"I Would Have Stayed Home if I Could Manage It Alone": A Case Study of Ethiopian Mother Abandoned by Care Providers During Facility-Based Childbirth.

BACKGROUND: Every woman is entitled to respectful care during pregnancy and childbirth as a basic human right. However, not all women are being treated equally well. CASE
PRESENTATION: This case study highlights some of the common disrespectful practices that women face. This is a testimony of a 28-year-old mother of two, narrated in her own words. The data were collected during an in-depth interview in November 2019. The interview was conducted in her house and her name has been changed to protect her identity. The interview was audio-taped using a digital voice recorder, later transcribed, and translated verbatim from the local language - Amharic, to English.
CONCLUSION: This woman's story highlights the unfortunate reality for some women. Five themes emerged from her narrative: denial of care: the provider left her unattended at a critical moment and denied her the care that she came for; non-consented care: she did not consent to the episiotomy; non-dignified care: she was carried by her arms and legs to the delivery couch, and left naked and bleeding on the couch after birth; taking a sick baby home without medical assistance: she was forced to leave the hospital even though her child had breathing difficulties and was not able to suck or breastfeed; and loss of trust in care providers: for her second birth this woman went to a facility where a relative works, as she no longer trusted these providers.

Plain Language Summary

Disrespect and abuse of women during facility-based childbirth includes the way care providers act, behave, or treat childbearing women, these actions contravene the basic human rights of childbearing women. Abandonment is among the seven categories of disrespect and abuse and is characterized by care providers denying care or neglecting a woman during labor, childbirth and/or immediately after birth. The authors sought the opinion of a mother who had experienced abandonment. This information was obtained via a face-to-face interview.

This testimony narrates the woman’s story of being a victim of disrespect and abuse in a facility. This abandonment by care providers during childbirth resulted in her child becoming disabled and the woman experiencing significant loss of trust in care providers.

In conclusion, disrespectful care during facility-based childbirth may lead to poor outcomes for both the mother and baby and can deter women from seeking lifesaving professional maternity care for subsequent births.

Background

Despite progress in reducing maternal mortality, Ethiopia still has one of the highest maternal mortality ratios in the world; this is estimated to be 401 per 100, 000 live births in a recent health survey.1 As maternal and newborn mortality mostly occur during birth and immediate postpartum period, ensuring access to quality maternity care is a key aspect of reducing avoidable deaths. Quality maternity care requires health facilities to be adequately equipped with compassionate skilled providers, physical resources and medical supplies.2

The United Nations established 17 Sustainable Development Goals in 2015. These Sustainable Development Goals are the blueprint to achieve a better and more sustainable future for all. Sustainable Development Goal 3 (SDG 3) outlines “Good Health and Well-being”.3 The first target of Sustainable Development Goal 3 is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030.4 In order to achieve this, Ethiopia needs to reduce its 2.3% annual maternal mortality threefold to 7.5%.5,6 Accordingly, the government of Ethiopia has focused considerable efforts on education of health care providers, building new and upgraded facilities, and making maternity care services cost free. As a result, primary healthcare coverage has improved.7 However, despite this progress, significant problems remain. This is reflected by the fact that only 48% of women gave birth in a health facility in 2019.8

Improving access to a health care facility is not a sufficient inducement to encourage pregnant women to seek professional maternity care.9 The perception and experience of women regarding the quality of the service also influences utilization.10 Improving the quality of care and humanizing maternity care is vital to increase service uptake.11 Recent studies have suggested that improving both access and quality of care are vital to reduce the maternal mortality ratio.9

Quality of care, however, is a complex phenomenon often explained as an interaction between health system structures, interpersonal and technical aspects of care provision, and outcomes of care.10,12 Respectful care is a universal human right for women and babies and is an important dimension of quality. The World Health Organization (WHO) has issued a statement for stakeholders on prevention and elimination of disrespect and abuse during facility-based childbirth, emphasizing respectful maternity care as core indicator of quality of care.13 Nonetheless, any attempt to understand quality of care concepts should start with an analysis of “what women need and want”.14

A global finding from 1.2 million women in 114 countries revealed that women prioritize respectful and dignified care above all else.15 Respectful care is a fundamental right for every woman and baby.11 However, many women in Ethiopia are mistreated by their attendants during facility-based childbirth.16–22 This mistreatment is manifested as any form of uncaring behavior or inhumane treatment,23 and such encounters can potentially deter women from seeking professional maternity care.24 As a result, they may opt to birth at home, often relying on traditional birth attendants rather than qualified health professionals. This in turn increases the risk of maternal and neonatal morbidity and mortality.25

