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Exposure to disrespectful patient care during training: Data from midwifery students at 15 midwifery schools in Ghana
Midwifery 41 (2016) 39–44
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Midwifery journal homepage: www.elsevier.com/midw
Exposure to disrespectful patient care during training: Data from midwifery students at 15 midwifery schools in Ghana Cheryl A. Moyer, PhD, MPH (Associate Director, Global REACH)a,n, Sarah Rominski, PhD, MPH (Senior Research Associate, Global REACH)a, Emmanuel Kweku Nakua, MSc (Lecturer)b, Veronica Millicent Dzomeku, MSN (Lecturer)b, Peter Agyei-Baffour, PhD (Lecturer)b, Jody R. Lori, PhD, CNM (Associate Dean for Global Affairs, Associate Professor)c a
University of Michigan Medical School, 1111 Catherine Street, Ann Arbor, MI 48109, USA Kwame Nkrumah University of Science and Technology, Accra Road, Kumasi, Ghana c University of Michigan School of Nursing, 400 North Ingalls Street, Ann Arbor, MI 48109, USA b
art ic l e i nf o
a b s t r a c t
Article history: Received 2 March 2016 Received in revised form 5 July 2016 Accepted 9 July 2016
Objective: to determine what midwifery students throughout Ghana were witnessing, perceiving, and learning with regard to respectful care during labour and childbirth. Design: cross-sectional survey. Setting: public midwifery schools in all 10 regions of Ghana. Participants: all graduating midwifery students in Ghana. Measurements: 929 final-year students at 15 public midwifery schools in Ghana were asked to complete a self-administered computerised survey addressing a range of topics, including experiences during training. All data were collected anonymously and analyzed using Stata 13.0. Findings: 853 students completed the questionnaire (91.8% response rate): 72.0% said maltreatment was a problem in Ghana and 77.4% said women are treated more respectfully in private than public facilities. Students described providers: telling women to stop making noise (78.5%), shouting at women (68.8%), scolding women if they didn’t bring birth supplies (54.5%), treating educated/wealthy women better than less educated / poor women (41.5%/38.9%), detaining women who couldn’t pay (37.9%), and speaking disrespectfully to women (34%). Only 4% of students reported not witnessing any disrespectful treatment. Students reported providers being overworked (76.5%), stressed (74.2%), and working without adequate resources (64.1%). Where students performed their clinical training (teaching hospital, district hospital, public health clinic, private facility) had no effect on perception of maltreatment as a problem. However, students who trained in district hospitals witnessed more types of disrespectful care than those who did not train in district hospitals (p¼0.01). Conclusions and implications: a majority of midwifery students throughout Ghana witness disrespectful care during their training. Implications include the need for provider curricula that address psychosocial elements of care, as well as the need to improve monitoring, accountability, and consequences for maltreatment within facilities without creating a culture of blame. & 2016 Elsevier Ltd. All rights reserved.
Keywords: Maltreatment Disrespect and abuse Respectful maternity care Midwifery education Developing countries Africa
Introduction Despite concerted efforts to increase skilled birth attendance in the global quest to reduce maternal mortality, approximately one
n
Corresponding author. E-mail addresses: [email protected] (C.A. Moyer), [email protected] (S. Rominski), [email protected] (E.K. Nakua), [email protected] (V.M. Dzomeku), [email protected] (P. Agyei-Baffour), [email protected] (J.R. Lori). http://dx.doi.org/10.1016/j.midw.2016.07.009 0266-6138/& 2016 Elsevier Ltd. All rights reserved.
