The objective of this study was to assess if there are substantial differences in experiences of care between women with or without obstetric complications. We pooled data on women who had recently given birth in Ghana, Kenya, and India from surveys that included the PCMC tool. The analysis showed that, although there were statistically significant differences in women’s experiences by complications based on several indicators, the magnitudes of these differences were in general small, and the directions of the associations were inconsistent. Based on summative sub-scale scores for the pooled sample, women who had complications had, on average, higher communication and autonomy scores, but lower supportive care scores, and about the same scores for dignity and respect and for the overall PCMC compared to women without complications. The findings were similar when we examined the association between experience of care and severity of complications. The direction of association was more consistent for mode of delivery for the pooled sample, with women who delivered via c-section reporting higher overall PCMC scores compared to those who delivered vaginally, and higher communication and autonomy and supportive care scores. However, there were variations by country, including in the direction of associations.
The lack of an overall association between PCMC scores and presence of an obstetric complication is inconsistent with previous research, where differences have been identified [6, 17, 19, 21]. But the lower PCMC scores among women with obstetric complications for the rural Kenya sample (in the stratified analysis) is consistent with prior studies. Findings from a study in Uttar Pradesh, India, for example, found that women who reported mistreatment by a provider during childbirth had higher odds of complications at delivery and postpartum [15]. Similarly, a study in Tanzania found that women who reported any complication during childbirth and those with self-reported depression in the last year were more likely to report any disrespect and abuse, while those who delivered by c-section were less likely to report any disrespect and abuse [16]. A longitudinal study in Kenya also found that women who reported higher PCMC scores at delivery had significantly lower risk of reporting both maternal and newborn complications and screening positive for depression at 2 and 10 weeks postpartum [4, 11]. This is the first study, however, to examine in detail the association between different experience of care indicators and domains from the PCMC scale with self-reported obstetric complications, severity of the complications, and mode of delivery. The inconsistency in the direction of associations for the individual indicators by complication explains the lack of significant association based on the overall PCMC scores. It also highlights that associations with composite scores will depend on the specific items constituting the score, stressing the importance of standardized tools. Provider interactions with patients may be influenced by the type and severity of the complication, which is a potential reason for the difference in the findings for the measure of complications and c-section. Further, the influence of receipt of c-section on experience may be capturing other factors such as the ability to get elective c-sections, which is influenced by social status. Moreover, the differences in the direction of the associations by country suggest contextual differences in how women with complications and those who deliver via c-section may be treated. These findings are important for understanding how women’s experiences may differ when they have a complication in a given context and for guiding future research.
Although the magnitude of the differences was small, women who reported a complication reported better experiences on several items in the communication and autonomy domain, which recorded the lowest mean score in the univariate analysis. Women with complications were more likely to report that providers introduced themselves, used a language they could understand, explained the purpose of exams/procedures and medicines, and asked for consent, than those without complications. On the other hand, women with complications were less likely to be allowed a birthing position of choice and more likely to report that they did not feel they could ask providers any questions. Potential reasons for these findings are that women with complications may be seen by specialists or unfamiliar providers, who recognize the need to introduce themselves, yet these providers might not realize that women with complications may have questions about their immediate care. Providers handling complex cases may also feel a greater need to properly inform and get consent from patients with complications because of the potential fear of litigation for adverse outcomes [24]. Another potential reason for improved communication reported by women with complications is that women with complications may stay longer in health facilities resulting in increased interaction with health providers, which in this case appeared more positive. Women who give birth by c-section are more likely to have longer stays in health facilities [25], which might explain their better experiences. In the survey in Tanzania, women who stayed less than a day in the facility were more likely to report disrespect and abuse, while women who delivered by c-section were less likely to report any disrespect and abuse [16].
In the supportive care domain, women who reported obstetric complications were more likely to report that providers talked to them about how they were feeling but they were less likely to be allowed a companion during labor and delivery. Women who had c-sections additionally reported better experiences compared to women who delivered vaginally, specifically on providers supporting them with their anxieties, paying attention when they needed help, and providing them with options for pain control. This difference could be because there is a general increase in provider attention when women have complications, [26] but women with complications may also be isolated from their families and other support persons leading to a lower sense of safety. For example, in a previous study in Kenya, providers reported not allowing companions for women with complications because they believed the presence of companions interfered with clinical management of the woman [27]. Women with complications are also more likely to give birth in higher-level facilities, where they might be less familiar, feel less safe, and be less trustful of providers [21].
In general, most women reported being treated with dignity and respect, regardless of complications. Women with complications were, however, more likely to report better privacy and feeling their medical records were kept confidential. Potential reasons include providers taking extra efforts to prevent other patients from seeing records related to the management of complications. Certain complications may also be treated in more private areas in the hospital. On the other hand, previous research suggests verbal and physical abuse tend to be heightened when there is a complication, the sense of urgency is high, and providers are afraid of a poor outcome, which might explain the higher reporting of verbal and physical abuse among women with complications in the study settings [28, 29]. Reports of more verbal and physical abuse were consistent with findings from two prior studies that examined women’s experiences and certain types of complications, using measures focused on disrespect and abuse [12, 13].
Limitations and strengths
There are some limitations in our study. Firstly, the four datasets used were designed for different purposes and not specifically to examine differences in experience of care by obstetric complication. Secondly, all data including obstetric complications are self-reported and subject to recall and social desirability bias. Studies using observation and medical record review may more accurately capture complications but may need to be combined with surveys to understand women’s experiences. Thirdly, all the surveys were cross-sectional, and we are unable to assess the temporal order of experiences and onset of complications or indication for c-section. Longitudinal or observational studies that account for temporal ordering of events are needed to assess associations between women’s experiences and complications. Larger studies may also be needed to better capture experiences within a particular location, given the small sample of women with complications in a given setting. The proportion of births that are complicated varies for different sub-populations, especially based on age and parity, and estimates of complication rates from various studies vary ranging from about 15 to 23% of which 8% are considered life threatening [30,31,32]. Qualitative studies to complement quantitative analyses would also provide a more in-depth understanding of women’s preferences and experiences during complications. We were unable to examine differences by specific complications, but rather we examined differences based on self-assessed severity of the complication and mode of delivery. This was further limited by the fact that questions were not asked consistently across the surveys, and we were, therefore, unable to analyze differences by severity of complications and mode of delivery for all the settings. All the datasets were obtained by non-probability sampling methods and are not nationally representative; the different sample sizes also imply the findings may be influenced more by the largest samples (e.g., India). We were also limited by the locations in which there were existing datasets that included both complication data and an experience of care score. Thus, there are limitations with regards to generalizability within and across the study settings.
This study has several strengths. The experience of care indicators are from a validated scale and questions had been examined in cognitive interviews to assess their relevance and comprehensibility in the study settings. The questions are also comprehensive—beyond mistreatment or disrespect and abuse—to capture the three domains of experience of care from the WHO vision for quality of maternal and newborn health [6]. Examining individual experience of care indicators enabled us to tease out the different aspects of care that were influenced by the presence of an obstetric complication. We were able to use multi-country data, providing sufficient sample size for country stratification. Using data from different countries collected from the same tool helps to increase the applicability of the findings in other settings. The findings provide preliminary information into how women’s experiences may differ in multiple settings for women with and without obstetric complications.