The White Ribbon Alliance (WRA) has categorised disrespect and abuse during facility-based childbirth in to seven categories; physical abuse, non-consented care, non-confidential care, non-dignified care, discriminatory care, abandonment or denial of care, and detention in facilities.10 Abandonment or denial of care may have negative health consequences for both a mother and her newborn.26 This may occur for a variety of reasons including; the facility being closed when it is supposed to operate 24 hours, a facility being open but no staff are available, if healthcare providers did not encourage a woman to call when she needed them, providers making a woman feel alone or unattended, providers not coming quickly when needed, providers denying support during labour, a woman being left unattended during birth of her baby, providers failing to intervene when medically indicated, or providers failing to grant a woman’s requests.27

The aim of this case report is to record and share one woman’s experience of disrespect in a facility that resulted in her child becoming disabled following abandonment by care providers during childbirth.

Case Presentation

This is a testimony of a 28-year-old mother of two, narrated in her own words. The participant is of Gurage ethnicity and has a bachelor’s degree. She lives in Fitche town, the capital of north showa zone, about 110kms to the north of Addis Ababa. The data were collected during an in-depth interview in November 2019, in her home. The interview was audio-taped using a digital voice recorder. The woman was invited to share her personal experience during facility-based childbirth. The interview was transcribed and translated verbatim from the local language, Amharic, to English. Both transcript and translated version of the document were cross-checked with the original interview by an experienced linguist.

This interview was conducted as part of project examining disrespect and abuse of women during facility-based childbirth in Ethiopia. While conducting a focus group and discussing the issue of abandonment or denial of care, I noticed some of the participants gave one another a surprised glance. On further enquiry, they told me that their neighbor is a woman with a traumatic experience of care, and that “her life was never the same since the incident. We can see the sorrow in her eyes you know.” Following the focus group, I invited the participants to speak to their neighbor and ask if she would like to share her story with me for our project. I was then invited to talk to her in her house the following day. The respondent was provided with the information sheet and given time and explanation to freely consent (or not) to be involved in the study.

The woman explained that she had visited the hospital to give birth to her first child on Oct 3, 2014 in the afternoon. However, she did not receive the care she had anticipated. Rather, she was abandoned by care providers during labor, and she believes that this lack of appropriate care for the baby led to birth complications and cerebral palsy. She has repeatedly visited different referral hospitals in Addis Ababa to seek better care for her baby. The woman explained that she has significantly lost trust in care providers, and as a result, she visited a different health facility for the birth of her second child, five years later. She has a relative who works in this other facility and could care for her, so that she felt safe.

Abandonment or Denial of Care

Upon our meeting, Aisha (name changed) welcomed me into her house and after taking a deep breath, began narrating her story in a deep sorrowful voice.

I have fresh memory of it. It was afternoon when I arrived at the hospital, they (care providers) kept me in the waiting room without any checkup till the night shift workers came. The night shift checked me only once as I spent the whole night laboring. Early morning, as I felt the urge to push down the baby, the doctor left me with interns, instructing them to attend me. The baby was coming out, but the doctor did not wait, he abandoned me. I screamed out of helplessness and overwhelming pain, nobody cared. The interns neither helped me nor did they call for help. They denied my very basic right, the care I came for.

Non-Consented Care

A couple of hours later, the reckless doctor came back very relaxed after I was exhausted by the prolonged labor. I was worn out and could not push anymore; he noticed a problem and rushed to a procedure. He cut my genitalia (episiotomy) without any explanation while I was in the waiting room. He was not careful when he cut my body without my consent. Then, two men hold my legs and other two my arms and took me to the delivery room. They put me on the delivery couch like a trash. What are they going to lose if they give me a tiny respect and took me on stretcher? They did not utter a word all this time, they just did what they think was right and took the baby out. After all who can question them? I gave birth about 24 hours after my admission.

Aisha went silent for a while …

The baby did not cry at birth and I thought I lost him. The doctor dashed to the bed at the corner. He was pumping something to my baby’s mouth and one of the interns was compressing his chest. Seeing my first born like this traumatized me. Still now, thinking of that moment gives me stab on the chest. I laid on that couch naked in humiliating way and bleeding till one of them came remove the placenta and stitch the tear they made down there, as if he was sewing a piece of cloth. The suturing was no more less than a labor, they did not give me any anesthesia. The wound took more than two months to heal. For a couple of weeks sitting was impossible. I turn from one side to the other on bed with so much pain. I was having a smaller number of meals than I should thinking of the misery during defecation. During that period only Allah knows what I went through. I have to ask my mom traditional wound care practices to prevent infection because they neither advised nor gave me antibiotics on my discharge.

