An investigation into mistreatment of women during labour and childbirth in maternity care facilities in Uttar Pradesh, India: a mixed methods study

This study investigated mistreatment during labour and childbirth in public and private sector hospitals in Uttar Pradesh, India.

Two hundred and seventy-five detailed observations of care provided during labour and delivery were conducted by clinical observers using mixed quantitative and qualitative research methods.

This study found that quality of care at the time of birth is generally poor at both public and private sector hospitals in Uttar Pradesh, India. Many inappropriate care practices are routinely utilised while providing maternity care services, which have largely been neglected in policies and programmes so far. There are complex reasons for mistreatment of women at maternity facilities. These include factors associated with policy, infrastructure and resources, ethics, culture, knowledge, skills and attitudes of maternity care providers, and standards at maternity facilities.

Addressing these issues will require long-term investments and focussed action for improvement. As facility-based births and the use of skilled birth attendants continue to rise, a focus on quality and woman-centred maternity care provision is needed to make further improvements.

The number of maternal deaths remains large in India with 45,000 estimated deaths in 2013 [1]. Since 2006, the Government of India has promoted skilled attendance at birth and rapidly expanded the Janani Suraksha Yojana (JSY) programme that now benefits approximately 40% of India’s birth cohort [2]. The JSY is a cash transfer programme that provides a monetary incentives to women attending institutions for birth [3]. Since 2013, JSY guidelines have been revised and conditionalities associated with parity and minimum age of the mother for institutional deliveries in high and low performing states and union territories have been removed.

However, recent evidence from JSY has been cautionary and highlights the need to improve Quality of Care (QoC), concomitantly, with efforts to increase utilisation of institutional births [4]. Ensuring high QoC at the time of birth encompasses the application of evidence- based obstetric and neonatal care and efforts to ensure positive birth experiences for pregnant woman [5]. Respect, dignity and emotional support, although, integral to ensuring positive birth experiences have been overlooked in research, policy, programmes and practice [6, 7].

There is now increasing research evidence on mistreatment of women during labour and childbirth from both high [8–12] and lower income settings [13–15]. Mistreatment has been previously described as disrespect and abuse [16], obstetric violence [17] and dehumanised care [18]. However, conceptualising what constitutes mistreatment, and therefore, how to measure mistreatment are both complex. A comprehensive definition of mistreatment needs to capture the health, human rights and socio-cultural dimensions of mistreatment, while, measurement efforts need to capture what, where, how and why mistreatment occurs [19]. Freedman et al. have highlighted that measurement efforts should also be able to capture whether mistreatment was intentional or not, and the role of local societal norms (for example- women’s status, patient-provider dynamics) that influences women’s perceptions of mistreatment in different contexts [19].

Given these challenges, a recent WHO systematic review tried to establish the evidence-base for mistreatment globally [11]. They found that most studies use different operational definitions and measurement approaches [11]. Amongst the quantitative studies, only three studies reported a prevalence of mistreatment at maternity facilities, which varied from 15 to 98% [11]. This review also proposed a typology of items considered mistreatment and identified the following: physical, verbal or sexual abuse, stigma and discrimination, lack of informed consent, breaches of confidentiality, neglect and abandonment, refusal to provide pain relief, lack of supportive care, detainment in facilities, bribery and extortion [11].

However, a phenomenon often overlooked in the disrespect and abuse discourse relates to the overuse of inappropriate or unnecessary interventions for care at normal birth. There are examples of health workers in both high and low-income settings underusing simple, inexpensive interventions (for example, birth companionship or counselling on breastfeeding) and overusing ineffective interventions that are more technical, lucrative or convenient despite potential for harm (for example: labour augmentation without indications or caesarean sections) [20–23].

As the 2016 Lancet maternal health series noted, there are two extremes of maternal health care provision in a growing number of LMICs [24]. The first extreme is associated with over-treatment or the routine over-medicalisation of normal labour and births, which they referred as “Too Much Too Soon”. The second extreme is under-treatment or underuse of evidence-based practices signified by the terminology “Too Little, Too Late” which is the underlying cause of high maternal mortality and considerable morbidity [24]. Both over-medicalisation such as increased use of unnecessary procedures like episiotomies without indications or under-treatment such as absent hygienic standards at maternity facilities are also against the rights of child bearing women [25].