third of mothers deliver without the help of a skilled provider (United Nations, 2014; UNICEF, WHO, 2015). Among the many well-known barriers to skilled birth attendance and facility childbirth, disrespect and abuse at the hands of providers is receiving increasing attention (Moyer and Mustafa, 2013; Bohren et al., 2015; Tuncalp et al., 2015; Vogel et al., 2016). In 2010 Bowser and Hill published a landscape analysis of disrespect and abuse during facility-based childbirth that synthesised findings from previous work and served as a catalyst for future researchers and practitioners attempting to document the
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prevalence of maltreatment (Bowser and Hill, 2010). The authors presented a classification system representing seven domains of disrespectful care: physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination based on specific patient attributes, abandonment of care, and detention in facilities as components of disrespectful care (Bowser and Hill, 2010). Since then, several systematic reviews of the facilitators and barriers to facility-based childbirth were published, all of which highlighted the role of maltreatment, respectful care, or disrespect and abuse in determining where women deliver their babies (Moyer and Mustafa, 2013; Bohren et al., 2014; Diamond-Smith and Sudhinaraset, 2015). In addition to many country-specific studies documenting the prevalence of disrespect and abuse, a mixed-methods systematic review of the mistreatment of women during childbirth in facilities was published in 2015,(Bohren et al., 2015) documenting women's and provider's perceptions and experience of disrespect and abuse in an effort to develop and refine an evidence-based typology (Vogel et al., 2016). Dozens of studies have documented disrespect and abuse in a variety of settings, (Kruk et al., 2014; Sando et al., 2014; Abuya et al., 2015a; Okafor et al., 2015; Rosen et al., 2015) including Ghana (Moyer et al., 2014; Yakubu et al., 2014). Yet few have sought to determine the root cause of such behaviours. Research has demonstrated that providers exposed to unrelenting health system challenges over a long period of time have lower morale, are less compassionate, and may engage in disrespectful treatment of clients and fellow providers (Leape et al., 2012; Prytherch et al., 2012; Rosen et al., 2015). While this substantiates anecdotal descriptions of disrespect and abuse often being perpetrated by older providers, or those who have been working in the facilities the longest, it doesn’t address the question of where such behaviour is learned. Thus far, none of the published studies to date has addressed how providers-in-training learn about disrespect and abuse – either explicitly or tacitly. This study used a national sample from ministry supported midwifery education programmes of final-year midwifery students in Ghana. Specifically, this study sought to learn whether midwifery training students were witnessing disrespectful care during their training, as well as the frequency and types of disrespectful care being observed.
Methods This cross-sectional study used a computerised, structured survey to quantify final year midwifery students’ experiences of disrespectful care during their educational programme. The study took place at 15 of the 16 public midwifery schools throughout Ghana between September 2013 and February 2014. All instruments, protocols, and consent documents were reviewed and approved for use by the Committee on Human Research, Publications, and Ethics at Kwame Nkrumah University of Science and Technology, the Ghana Health Service Ethics Review Committee, the University of Michigan Institutional Review Board, and Brown University Institutional Review Board. Setting Ghana is a west African nation with a population of approximately 25 million people, 70% of whom live in the southern half of the country (Ghana Embassy, 2016). According to the State of the World's Midwifery Report, there were 4185 midwives working in Ghana in 2012 who were responsible for approximately 1,063,000 pregnancies each year (SOMW, 2014). Dividing these two numbers suggests that each midwife in Ghana is responsible for approximately 254 births per year, however, this does not account for
rural/urban and district / regional maldistribution. The Ministry of Health reported more than 3000 different health facilities were operational in 2010, ranging from small Community-based Health Planning Services (CHPS) compounds which may include one or two providers to large tertiary care centers and teaching hospitals which may include hundreds of providers (Ghana Ministry of Health, 2010). In between are maternity homes, health centres and clinics, and district and regional hospitals, not to mention private facilities of various sizes. Thus the context for individual practicing midwives in Ghana is incredibly variable. Nonetheless, district hospitals are typically the first point of referral for complicated cases. Study sites Table 1 illustrates the midwifery training schools whose finalyear students participated in this research. Schools were located in all 10 regions of Ghana and represented all but one of the public training schools of midwifery in the country. The one non-participating school had recently opened and therefore did not have a final year class during the 2013–2014 academic year, thus it was excluded from the study. Participants and recruitment A convenience sample of all final-year midwifery students who were in attendance at the training colleges on the days that the research team administered the survey was used. Final year students included diploma students in their third year of midwifery training and post-basic students in their second year of training. Informed consent was obtained prior to participation in the study. All data were collected and stored anonymously. Data collection and analysis Data were collected via a self-administered computer-assisted interface using a study-specific structured questionnaire that was developed based upon the previous work of several of the investigators (Moyer and Mustafa, 2013; Lori et al., 2014; Yakubu et al., 2014). The questionnaire included an assessment of Table 1 Participating midwifery schools and participating final-year students. Ashanti Region Offinso Midwifery Kumasi Midwifery Mampong Midwifery Brong Ahafo Region Berekum Midwifery Central Region Cape Coast Midwifery Twifo PRASO Eastern Region Antibie Midwifery Koforidua Midwifery Greater Accra Region Korle Bu Midwifery Northern Region Tamale Midwifery Upper East Region Bolgatanga Midwifery Upper West Region Jirapa Midwifery Volta Region Hohoe Midwifery Western Region Tarkwa Midwifery Sekondi Midwifery Unspecified
N ¼67 N ¼60 N ¼96 N ¼ 61 N ¼26 N ¼28 N ¼101 N ¼66 N ¼57 N ¼49 N ¼21 N ¼57 N ¼60 N ¼44 N ¼56 N¼ 4
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participant demographics and addressed such areas as barriers to and incentives for working in underserved areas, observations of respectful and disrespectful care during training, and perceptions of working conditions in the settings where clinical training was conducted. The questions specific to witnessing elements of disrespect and abuse had three response options: rarely or never, sometimes, or most of the time. When percentages are reported, they reflect the combination of ‘sometimes’ and ‘most of the time’, thus not including behaviours that were witnessed rarely. The survey was designed such that global questions (e.g. ‘do you think disrespectful care is a problem’) were asked first, before more specific questions regarding types of disrespectful care or frequency of observations. This was done to reduce the likelihood of priming the respondent with detailed questions to influence their answer to the more global question (Sudman and Bradburn, 1982). The questionnaire was administered in the computer laboratories at each participating school, and took respondents approximately 30-45 minutes to complete. Participants were given a nominal incentive ( $2US) as a token of appreciation for their time. All data were cleaned and imported into Stata 13.1 for analysis (College Station, TX). Frequencies and descriptive statistics were calculated, and bivariate analyses were conducted using Chi Square and t-tests to explore differences between those who said they believed maltreatment was a problem in Ghana and those who did not. Age was examined using Student's T-test, and gender, marital status, location of deliveries in which the trainee participated, and opinion regarding whether women were treated more respectfully in private facilities than public facilities were examined using Chi square analysis. A p value of 0.05 was taken to be statistically significant.