Non-Dignified Care

They transferred me to the postnatal room and kept my child behind. Though I was drained by the prolonged labor I could not rest because of my child’s circumstance. None of this could have happened to me if that devil doctor were around. He could have shortened my suffering. I knew my baby was in trouble but nobody, nobody said a word to me, let alone reassuring me. They even yelled at me for crying out loud ‘do not make our work difficult already, act like a grown woman.’ My husband and family who were waiting outside the ward the whole time heard my cry and interfered. Only then, one of the interns told them that the baby was suffocated (asphyxiated) and is on oxygen. (being resuscitated)

After a long resuscitation that took more than twenty minutes, my baby cried, and they gave it to me. They did not tell me how to proceed with nursing or any precaution with the illness that my baby had. They just told me I am ready to go off within 3 hours. I wonder how many lives went wrong in their reckless hands. They are accountable for my darkened life. The baby was not breathing well, let alone sucking breast when I left the hospital and they did not care at all, they just wanted me to get out of their sight. The doctor said, ‘your child is ok and will start sucking breast any time soon.’ He was not sorry that he abandoned me at that critical moment with students who were supposed to work under his supervision and now he rushed me to leave the hospital. I do not know what I did to him to deserve this, he just watched me when I took home a sick baby. I believe someday Allah will punish him the way he deserves. He made me hate all care providers and the entire health care system.

Aisha could not talk any longer and started crying. I gave her time to recover.

Taking Sick Baby Home without Support

After a while Aisha took a breath and continued:

I left the hospital three hours after giving birth as per his (the doctor) decision though the baby was still unable to suck breast. We waited till next morning and even tried canned milk, but he could not take it. We returned to the hospital after 24 hours when the baby’s breathing difficulty got worse. Another team of care providers received us and told us that the baby was not breathing well and should not have left the hospital in the first place. They checked and admitted him (to neonatal intensive care unit) for ten days. They were even planning to refer him to Addis Ababa but later changed their minds and kept him there. Nobody updated me about my child’s circumstance. Imagine staying in hospital separated from your sick newborn baby that long, thinking they will hand me over his body sooner or later. As a mother that was the worst time of my life.

We went home after 10 days; my baby was spoon feeding, still unable to suck my breast. They told me that was the maximum they could do. As advised, I tried to breast feed him, but did not succeed. My life changed from that day on, he cries day and night. I have to carry him at all times, I cannot rest during the day or sleep at night. I have visited referral hospitals in Addis Ababa and got nothing except wasting my time and money. Finally, a pediatrician neurologist at Tikur Anbessa specialised referral hospital diagnosed him with cerebral palsy. He told me my boy’s brain was irreversibly damaged because of the prolonged labor without intervention or help. He told me the poor prognosis of my child: that he may encounter developmental delay, speech problems, not dressing by himself … soooo many disabilities. He is five years old now and still looks like a newborn, he cannot sit, and feed himself. I have to change his position as he cannot move his head. He takes only milk (bottle feeding) and I have to widen the opening of the bottle because he cannot suck. I have tried to diversify his food, but he cannot take them. As to his friends he was in kindergarten, but he never left the bed by himself. They disabled my child and took away his future.

Aisha is still very angry towards the care providers:

“This problem would not have happened to my baby if that doctor has some humanity in him. I feel bad when I think of hospitals now, I have a negative memory. He considered my cry as a joke and abandoned me. My family believes the baby is disabled because of my abandonment during labor. Nobody anticipated this to happen to my child. Since it was my first pregnancy, I was curious and had full antenatal care follow up. I had paid attention to every detail they (care providers) told me. I was never told that my pregnancy has a problem. My relatives and neighbors were all preparing to celebrate Allah’s gift with my family. Now, some people say it was a bad luck, but I will always say he (the doctor) put an end to my child’s life before it even started. What is the fate of my child, until when he is going to stay in bed?” She became very emotional and cried but continued to tell her story. “I always live with a grief when I see my child lying in bed unable to talk and feed himself. He follows me with his eyes across the room and this breaks my heart most. My life turned upside down, I cannot sleep at night or leave home during the day.” Aisha cried again. “I am hopeless creature. What sin did I do to get such a punishment?”

