Health providers' compliance with pregnant women's Bill of Rights in labor and delivery in Iran.

BACKGROUND: Delivery is one of the most important crises with mental, social, and deep emotional dimensions in women's life. Health providers' respect to pregnant women's Bill of Rights, as an important component of providing humanistic and ethical care, is of utmost importance. This study aimed to determine health providers' compliance with the pregnant women's Bill of Rights in labor and delivery and some of its related factors in 2013.
MATERIALS AND METHODS: This descriptive, cross-sectional study was carried out on the subjects selected through census sampling (N = 257) from among the healthcare providers working in the labor rooms of four educational hospitals. The data were collected by a self-reported questionnaire whose validity and reliability were established. Data were analyzed through descriptive and inferential statistics.
RESULTS: The compliance with pregnant women's Bill of Rights was found to be at a very high level in 22.8% of the midwifery students, 28.6% of the residents of obstetrics and gynecology, 21.9% of the interns, 50% of the obstetrics and gynecology faculty members (professors), and 31.9% of the midwives. There was a significant difference between the five groups of service providers in terms of overall compliance with mothers' rights (P = 0.002). The results showed that the residents in higher years of education (P = 0.001), midwifery students in higher semesters (P = 0.001), midwives with more work experience (P < 0.001), and personal experience of being hospitalized in labor room (P < 0.001) had a higher compliance with Bill of Rights. Meanwhile, there was no significant difference in compliance with Bill of Rights between labor and age (P = 0.82).
CONCLUSIONS: The results showed that the health providers' compliance with the pregnant women's Bill of Rights was not acceptable in the labor room. Therefore, necessary actions are needed to remove the barriers against pregnant women's compliance of Bill of Rights and to facilitate the compliance with it in hospitals.

INTRODUCTION

Delivery is one of the important events that a woman experiences in her life. This is an experience that affects women's future health and their relationship with their families.[12] Positive experience of delivery in women is formed when they are well supported at the time of delivery. Since 1993, some changes in maternal and delivery care have occurred after designing various guidelines and bills of rights in most of the countries with the goal of modification of care quality and compliance with mothers’ rights including their awareness of various care methods and their informed selection and the increase of justice in receiving care.[34] In Iran, patients’ Bill of Rights was firstly designed in the Ministry of Health and Medical Education in 2001 and was revised due to its existing defects. The new Bill of Rights was issued to all universities in 2009.[5]

Bill of Rights for the mothers in labor and delivery was designed in accordance with the Iranian culture by the Ministry of Health, Treatment and Medical Education. This Bill of Rights, like the other bills of rights, includes conservation of privacy, confidentiality of the information related to the mother in labor, availability of information, informed consent, and respect to the mothers’ preferences and decisions, freedom, independency, and the right to participate in decision-making, receiving appropriate care, and being safe against any type of physical and psychological hazards, which should be obeyed by all treatment team members.[6] Labor Bill of Rights is just a collection of ethical codes, already learned by the treatment team during their education, is laid in emotional domain with regard to categorization of educational goals, and should be institutionalized and valued.[7] Based on this, it is recommended to consider this issue not only during the education as a theoretical lesson but also in clinical skills training. Even after graduation, it should continue in the form of continuing education.[8] It is understood that compliance with patients’ Bill of Rights leads to improvement in patients–health staff interaction. Patients’ awareness of their own rights results in an increase in quality of care and reduction of the costs.[9] Meanwhile, disrespecting patients’ rights can endanger their health, life, and safety and results in a lowered efficiency of the care and services given to the patients.[10] Literature review shows a wide gap between national policies and treatment team performance in giving services and the compliance with patients’ rights (especially among mothers during labor). The results of studies showed that neither the mother nor the treatment team staff is familiar with the rights of the mothers in labor. Meanwhile, some personnel, despite being aware of these rights, actually disrespect the Bill of Rights, which results in a disorder in their function. Khodakarami et al. showed that 85% of the women were unaware of their rights in labor room and although most of them had signed the consent form, only 12.4% actually had an informed consent and most of them had no idea about the content of consent form. In addition, most of the mothers did not receive adequate knowledge about delivery stages, treatment interventions, and the related delivery mode.[11] Bayrami showed that after holding an educational workshop on patients’ rights for the midwives, based on the viewpoints of 70% of the subjects in the study group, psycho-social legal rights issues had been followed at a very high level in the study group, While 96.5% of control group believed that their psycho-social rights were respected at “medium” level.[12] Ozdemir reported that in Turkey, 51% of the midwives and nurses claimed not to have studied any materials in relation with patients’ rights.[13] Afshari reported that most of the midwives had adequate knowledge about religious legal issues (coverage of labor women's body, not looking at or touching her body, conducting episiotomy, etc.), but their function was poor in some contexts.[14] Respect to patients’ rights depends on social, cultural, economic, and ethical variables in a society.[15] With regard to the importance of mothers’ compliance with the rights in the labor room and its role in different and specific outcomes among various patients, this study aimed to determine health providers’ compliance with the pregnant women's Bill of Rights in labor and delivery and some of its related factors in the year 2013.