Findings Table 2 illustrates the demographics of the sample. Out of the 929 eligible students enroled in participating schools, a total of 853 Table 2 Participant demographics (N ¼ 853).
Age Female gender Marital status Currently Married or Cohabitating In a relationship but not living together Not in a relationship Participated in deliveries as part of training District Hospital Teaching Hospital Public Health Clinic Private Facility Maltreatment of labouring women is a problem Yes No Women are treated more respectfully in private facilities than public facilities Yes No
Mean (95% CI)
Relationship to belief about maltreatment being a problemn
25.03 (24.8–25.3) N (%) 849 (99.6%)
t¼ 1.12, p ¼0.26
161
(19.1)
488
(57.9)
193 848
(22.9) (99.4)
734 92 86 45
(86.1) (10.8) (10.1) (5.3)
614 239
(72.0) (28.0)
χ2 ¼ 2.61, p¼ 0.27 χ2 ¼ 2.66, p ¼0.26
χ2 ¼0.34, p ¼ 0.56 χ2 ¼0.62, p ¼ 0.43 χ2 ¼0.97, p ¼0.32 χ2 ¼ 1.34, p ¼0.25 –
χ2 ¼ 76.25, p o 0.001
660 193
(77.4) (22.6)
n Means compared using Student's t-test, categorical comparisons made using Pearson's χ2.
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students completed the questionnaire, yielding a 91.8% response rate. Most respondents (99.6%) were women, the mean age of study participants was 25.3 years, and 14.6% of respondents were currently married. Most students (99.4%) participated in deliveries as part of their training, with the vast majority (86.1%, N¼734) working in a district hospital at some point in their training. Nearly three-quarters of respondents (72.0%, N ¼614) said that maltreatment of labouring women is a problem in Ghana. More than three-quarters (77.4%, N ¼660) said that women are treated more respectfully in private facilities than in public facilities in Ghana. In addition, 86.6% said they thought how women are treated during labour and childbirth influences whether women choose to deliver in facilities, and 79.9% said that fear of maltreatment is one reason women choose to deliver their babies at home. None of the assessed demographic characteristics of the students showed a significant relationship with the belief that maltreatment during labour and childbirth is a problem in Ghana. However, the belief that maltreatment is a problem was significantly associated with the belief that women are treated better in private facilities than in public facilities (p o0.001). Fig. 1 illustrates the per cent of students witnessing various types of behaviours during training. The most commonly reported behaviours included shouting at labouring women (68.8%), telling family members to leave (76.4%) and telling labouring women to stop making noise (78.6%). Students also reported witnessing positive behaviours, including seeing providers hold the labouring woman's hand (78.3%), telling the woman she was doing a good job (95.9%), asking the woman if she needed anything (95.6%), explaining to the labouring woman what was happening to her (94.9%), asking the labouring woman if she had any questions (82.8%), and asking permission before examining the woman (94.6%). When asked about the most common ways providers encourage women to push, students reported quiet urging (36.6%) and shouting or yelling (27.6%) as the two most common means to encourage pushing during contractions. When asked how students anticipated encouraging women to push when they are the midwives in charge, students listed quiet urging (49.6%) and holding the woman's hand (39.4%) as the most common means they would employ. Only 3.1% said they intended to shout or yell at a woman to encourage her to push. Fig. 2 illustrates the number of different types of disrespectful care reported to be witnessed by respondents. Nearly half of respondents (49.0%) reported witnessing at least 5 different types of disrespectful care during their training. Four per cent reported not witnessing any disrespectful care. Students who trained in a district hospital were significantly more likely to report witnessing a greater variety of disrespectful care behaviours than those who did not train at a district hospital (t¼ 2.59, p¼ 0.01). None of the other sites (teaching hospital, public health clinic, private facility), showed significant differences between students who trained there and those who did not in terms of the number of different types of disrespectful care observed. Students also reported contextual factors that they perceived to be related to disrespectful treatment. More than half of students (61.7%) reported that providers did not have enough equipment and supplies to do their jobs, and 57.0% said that providers did not have a supportive management environment. Students also reported that providers were overworked (76.5%) and stressed (74.2%). More than two-thirds of students (69.6%) said that the resources providers have available to them influences the way they treat patients.