For this study, we operationalised mistreatment as those related to 1. disrespect and abuse (no privacy, no birthing position choice, not informing women prior to a vaginal examination, not allowing birth companions, not explaining reasons for augmentation of labour, restricting food and water and informal payments) 2. Overtreatment (routine use of enema, routine use of perineal shaving, application of extreme fundal pressure, routine uterine lavage, routine manual exploration of the uterus and routine episiotomy) and lastly, 3. Under-treatment (deficiencies in infection prevention by individual health workers, deficiencies in hospital environmental hygiene and use of unqualified attendants). Research and programme efforts to improve QoC at the time of birth have largely neglected to examine and address mistreatment in such a comprehensive manner. Further, it is also possible for both under treatment and overtreatment to occur within the same patient and within the same facility [21] which makes interpreting data difficult but this should be considered by researchers working to improve QoC.

Uttar Pradesh (UP) is India’s most populous and deprived state [26]. In related work, we previously described overall poor quality of care at the time of birth [27] but did not specifically examine mistreatment of women at maternity facilities. There are limited number of studies that have described patterns and the context of such care at maternity facilities especially in the private sector which has an estimated 18% of the market share for maternity care in UP [26]. This information is essential for understanding the context of care provision and in developing effective interventions, policy and advocacy approaches for improvement of QoC at the time of birth. Available research evidence indicates that women with previously negative pregnancy outcomes tend to choose private sector [28]. Higher socio-economic status and accessibility are associated with increased private sector use [28]. Scheduled caste and tribe status are negatively associated with use of private facilities [29]. The private sector is thought to be more expensive than the public sector and there is a general perception amongst Indian women that the private sector provides better amenities and a higher standard of care [29].

Qualitative studies from public sector facilities in India have described many challenges to ensuring high QoC during childbirth such as overcrowding of labour rooms, chaotic work environments, poor coordination between health workers, limited skills and competence of health workers in performing routine care procedures [30–32]. They have also described situations where labouring women have been left unsupported, were shouted at or slapped, not given information about what procedures were being done and why they were receiving it [30, 33].

In this paper, we report on the nature and context of mistreatment recorded during 275 clinical observations of labour and childbirth in 26 maternity facilities in Uttar Pradesh. This rich observational data helps us in describing the context of care-provision in a low- resource setting including what, how and why mistreatment of women during labour and childbirth occurs at maternity facilities.

Figure 1 shows that amongst mistreatment practices, birthing position choice not offered to the labouring woman (92%) and manual exploration of the uterus after delivery (80%) were particularly high at facilities in both sectors.

Table two shows that amongst all socio-demographic characteristics, the highest mistreatment scores (mean) for women, were found in women above 35 years of age (5.1); primiparous (5.2);those that were referred from another facility (5.0); amongst women belonging to “scheduled caste and tribes” (5.0), those in the fifth (richest) wealth quintile (5.1), and amongst cases admitted during work-hours (5.0) on weekdays (5.0) in the public sector (4.9). However, the timing of admission (during weekdays or weekends) influenced a greater number of indicators of mistreatment compared to admission during regular work-hours, despite total mistreatment scores being similar across both co-variates. More women admitted during weekdays underwent episiotomies (p = 0.04) and enemas (p = 0.01) whereas, more women admitted during weekends were not informed prior to vaginal examination (p = 0.03) and did not have the process of labour explained to them (p = 0.04). We found that more women admitted during regular work-hours delivered without adequate privacy (p = 0.01), underwent enemas (p = 0.03) and extreme fundal pressure (p = 0.01) more frequently. Most women had repeat instances of mistreatment (mean = 4.8 and SD = 1.7).