MATERIALS AND METHODS

This is a descriptive, cross-sectional survey conducted in four educational hospitals affiliated to Isfahan University of Medical Sciences. In the present study, 257 subjects were selected through census sampling (N = n), including undergraduate midwifery students (over semester 5), all non-straight BS students and MS midwifery students who were passing their internship or clerkship periods in labor rooms at the time of the study (n = 84), all residents of gynecology and obstetrics (n = 40), interns of general medicine (who were passing their internship period at the time of study) (n = 34), all academic members of the gynecology department (n = 21), and midwives (including casual or employed staff who attended the research environment) (n = 78). In case of losing interest in continuing with the study or not responding to the questions, the subjects were excluded. Finally, data analysis was performed with 226 completed questionnaires (response rate of 87%). Data collection tool was a researcher-made questionnaire designed based on mothers’ Bill of Rights in relation with labor that was issued by the Ministry of Health and Medical Education, and was completed through self-report method. The first section of the questionnaire included demographic characteristics such as age, school year of the residents, semester, marital status, and subjects’ personal experiences of labor. The second section was about the level of compliance with the mothers’ Bill of Rights in labor, designed by the Ministry of Health and Medical Education (16 items), scored in a five-point Likert's scale (always, often, sometimes, rarely, and never) with points ranging 0–4, which was evaluated through a self-assessment method. Then, the total score was calculated. In addition to calculation of relative and concrete frequency, the scores were categorized into five groups of very poor (0–20), poor (20–40), moderate (40–60), good (60–80), and very good (80–100). Content validity was used to establish the validity of the questionnaire through consideration of indications of 10 academic members of Isfahan University of Medical Sciences. Test-retest was used to establish the questionnaire's reliability, and the questionnaire was completed by 15 students, residents, and midwifery personnel who were qualified to complete the questionnaire.

Next, with a 10-day interval, the questionnaire was completed again and a correlation of over 80% was obtained for all items. Researcher obtained permission from the authorities of the nursing school and the educational hospitals, affiliated to Isfahan University of Medical Sciences, based on subjects’ internship and working shift schedule. Then, after getting her letter of introduction and an informed consent from the subjects, the researcher distributed the questionnaires among the subjects to notify their viewpoints concerning their compliance with mothers’ Bill of Rights in a self-report method and collected them back. Data were analyzed by Mann–Whitney, Kruskal–Wallis, Spearman, and Pearson correlation coefficients through SPSS. Significance level was considered to be 0.05.

Ethical considerations

Ethics approval was obtained from the ethics committee of Vice Chancellery for Research in Isfahan University of Medical Sciences. Voluntary return of the completed questionnaires by subjects showed their informed consent.

RESULTS

The findings showed that mean age of the subjects was 30.0 (8.29) years. There were general medicine interns (n = 32), midwifery personnel (n = 69), gynecology and obstetrics residents (n = 28), midwifery students (n = 79), and gynecology and obstetrics department academic members (n = 18). The results showed that there were 132 married (58.40%) and 94 single (41.60%) subjects. Only 82 subjects (36.28%) had experienced hospitalization in the labor room, while the rest did not have such an experience. The level of compliance with mothers’ Bill of Rights was found to be at an excellent level in 22.8% of midwifery students, 28.6% of gynecology and obstetrics residents, 21.9% of general medicine interns, 50% of gynecology and obstetrics academic members, and 31.9% of midwives [Table 1]. Kruskal–Wallis test showed that the compliance with mothers’ Bill of Rights was not the same in the different groups (the lowest score was in the two groups of midwifery interns and midwives and the highest in gynecology and obstetrics academic members) (P = 0.002) [Table 2]. There was a significant association between the level of mothers’ Bill of Rights compliance and the school year of gynecology and obstetrics residents (P = 0.001), midwifery students’ semester (P = 0.001), and work experience (P < 0.001), but it showed no significant association with age (P = 0.826). Mann–Whitney test showed that the level of compliance with mothers’ Bill of Rights was higher in those with a personal experience of labor, compared to those without such an experience (P < 0.001).