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Fig. 1. Percent of final-year midwifery students who reported witnessing midwives and nurses engage in the following behaviours either ‘sometimes’ or ‘most of the time’ when participating in childbirths as part of their training.
30 26.2
25
21.6
20.8
20 Percent
27.4
15 10 5 0
4.0 None
1 to 2
3 to 4
5 to 6
7 or more
Number of different types of disrespectful care witnessed
Fig. 2. Percent of final-year midwifery students who reported witnessing various numbers of different types of disrespectful care ‘sometimes’ or ‘most of the time’ as part of their training.
Discussion This study, which found that a majority of midwifery students in training throughout Ghana are witnessing disrespectful care as a part of their midwifery education, has several important implications for educators, policy makers, and programmatic staff. Despite students witnessing positive behaviours during their training – which suggests they can differentiate between appropriate and inappropriate practice when they see it – students witnessed a variety of disrespectful and abusive care practices during their clinical education, which has troubling implications for the future quality of maternity care in Ghana. By observing disrespect and abuse of labouring women during their training, and practicing in contexts where abusive and disrespectful care is widespread and tacitly accepted by professional and facility leadership, these students may assume these actions have at least partial support from supervisors, hospital management, and even the professional societies in the country (Kim and Motsei, 2002). In settings where abusive care has been normalised, it becomes routine, accepted, and expected (Kruk et al., 2014). To reverse the normalisation of this behaviour, the organisational, professional, and educational culture will need to be changed.
This study is one of very few to explore the role of students in disrespectful care. Nonetheless, there is a growing body of literature on disrespect and abuse during labour and childbirth, as well as its complement, respectful maternity care, due in large part to the work of the White Ribbon Alliance (WRA) (White Ribbon Alliance, 2016). The White Ribbon Alliance is an advocacy organisation that has mobilised funding, research, programmatic endeavours, policy briefs, and evaluation of efforts to improve respectful maternity care throughout the world (Hastings, 2015). As many of the projects sparked by the WRA begin to yield results, the picture of disrespect and abuse that is emerging is increasingly complex. For example, disrespect and abuse observed by researchers is universally higher than that which is reported by women or providers (Abuya et al., 2015b; Kruk et al., 2014), raising questions about whose reports are the most ‘valid’, given the subjective nature of disrespectful treatment. It is also not clear whether provider behaviour is attributable to individual provider characteristics or results from systemic failures – or both (Hastings, 2015). Research on the nurse-patient relationship provides insight into this study's findings. A seminal study by Jewkes et al. (1998) in South Africa described nurses as engaging in a continuous struggle to assert control and maintain their professional and middle-class identity, resulting in violence as a means to create social distance. This finding is supported by the data presented here, with trainees reporting witnessing their preceptors treating wealthy and educated women better than poor and less educated women, and scolding women if they didn't bring childbirth supplies. A later study exploring the role of nurses in identifying and addressing domestic violence emphasised the fact that nurses are women and community members first, and are thus subject to community norms surrounding how women are expected to be treated (Kim and Motsei, 2002). Thus in societies where domestic violence is condoned, violence in a health care setting may not be seen as unusual. According to the 2008 Ghana Demographic and Health Survey – the most recent year with domestic violence data – 20.6% of women reported experiencing physical violence at the hands of their partner at some point in their lives, with 23% experiencing violence in the past year by an intimate partner (Ghana Statistical Service, 2009). In the 2014 administration, 28% of women agreed that a man had a right to beat his wife if she did any of the following: burned the food, argued with him, went out without telling him, neglected the children, or refused sexual intercourse. Interestingly, only 13% of men agreed that it was acceptable for a man to beat his wife is she did any of the above (Ghana Statistical
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Service, 2015). The point is that behaviours that occur in a health facility do not occur in a vacuum, but instead reflect a broader societal milieu. In the case of this study, midwives may feel as though hitting or shouting at women in labour who are not complying with their instructions is perfectly acceptable, given a broader social norm that – for many – supports the idea that non-compliance can be dealt with through violence. D’Oliveira et al. (2002) described how the use of disciplinary measures to make women conform to expected behaviours has become legitimised, citing that in South Africa, nursing training has been explicitly linked to ideas of moral superiority for decades. In addition, in settings with a rigid social hierarchy, menial tasks that are associated with providing good care to women may be seen as low-class activities, and thus may not be valued by health professionals (D’Oliveira et al., 2002). This may lead to such behaviours as midwives asking women to clean up after themselves following their childbirth. In one small study in Ghana, Yakubu et al. (2014) found that the interaction between midwives and labouring women was seen as analogous to a mother/daughter relationship, including both a knowledge imbalance and the need for disciplinary action when necessary. This perception was shared by both midwives and