Deficiencies in infection prevention by individual health workers was also an important theme in the observers’ comments. These deficiencies by individual health workers ranged from using dirty clothes to clean the perineal and vaginal areas, pouring oil over the vagina/ perineum, conducting unnecessary manual exploration of uterus, and using unsterile gloves and equipment. Although quantitative data is not available for all of these practices, available quantitative results suggest deficiencies in infection prevention measures while conducting unnecessary procedures. For example, there was a high prevalence (80%) of manual exploration of the uterus which was similar in both sectors (p = 0.10). Enemas were also observed in 30% of cases risking possible faecal contamination. It is encouraging to note that most health workers used sterile gloves; use of unsterile gloves to conduct vaginal examinations was low and happened in just 2.2% of all cases, all in the public sector (3%). Uterine lavage after delivery was also infrequent in both public (3%) and private sectors (6.3%) cases. Observers’ comments also indicate that in some facilities, instruments were sterilised once a day and often just dipped in warm water and chlorhexidine solution and reused multiple times. Vaginal examinations were observed to be conducted multiple times by different health workers. In a few instances, observers’ comments mention that used syringes were left discarded on the floor, which is a potential hazard for needle-stick injuries.

The practice of maternity care personnel asking for informal payments at public sector facilities was the most common theme identified from the observers’ comments and is a form of disrespect and abuse. However, quantitative data capturing this phenomenon were not captured during clinical observations. Observers’ comments indicate that in most instances, maternity care personnel demanded money from families for doing activities that are a part of their job description such as drying and wrapping the newborn, weighing the newborn, cleaning blood spills on the delivery bed or labour room floor and cleaning up. Often in public-sector hospitals, maternity care personnel demanded money from clients and their families to cover their costs, as they were contractual staff, allegedly, without a regular monthly income source. In some instances, informal payments were also given to health workers as gratuity payments given to express happiness at the birth of newborn.

Field notes also indicate that there is an understanding between the maternity care personnel and community health worker such as ASHAs who often act as the intermediary between the clients and health workers, facilitating the exchange of such payments. In addition, in most observations, families were asked to purchase drugs and commodities such as gloves, baby towels, medicines, delivery kits from outside, although, in principle these items should be provided free of cost at health facilities under the JSY scheme. There were also a few cases where observers documented that newborns were withheld from families until providers received payments from families. If the providers did not receive money, women were more likely to be mistreated during their hospital stay. The amount of informal payments varied between Rupees 200–2000, equivalent £2.4 to £24. The quotes below illustrate some examples of the practices of informal payments at maternity facilities.

This study explored the nature and context of mistreatment amongst women attending public and private sector maternity facilities in Uttar Pradesh. All women in the study encountered at least one indicator of mistreatment. Our estimates are similar to another cross-sectional study from a teaching hospital in south-eastern Nigeria where 98% of women reported some kind of mistreatment during childbirth [42]. Similarly, another cross-sectional study in Ethiopia also found a high prevalence of mistreatment where 100% of women that went to a teaching hospital and 89.4% that went to peripheral health centres encountered some form of mistreatment [43]. The prevalence of mistreatment reported across studies varies depending on how mistreatment is conceptualised and measured [11]. A recent cross-sectional study from Uttar Pradesh, India reported that 57% of urban slum-resident women reported some form of perceived mistreatment during childbirth [44]. In Tanzania, researchers found 19% perceived mistreatment amongst a sample of women while using hospital-exit interviews and up to 28% mistreatment amongst the same women followed-up at home which they attribute to courtesy bias in the exit interviews [45]. However, unlike in our study, both of these studies measured perceived mistreatment rather than direct observations of labour and childbirth.

We found that total mistreatment scores were higher amongst women attending district hospitals (6.14), women above than 35 years of age (5.1), primiparous (5.2), those that were referred from another facility (5.0), amongst women belonging to the “scheduled caste and tribe” (5.0), those in the fifth (richest) wealth quintile (5.1), and amongst cases admitted during work-hours (5.0) on weekdays (5.0) in the public sector (4.9). The cross-sectional study from urban slums in Uttar Pradesh, mentioned earlier also found that wealthier women, migrant women and women from lower castes reported higher levels of disrespect and abuse [44]. The importance of caste is well documented in India with many studies reporting inferior care and discrimination against women belonging to these so-called scheduled castes [44, 46–48]. Researchers have suggested that since these women are less empowered, health workers are more likely to think that they can get away with mistreatment of these women [44].

We found that not offering woman a choice of birthing position (92%) and manual exploration of the uterus after delivery (80%) were particularly high at facilities in both sectors. There is evidence from a systematic review supporting the benefits of delivering in alternative positions compared to supine positions for normal births such as shorter labour duration, fewer episiotomies and fewer second-degree tears [49]. Manual exploration of the uterus is an important risk factor for puerperal sepsis and shock [50] and should be avoided unless indicated and constitutes overtreatment which is form of mistreatment. Further, it is essential to provide all women with adequate information and obtain an informed consent prior to any invasive clinical procedure such a vaginal examination [50].