She wiped her tears and continued after a long sigh,

… First, it is a job they are paid for and above all it is a matter of life and death for us. If they do not like the profession, they should change it, otherwise it is not decent to play with our lives. Why are they in a white coat if they are not keen to help others? I would have stayed home if I could manage it alone; it broke my heart when they abandoned me.

Loss of Trust in Care Providers

When I gave birth to my second child six months ago, I carefully chose the facility where my relative works and she took good care of me. If not for her, I would have given birth at home. I did not allow any other staff to come near me except for her. How can I trust care providers and give birth in their hands after all that they did to me? Look, I am an educated urban woman and understand well the risks of home birth. Likewise, I had bad experience in hospital; the care providers were very mean to me. Their bad attitude deters women from seeking skilled attendants at birth. How can you go there knowing they will degrade your humanity? They treat you with respect only if they know you. So, it is not wise to visit a random health facility for a childbirth, or else you may regret it. I advise women of my community to visit health facilities where they have a relative or at least a friend.

Discussion

Every woman has the right to receive respectful care during childbirth. Nevertheless, not all women are being treated in this way. This case report provides insight from a testimony provided by a woman using her own words. She clearly describes what it is like to feel abandoned by health care providers during facility-based childbirth, and the devastating ongoing consequences of this. The main themes that arose through her story were denial of care, non-consented care, non-dignified care, taking sick baby home without support, and loss of trust in care providers.

Interpersonal quality of care and disrespect and abuse during facility-based childbirth has garnered increased attention internationally. Studies from a range of cultural contexts have recently reported on care providers’ lack of empathy, rudeness, uninformed decision making and denial of care.25,28 Such abusive practices violate the basic right of women to be treated with respect and dignity10 and can significantly impact women’s willingness to seek life-saving maternity care.13,25 This case study clearly outlines that the healthcare providers treated Aisha in a disrespectful way and failed to appropriately assess her, with devastating results. She was abandoned during labor and her baby did not receive appropriate treatment after birth.

Appropriate medical care can shorten labor.29 Conversely, abandonment of a woman during the second stage of labor may prolong the labor and lead to dangerous health complications. Prolonged labor can cause neonatal cerebral palsy, a neurological condition that damages part of the brain that controls muscles and motor skills.30,31 Oxygen deprivation during prolonged labor is one of major factors that cause this brain damage. This condition largely affects movement and muscle tone, but can include far-reaching complications, such as speech difficulties.32 This woman was abandoned during labor and her baby did not receive appropriate treatment after birth.

Every woman is entitled to an explanation of any proposed procedures in a language and at a level of explanation that she can comprehend, so that she can knowingly consent or refuse a procedure.10 The universal definition of non-consented care includes when a provider does not (a) introduce herself/himself, (b) encourage a woman to ask questions, (c) respond politely, truthfully, and promptly, (d) explain procedures and expectations, (e) give periodic updates on status and progress, (f) allow the woman to move during labor, (g) allow the woman to assume a position of choice, (h) ensure informed consent for procedures. Non-consented care violates women’s right to information, informed consent and refusal, and respect for choices and preferences, including companionship during maternity care.33

Care providers must ensure client’s comfort during procedures. Every woman seeking care is a person of value and has the right to be treated with respect and dignity.13 A laboring mother should be encouraged to express her views freely, even when they differ from service providers’ views.33 Non-dignified care is characterized by (a) humiliation by shouting, blaming, or degrading, (b) not speaking politely, (c) using abusive language, and (d) making insults or threats. In this case study the woman experienced a myriad of these aspects of non-dignified care, was carried into the labor ward by her arms and legs and was left naked and bleeding for an extended period of time.

Disrespect and abuse in facilities are among the biggest barriers to women seeking maternal health services globally24 and is perceived differently (or even normalized) depending on the specific setting.20 Therefore, a human rights approach to maternity care internationally is vital to support efforts to reduce maternal mortality. Incorporating fundamental human rights into legal and medical frameworks and translating them into measurable actions and outcomes is critical.34 Every laboring woman should feel valued, respected, and appreciated by her attendants.33

Conclusion

In this case, the provider left the mother unattended and denied her the care she came for. Abandonment of the mother during labor and lack of appropriate care for the baby led to cerebral palsy and significant loss of trust in care providers. As a result, this woman only feels safe attending a facility where a relative works and can care for her. Disrespectful care during facility-based childbirth deters women from seeking lifesaving professional maternity care for subsequent births.