women, with women understanding that midwives were simply trying to get them to do what they needed to do to have a healthy infant. Such normalisation means that women may not be able to distinguish between behaviour that is acceptable and that which is abnormal, illegal, or ethically wrong (Abuya et al., 2015). A recent systematic review by Filby et al. (2016) highlights the complexity of delivering high quality midwifery care, citing social and cultural, economic, and professional barriers to quality care provision. The authors describe barriers as including gender inequality (female midwives are vulnerable to attack or seen as inviting violence when travelling to nighttime deliveries, and they are held to the same domestic expectations of wives and mothers who do not work outside the home), extremely low wages for long hours worked, poor training opportunities, and the challenges associated with working in remote regions with minimal chance for continuing education (Filby et al., 2016). These factors, while described in the context of overall quality of care, provide insight into the circumstances surrounding maltreatment. This study has several notable strengths. First, it is a national sample of all final-year midwifery students attending public educational programmes for midwifery in the country of Ghana, rather than a sub-sample. Second, study methodology ensured private, anonymous data collection to minimise the likelihood of social desirability bias influencing participant responses. Third, the study addressed several topics, including such things as respondents’ long term career goals, preferences regarding rural postings, training in family planning, and experiences with respectful care. We believe this diversity in topic areas may have minimised respondents’ sense that the researchers were looking for ‘appropriate’ answers – a finding that has been borne out by the diversity of responses seen across all topics. Finally, the order of the items on the survey ensured that respondents were asked about their global perceptions of disrespectful care before being primed by their responses to more specific questions about types of disrespectful care. This format leads to more of an instinctive response to the global question, rather than allowing a respondent to mentally tally their specific responses to inform their global judgment if the global question is asked last in the series. We believe this format is likely to lead to a more realistic assessment of students’ attitudes, unimpeded by their subsequent reporting of observations. Despite its strengths, this study has several limitations. First, the study relies upon self-reported data from students, none of which was corroborated by observational data that could verify
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what the students reported. However, given that observation often changes behaviour, self-reported data is the strongest option in this setting. Second, the measurement tool did not ask students to report events that were ‘ever’ witnessed or seen only once. Thus we may be underestimating the magnitude of the issue. The study was also not designed to count the number of occurrences of disrespectful behaviour beyond ‘sometimes’ or ‘most of the time’, both of which have subjective interpretations and may mean different things across different respondents. Nonetheless, we believe that events reported as being seen sometimes or most of the time are occurring frequently enough as to warrant attention. The study also did not include explicit questions regarding how they would address disrespectful care if it was identified as a problem. Finally, given the homogeneity of the study population in terms of age, level of education, and gender, we were not able to determine whether there were differences between individuals that might have had a relationship to their perceptions of maltreatment. We were also not able to determine differences between responders and non-responders to the survey. The results of this study indicate that adequately resourcing health systems, both with human and material resources, is imperative for ensuring adequate quality of care for women. Healthcare workers need to be well-supported if they are to be held accountable for their actions. There are very real resource limitations within the health system in Ghana, and this may negatively impact the way providers deliver care (Banchani and Tenkorang, 2014). While women have a right to high quality and respectful care, providers also have a right to the means to deliver this care (Hulton et al., 2014). The State of the World's Midwifery report from 2014 described the need to evaluate the quality of midwifery education, including such things as infrastructure, skills of the instructors, types of students matriculating, educational curricula, and influencing factors (SOWM, 2014). We would argue that midwifery (as well as nursing and medical) education must also be evaluated with an eye toward teaching, role-modelling, and rewarding positive women-provider interactions. Most midwifery and nursing cadres have a national curriculum in low and middle income countries (State of the World's Midwifery Report, 2014). The addition of thoughtful, well-designed, properly evaluated modules addressing respectful care is urgently needed. The research presented here suggests the need to improve monitoring, accountability, and consequences for maltreatment within facilities to improve the care that pregnant and labouring women receive. The challenge moving forward, however, is to create a culture of accountability on the part of providers to ensure respectful maternity care without creating a commensurate culture of blame. As the White Ribbon Alliance has made clear, while women need legal recourse when faced with disrespectful and abusive treatment, a punitive approach is not always the most effective (Hastings, 2015). And while we concur with the WRA that interventions should address as many levels of the system as possible, we believe one logical starting place is in the educational institutions teaching tomorrow's midwives.