We found that the public sector performed worse than the private sector for not ensuring privacy of the labouring women (p = < 0.001), not informing women prior to a vaginal examination (p = 0.01) and for physical violence (shout, hit or pinch) towards the labouring woman (p = 0.04). There could be many reasons for poor performance of the public sector such as inadequate infrastructure, high-workloads, poor communication skills and normalisation of disrespect and abuse in actual practice. During fieldwork, we noted that public sector facilities were crowded and that maternity care personnel worked in challenging environments often without basic amenities, limited incentives and these environments were not conducive to practice evidence based maternity care.

On the other hand, the private sector was found to perform worse than the public sector for not allowing birth companions to accompany the labouring woman (p = 0.02) and for perineal shaving (p = < 0.001). This could perhaps be due to existing institutional polices in private hospital labour rooms which do not allow birth companions. A recent Cochrane review found that that continuous support from a chosen family member or a friend increased women’s satisfaction with their childbearing experience [51]. Although, performed with the belief that perineal shaving reduces the risk of infection, a systematic review has found no associated clinical benefits of shaving [52]. Perineal shaving is also recommended-against in the Indian skilled birth attendance training materials [53], which suggests that, perhaps, private sector health workers may not have received these trainings or that quality of such trainings is poor. It is also possible that perineal shaving is done more frequently in the private sector as a way of demonstrating that they provide better value for money.

We also found some interesting associations between women’s socio demographic characteristics and the prevalence of specific indicators of mistreatment. Caste was only associated with episiotomy and women in the so-called “general caste” were found to have greater proportions of routine episiotomies (p = 0.04) perhaps because they used public sector facilities more often. Women in the first quintile (poorest) were least likely to be informed prior to a vaginal exam (p = 0.002) which suggests discriminatory care based on wealth status [47]. However, women in the highest wealth quintile (richest) were more frequently unaccompanied by a birth companions (p = 0.01), had higher rates of perineal shaving (p = 0.001) and episiotomy (p = 0.001) which could perhaps reflect greater use of the private sector and consequent overtreatment of women that attend private sector facilities.

Mistreatment was found to be higher amongst women > 35 years perhaps because they had higher rates of physical abuse (p = 0.04) compared to women in other age groups. Primiparas also received higher mistreatment scores because they had higher rates of episiotomies (p < 0.001) and pubic shaving (p = 0.003) compared to women with higher parity. Women in the fifth wealth quintile (highest) also received higher mistreatment scores compared to other women because they had higher rates of episiotomies (p = 0.001), pubic shaving (p = 0.001) and were not allowed birth companions (p = 0.01), probably a reflection of where they went for labour.

Overall mistreatment scores were marginally higher for qualified attendants (4.9) compared to unqualified attendants (4.8). However, the prevalence of mistreatment is different depending on the on the type of provider. Unqualified attendants had higher rates of not informing women prior to a vaginal exam (p = 0.01) whereas qualified attendants were more likely to work in settings that did not allow birth companions (p = 0.01), and routinely performed enemas (0.001) and episiotomies (p = 0.001).

The Indian government recommends provision of maternity services by appropriately trained and qualified skilled birth attendants at health facilities. However, given the various context specific challenges in Uttar Pradesh, the prospect of all deliveries being cared for by qualified personnel at health facilities remains an important challenge. Therefore, it is important for policymakers to issue clear and comprehensive guidance on the role of unqualified providers at maternity facilities. Women that go to institutions for maternity care have a right to expect care from qualified personnel irrespective of whether it is the public or private sector. It is the duty of the government to protect those rights and design robust monitoring mechanisms to ensure that that unqualified personnel are not involved in provision of services.

