**5. Conclusion**

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,

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

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 the need to treat women with respect and dignity during childbirth.

through during childbirth.

80 Selected Topics in Midwifery Care

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 midwife as against an obstetrician/gynaecologist.

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 thus far in many countries in Africa has clear implications for midwifery and future research. First, we think our findings provide a basis for large-scale further quantitative and qualitative studies in different contexts in Ghana and in other African countries to estimate the prevalence and forms of mistreatment of women during childbirth, identify important determinants, and explore detailed contextual, structural and personal level explanatory factors as well as relevant remedial policy options and interventions. Second, and beyond this proposed research agenda, we think the time has come for this evidence to be taken up more seriously not just by individual countries like Ghana or health facilities like the Tema General Hospital, but also by midwifery training institutions and professional bodies in different African countries such as the Ghana College of Nurses and Midwives and the West African College of Nurses and Midwives. In addition to a need for critical self-reflection and professional re-orientation of the practice of contemporary nursing and midwifery care within these training institutions and professional organisations to uphold human rights and patient dignity, there should also be professional ethics training for midwives as part of both the core curriculum for training midwives and routine in-service or on-the-job training. This training could also include patient-centred care and interpersonal communication and relationships building.

**Conflict of interest**

**Author details**

**References**

The authors declare that they have no conflict of interest.

1 Department of Population, Family and Reproductive Health, School of Public Health,

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

http://dx.doi.org/10.5772/intechopen.82432

83

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Childbirth. Geneva: World Health Organisation; 2015

2 Stellenbosch Institute for Advanced Study, Stellenbosch University, South Africa

John Kuumuori Ganle1,2\* and Ebenezer Krampah1 \*Address all correspondence to: jganle@ug.edu.gh

University of Ghana, Accra, Ghana

s12978-017-0290-9

s12939-016-0367-z

10.1016/j.midw.2016.06.014

Given that women who experience mistreatments from healthcare providers are less likely to go to the health facility again during future pregnancy and childbirth, our results also have specific practical implications for the Ghana Health Service more generally, and the Tema General Hospital more specifically. It is important that interventions are put in place to train service providers in patient-centred care and interpersonal communication and relationships so as to minimise mistreatment. Specifically, the Tema General Hospital, together with the Ghana Health Service (GHS), and the Ministry of Health (MoH) should strengthen education of both patients and healthcare providers on patients' rights and responsibilities under the Patients' Charter, and to establish reporting mechanisms in the hospital so that women who suffer unjust mistreatments during childbirth could feel free to report and be responded to appropriately. A sanctions regime, including temporary suspension and total dismissal from work, should also be considered in this regard to deter healthcare providers who unjustifiably mistreat women. Before the above recommendations are implemented however, we recommend expansion in health infrastructure especially in urban areas as well as increasing the human resource base especially the number of midwives so as to reduce work overload and overwork. Finally, there is a need for both public and private sector health facilities that provide maternity care to women to liaise with the GHS and the MoH to ensure that the free maternal health benefit package under the NHIS is comprehensive and covers all women in order to eliminate all informal payments. Also, sanctions should be meted out to healthcare providers who charge unofficial fees. This could help reduce the phenomenon of maternity detention after birth, which contributes to mistreatment.

## **Acknowledgements**

This manuscript was first drafted when the first author (JKG) was a Fellow at the Stellenbosch Institute for Advanced Study (STIAS), Stellenbosch University, South Africa. Writing space for the manuscript was graciously provided by STIAS. We are grateful for this support.