Conflict of interest None of the authors has conflicts of interest to declare, financial or otherwise.
Acknowledgements This research was supported in part by the African Studies Center at the University of Michigan, as well as in part by research
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grant 1 K01 TW008763-01A1 from Fogarty International, National Institutes of Health (Dr. Jody R. Lori, PI). The content is solely the responsibility of the authors and does not necessarily represent the official views of Fogarty International or the National Institutes of Health.
Appendix A. Supplementary material Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.midw.2016.07.009.
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Hulton, L., Matthews, Z., Martin-Hilber, A., et al., 2014. Using evidence to drive action: a “revolution in accountability” to implement quality care for better maternal and newborn health in Africa. International Journal of Gynecology and Obstetrics 127, 96–101. Jewkes, R., Abrahams, N., Mvo, Z., 1998. Why do nurses abuse patients? Reflections from South African obstetric services. Social Science & Medicine 47, 1781–1795. Kim, J., Motsei, M., 2002. “Women enjoy punishment”: attitudes and experiences of gender-based violence among PHC nurses in rural South Africa. Social Science & Medicine. 54, 1243–1254. Kruk, M.E., Kujawski, S., Mbaruku, G., Ramsey, K., Moyo, W., Freedman, L.P., 2014. Direspect and abusive treatment during facility delivery in Tanzania: a facility and community survey. Health Policy Plan, 1–8. http://dx.doi.org/10.1093/ heapol/czu079. Leape, L.L., Shore, M.F., Dienstag, J.L., et al., 2012. Perspective: a culture of respect, Part 1: the nature and causes of disrespectful behavior by physicians. Academic Medicine 87, 845–852. Lori, J.R., Livingston, L., Eagle, M., Rominski, S., Nakua, E., Agyei-Baffour, P., 2014. Rural origin and exposure drives Ghanaian midwives reported future practice. African Journal of Reproductive Health 18, 95–100. Moyer, C.A., Mustafa, A., 2013. Drivers and deterrents of facility delivery in subSaharan Africa: a systematic review. Reproductive Health 10, 40. http://dx.doi. org/10.1186/1742-4755-10-40. Moyer, C.A., Adongo, P.B., Aborigo, R., Hodgson, A., Engmann, C., 2014. “They treat you like you are not a human being”: midwifery maltreatment in rural northern Ghana. Midwifery 30, 262–268. http://dx.doi.org/10.1016/j.midw.2013.05.006. Okafor, I.I., Ugwu, E.O., Obi, S.N., 2015. Disrespect and abuse during facility-based childbirth in a low-income country. International Journal of Gynaecology and Obstetrics 128, 110–113. Prytherch, H., Kakado, D.C., Leshabari, M.T., Sauerborn, R., Marx, M., 2012. Maternal and newborn healthcare providers in rural Tanzania: in-depth interviews exploring influences on motivation, performance, and job satisfaction. Rural Remote Health 12, 2072. Rosen, H.E., Lynam, P.F., Carr, C., et al., 2015. Direct observation of respectful maternity care in five countries: a cross-sectional study of health facilities in East and Southern Africa. BMC Pregnancy and Childbirth 15, 306. Sando, D., Kendall, T., Lyatuu, G., et al., 2014. Disrespect and abuse during childbirth in Tanzania: are women living with HIV more vulnerable? Journal of Acquired Immune Deficiency Syndrome 67 (Suppl 4), S228–S234. State of the World's Midwifery, 2014. A universal pathway, a woman's right to health. Available at: 〈http://www.unfpa.org/sites/default/files/pub-pdf/EN_ SoWMy2014_complete.pdf〉. Sudman, S., Bradburn, N.M., 1982. Asking Questions: A Practical Guide to Questionnaire Design. Jossey Bass Publishers, San Francisco. Tuncalp, O., Were, W.M., MacLennan, C., et al., 2015. Quality of care for pregnant women and newborns – the WHO vision. An International Journal of Obstetrics and Gynaecology 122, 1045–1049. UNICEF, WHO, 2015. Countdown to 2015. A decade of tracking progress for maternal, newborn and child survival: The 2015 Report. WHO, Geneva. ISBN: 97892-806-4814-0. United Nations, 2014. The millennium Development Goals Report 2014. United Nations, New York, Available at http://www.un.org/millenniumgoals/2014% 20MDG%20report/MDG%202014%20English%20web.pdf. Vogel, J.P., Bohren, M.A., Tuncalp, O., Oladapo, O.T., Gulmezoglu, A.M., 2016. Promoting respect and preventing mistreatment during childbirth. An International Journal of Obstetrics and Gynaecology 123 (5), 671–674. http://dx.doi. org/10.1111/1471-0528.13750. White Ribbon Alliance. 〈http://whiteribbonalliance.org/〉 (accessed 15 June 2016). Yakubu, J., Benyas, D., Emil, S., Amekah, E., Adanu, R., Moyer, C., 2014. It's for the Greater Good: Perspectives on Maltreatment during Labor and Delivery in Rural Ghana. Open Journal of Obstetrics and Gynecology 4, 383–390. http://dx.doi. org/10.4236/ojog.2014.47057.