Table 1

Frequency distribution of the subjects’ compliance with labor women's Bill of Rights

Table 2

Comparison of mean (SD) of subjects’ compliance with labor mothers’ Bill of Rights

DISCUSSION

This study investigated the level of compliance with mothers’ Bill of Rights in the labor room and during parturient period among members of the treatment team in educational hospitals in Isfahan. The results showed that about half of the academic members complied with the Bill of Rights at an excellent level. Meanwhile, in the other four groups, only about one-fourth of the subjects complied with mothers’ Bill of Rights at an excellent level, which shows a defective compliance. The subjects’ levels of compliance with mothers’ Bill of Rights in labor was not the same in such a way that the lowest was in the two groups of interns and midwives and the highest was in gynecology and obstetrics academic members. Based on researcher's investigations, no study has been conducted by the Iranian Ministry of Health on compliance with labor mothers’ Bill of Rights in Iran. Most of the studies had been conducted on compliance with patients’ Bill of Rights. Bazrafkan et al. reported that the compliance with professionalism was appropriate among clinical academic members.[16] An investigation on staff's viewpoints about patients’ rights in Thailand showed that the healthcare providers had a high level of attitude and function concerning patients’ rights and reported that one of the reasons for such a high function of the treatment team was administration of care based on ethical codes.[17] Meanwhile, numerous studies revealed a relative incompliance with patients’ rights. Simbar et al. showed that administration of care during labor contractions by the treatment team in Tehran was at its lowest level of appropriateness.[18] Mossadeghrad and Esnaashary also reported that the compliance with patients’ rights was poor in Shahid Beheshti hospital in Isfahan.[19] Kazemnezhad and Hesamzadeh, in a study on the level of compliance of the physician and nurses with patients’ Bill of Rights from the viewpoints of their colleagues, reported a significant difference in the two groups of physicians and nurses concerning general compliance with patients’ rights, and also reported that general compliance with patients’ rights was lower among the physicians.[20] In the present study, compliance with mothers’ Bill of Rights was significantly higher among the subjects with previous experience of hospitalization in labor, compared to those without. In fact, they had a better understanding of the pregnant mothers’ condition in parturient period, which resulted from their own personal experience. The findings showed a direct association between compliance with mothers’ Bill of Rights in labor and the number of BS midwifery students’ semester and the residents’ school year in such a way that higher semesters of midwifery students and higher school years of residents brought about more compliance with the Bill of Rights. This issue reveals the role of education and exposure to a clinical setting. The obtained results showed that midwifery students and general medicine interns had a lower compliance with clients’ Bill of Rights, possibly due to their less exposure to a clinical setting. Patenaude et al. reported that ethical considerations were higher among senior students compared to junior students. Meanwhile, in the same study, ethical consideration was reported to be higher in some university students attending hospital in their first year, and decreased with time.[21] Yamany reported that the role of clinical education in learning professional ethical specifications was very important and suggested paying more attention to the role model character of an academic member to improve the role of clinical education in professional ethics. She also indicated professional ethical criteria in students’ and academic members’ evaluation.[22] The present study showed a significant association between subjects’ compliance with mothers’ Bill of Rights and their age. Limjaroen reported no significant association between treatment team's attitude toward compliance with patients’ rights and their age in Thailand.[17] There was a direct association between subjects’ compliance with mothers’ Bill of Rights and their work experience in such a way that higher work experience brought about higher compliance. Nasiriani et al., in a study on implementation of patients’ rights from nurses’ viewpoints, reported a significant association between the experienced staff having skills such as braveness, problem-solving skills, increased preparation for risk taking, and ability to overcome the problems during care, and administration of ethical care based on patients’ need.[23] Therefore, one of the challenges in the educational system of the managers is development of the strategies that support the treatment team in development of such abilities and emphasizing on these skills.[24]

CONCLUSION

Compliance with patients’ Bill of Rights is based on cultural and social conditions in each society.[25] Therefore, the advantages and disadvantages of its implementation in various societies should be investigated and modified with help of the results obtained in other studies and their localization. In the present study, observation of function of treatment team was conducted through self-report method in which the subjects might have scored their function falsely higher (compared to their real score), which it can be counted as a limitation. Therefore, conducting further studies through a non–self-report method, as well as supervision, inspection, and evaluation of labor rooms in hospitals are recommended.