical analysis (frequency, mean and standard deviation) was performed to describe important characteristics of respondents as well as estimate prevalence and forms of mistreatment women received during childbirth. Bivariate and logistic regression analyses were then performed to examine factors associated with mistreatment of women during childbirth. Statistical significance was considered at 95% confidence level and a p < 0.05.

#### **2.9. Ethical issues**

Ethical approval was sought and obtained from the Ghana Health Service Ethical Review Committee. In addition, administrative consent and approval to conduct the study in the hospital was sought and obtained from the director of medical services of the Tema General Hospital. Participation in the study was entirely voluntary, and this was communicated to all selected respondents. Before interviews were conducted, each participant signed or thumb printed an informed consent form to confirm their voluntary consent to participate in the study. However, respondents were told that they could withdraw consent and discontinue their participation in the study without any adverse consequences. Also, as some aspects of the mistreatment some women received were emotionally traumatising for them to recount during our study, we ensured that all such women were referred to a clinical psychologist based at the same health facility for counselling. However, this process was entirely voluntary, and no woman was referred if she did not want to see the psychologist. In addition, interviews were conducted in a private room where maximum anonymity and confidentiality were ensured. No direct compensation or benefits were paid to respondents. However, each respondent received age and sex-appropriate toy for their baby worth only GHȻ5 (\$1).