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Exposure to disrespectful patient care during training: Data from midwifery students at 15 midwifery schools in Ghana Cheryl A. Moyer, PhD, MPH (Associate Director, Global REACH)a,n, Sarah Rominski, PhD, MPH (Senior Research Associate, Global REACH)a, Emmanuel Kweku Nakua, MSc (Lecturer)b, Veronica Millicent Dzomeku, MSN (Lecturer)b, Peter Agyei-Baffour, PhD (Lecturer)b, Jody R. Lori, PhD, CNM (Associate Dean for Global Affairs, Associate Professor)c a
University of Michigan Medical School, 1111 Catherine Street, Ann Arbor, MI 48109, USA Kwame Nkrumah University of Science and Technology, Accra Road, Kumasi, Ghana c University of Michigan School of Nursing, 400 North Ingalls Street, Ann Arbor, MI 48109, USA b
art ic l e i nf o
a b s t r a c t
Article history: Received 2 March 2016 Received in revised form 5 July 2016 Accepted 9 July 2016
Objective: to determine what midwifery students throughout Ghana were witnessing, perceiving, and learning with regard to respectful care during labour and childbirth. Design: cross-sectional survey. Setting: public midwifery schools in all 10 regions of Ghana. Participants: all graduating midwifery students in Ghana. Measurements: 929 final-year students at 15 public midwifery schools in Ghana were asked to complete a self-administered computerised survey addressing a range of topics, including experiences during training. All data were collected anonymously and analyzed using Stata 13.0. Findings: 853 students completed the questionnaire (91.8% response rate): 72.0% said maltreatment was a problem in Ghana and 77.4% said women are treated more respectfully in private than public facilities. Students described providers: telling women to stop making noise (78.5%), shouting at women (68.8%), scolding women if they didn’t bring birth supplies (54.5%), treating educated/wealthy women better than less educated / poor women (41.5%/38.9%), detaining women who couldn’t pay (37.9%), and speaking disrespectfully to women (34%). Only 4% of students reported not witnessing any disrespectful treatment. Students reported providers being overworked (76.5%), stressed (74.2%), and working without adequate resources (64.1%). Where students performed their clinical training (teaching hospital, district hospital, public health clinic, private facility) had no effect on perception of maltreatment as a problem. However, students who trained in district hospitals witnessed more types of disrespectful care than those who did not train in district hospitals (p¼0.01). Conclusions and implications: a majority of midwifery students throughout Ghana witness disrespectful care during their training. Implications include the need for provider curricula that address psychosocial elements of care, as well as the need to improve monitoring, accountability, and consequences for maltreatment within facilities without creating a culture of blame. & 2016 Elsevier Ltd. All rights reserved.
Keywords: Maltreatment Disrespect and abuse Respectful maternity care Midwifery education Developing countries Africa
Introduction Despite concerted efforts to increase skilled birth attendance in the global quest to reduce maternal mortality, approximately one
n
Corresponding author. E-mail addresses: [email protected] (C.A. Moyer), [email protected] (S. Rominski), [email protected] (E.K. Nakua), [email protected] (V.M. Dzomeku), [email protected] (P. Agyei-Baffour), [email protected] (J.R. Lori). http://dx.doi.org/10.1016/j.midw.2016.07.009 0266-6138/& 2016 Elsevier Ltd. All rights reserved.