Mistreatment was seen to coexist with limited adherence to evidence-based practices in this setting [27]. Saini et al. (2017) suggest that the primary drivers for poor care arise out of inequalities of information, wealth, and power [21]. In this context, we suggest that the drivers for mistreatment include resource-constraints, shortages of health workers, limited incentives, weak mentorship and supervision, restrictive institutional policies, lack of up-to-date knowledge, socio-economic factors and unequal power dynamics between health workers and pregnant women [45, 54–57]. Some researchers have also articulated that long-standing patterns of poor work-conditions, resource-scarcity, low-skills or overburdened health workers at facilities and limited choice for clients leads to poor QoC [16]. In addition, health workers may often not be aware of rights-based approaches or unable to provide high quality care despite their best intentions due to inherent organizational and work- environment related constraints, which are particularly relevant in this setting. Previous research has uncovered that there is a serious shortage of health workers in Uttar Pradesh. In fact, data from the National Sample survey (2011–2012) estimated that the density of doctors, nurses and midwives in Uttar Pradesh of 7.8 per 10,000 population was significantly below the WHO benchmark of 22.8 workers per 10,000 population [58].

While defining and measuring mistreatment, the concept of intentionality complicates measurement efforts. For example, some practices, such as fundal pressure or routine episiotomy are not evidence based and can be harmful [24, 50], but often health workers have been trained to do these things and think they are for the woman’s benefit. Are these indicators of mistreatment or of poor quality of care? Although, health workers may have been taught to use these interventions in the past, these harmful interventions are no longer recommended. Therefore, further conceptual clarity on the boundaries between mistreatment and poor quality of care is needed.

Another important finding of this study captured through observer’s comments was informal payments. Upon reflection, our QoC assessment tool should have specifically captured detailed information on informal payments. Informal payments can range from gratuity payments from appreciative patients, payments to jump the queue, receive better or additional care, to obtain drugs and commodities, or simply to receive any care at all [59]. Informal payments are considered to be inequitable and constitute institutionalised bribery, which may hamper the entire health system [59, 60]. Further, they tend to be prevalent in settings where health systems are under-funded, supervisory mechanisms are weak; where women are not empowered or not aware of their rights, and where providers are unlikely to face disciplinary action for their behaviours [59].

In summary, the literature suggests that mistreatment during labour and childbirth may be the result of many factors such as unfavourable institutional policies, resource and infrastructural constraints, socio-cultural factors, power differences between health workers and clients, limited knowledge and skills of health workers [6, 11, 56, 57]. We argue that non-adherence to clinical protocols such as through under treatment or overtreatment also constitute mistreatment of women at maternity facilities. An important question that emerges from our study is whether it is ethical to allow women to deliver in conditions where basic standards of evidence-based care, cleanliness, hygiene, dignity and equity are not met? The three districts where this study was conducted are not a part of the high priority districts of the Government of India. Therefore, it would be useful to conduct a similar study in high priority districts in Uttar Pradesh.

We demonstrated that mistreatment of women often occurs because of over-treatment and under-treatment which constitute a failures to adhere to professional standards of care [11]. Over-treatment and under-treatment should be considered in the global discourse on disrespect and abuse, as they are also a violation of human rights and constitute poor quality of care at maternity facilities. It is possible that some practices such as those related to individual health worker’s deficiencies in knowledge or skills are perhaps easier to change compared to long-standing socio-cultural factors that may give rise to mistreatment. Ultimately, mistreatment occurs, at least in part, because governments have not committed to or invested in participatory accountability mechanisms like social audits, community scorecards and others, which ensure that women’s experiences and perceptions of care are addressed and that respectful maternity care standards are followed [19]. This is one of the key recommendations emerging from this work.

Mistreatment is common in both private and public sectors, albeit of different types. Efforts to expand institutional births in Uttar Pradesh and other high maternal and perinatal mortality settings would benefit from strengthening the quality of maternity care in both sectors so that evidence-based maternity care is provided, and positive births experiences are ensured. There are at least five specific recommendations emerging from this work. First, there needs to be a systematic and context-specific effort to measure mistreatment in high burden states in India in both public and private sectors. Second, a training initiative to orient all maternity care personnel to the principles of respectful maternity care would be useful. Third, systems to promote accountability for the application of respectful, woman-centred, maternity care pathways are needed. Fourth, participatory community and health system interventions need to be designed to articulate norms, standards of care and support the implementation of respectful maternity care standards. Lastly, we note that there needs to be a long-term, sustained investment in health systems so that supportive and enabling work-environments are available to front- line health workers.