third of mothers deliver without the help of a skilled provider (United Nations, 2014; UNICEF, WHO, 2015). Among the many well-known barriers to skilled birth attendance and facility childbirth, disrespect and abuse at the hands of providers is receiving increasing attention (Moyer and Mustafa, 2013; Bohren et al., 2015; Tuncalp et al., 2015; Vogel et al., 2016). In 2010 Bowser and Hill published a landscape analysis of disrespect and abuse during facility-based childbirth that synthesised findings from previous work and served as a catalyst for future researchers and practitioners attempting to document the
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prevalence of maltreatment (Bowser and Hill, 2010). The authors presented a classification system representing seven domains of disrespectful care: physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination based on specific patient attributes, abandonment of care, and detention in facilities as components of disrespectful care (Bowser and Hill, 2010). Since then, several systematic reviews of the facilitators and barriers to facility-based childbirth were published, all of which highlighted the role of maltreatment, respectful care, or disrespect and abuse in determining where women deliver their babies (Moyer and Mustafa, 2013; Bohren et al., 2014; Diamond-Smith and Sudhinaraset, 2015). In addition to many country-specific studies documenting the prevalence of disrespect and abuse, a mixed-methods systematic review of the mistreatment of women during childbirth in facilities was published in 2015,(Bohren et al., 2015) documenting women's and provider's perceptions and experience of disrespect and abuse in an effort to develop and refine an evidence-based typology (Vogel et al., 2016). Dozens of studies have documented disrespect and abuse in a variety of settings, (Kruk et al., 2014; Sando et al., 2014; Abuya et al., 2015a; Okafor et al., 2015; Rosen et al., 2015) including Ghana (Moyer et al., 2014; Yakubu et al., 2014). Yet few have sought to determine the root cause of such behaviours. Research has demonstrated that providers exposed to unrelenting health system challenges over a long period of time have lower morale, are less compassionate, and may engage in disrespectful treatment of clients and fellow providers (Leape et al., 2012; Prytherch et al., 2012; Rosen et al., 2015). While this substantiates anecdotal descriptions of disrespect and abuse often being perpetrated by older providers, or those who have been working in the facilities the longest, it doesn’t address the question of where such behaviour is learned. Thus far, none of the published studies to date has addressed how providers-in-training learn about disrespect and abuse – either explicitly or tacitly. This study used a national sample from ministry supported midwifery education programmes of final-year midwifery students in Ghana. Specifically, this study sought to learn whether midwifery training students were witnessing disrespectful care during their training, as well as the frequency and types of disrespectful care being observed.
Methods This cross-sectional study used a computerised, structured survey to quantify final year midwifery students’ experiences of disrespectful care during their educational programme. The study took place at 15 of the 16 public midwifery schools throughout Ghana between September 2013 and February 2014. All instruments, protocols, and consent documents were reviewed and approved for use by the Committee on Human Research, Publications, and Ethics at Kwame Nkrumah University of Science and Technology, the Ghana Health Service Ethics Review Committee, the University of Michigan Institutional Review Board, and Brown University Institutional Review Board. Setting Ghana is a west African nation with a population of approximately 25 million people, 70% of whom live in the southern half of the country (Ghana Embassy, 2016). According to the State of the World's Midwifery Report, there were 4185 midwives working in Ghana in 2012 who were responsible for approximately 1,063,000 pregnancies each year (SOMW, 2014). Dividing these two numbers suggests that each midwife in Ghana is responsible for approximately 254 births per year, however, this does not account for
rural/urban and district / regional maldistribution. The Ministry of Health reported more than 3000 different health facilities were operational in 2010, ranging from small Community-based Health Planning Services (CHPS) compounds which may include one or two providers to large tertiary care centers and teaching hospitals which may include hundreds of providers (Ghana Ministry of Health, 2010). In between are maternity homes, health centres and clinics, and district and regional hospitals, not to mention private facilities of various sizes. Thus the context for individual practicing midwives in Ghana is incredibly variable. Nonetheless, district hospitals are typically the first point of referral for complicated cases. Study sites Table 1 illustrates the midwifery training schools whose finalyear students participated in this research. Schools were located in all 10 regions of Ghana and represented all but one of the public training schools of midwifery in the country. The one non-participating school had recently opened and therefore did not have a final year class during the 2013–2014 academic year, thus it was excluded from the study. Participants and recruitment A convenience sample of all final-year midwifery students who were in attendance at the training colleges on the days that the research team administered the survey was used. Final year students included diploma students in their third year of midwifery training and post-basic students in their second year of training. Informed consent was obtained prior to participation in the study. All data were collected and stored anonymously. Data collection and analysis Data were collected via a self-administered computer-assisted interface using a study-specific structured questionnaire that was developed based upon the previous work of several of the investigators (Moyer and Mustafa, 2013; Lori et al., 2014; Yakubu et al., 2014). The questionnaire included an assessment of Table 1 Participating midwifery schools and participating final-year students. Ashanti Region Offinso Midwifery Kumasi Midwifery Mampong Midwifery Brong Ahafo Region Berekum Midwifery Central Region Cape Coast Midwifery Twifo PRASO Eastern Region Antibie Midwifery Koforidua Midwifery Greater Accra Region Korle Bu Midwifery Northern Region Tamale Midwifery Upper East Region Bolgatanga Midwifery Upper West Region Jirapa Midwifery Volta Region Hohoe Midwifery Western Region Tarkwa Midwifery Sekondi Midwifery Unspecified
N ¼67 N ¼60 N ¼96 N ¼ 61 N ¼26 N ¼28 N ¼101 N ¼66 N ¼57 N ¼49 N ¼21 N ¼57 N ¼60 N ¼44 N ¼56 N¼ 4
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participant demographics and addressed such areas as barriers to and incentives for working in underserved areas, observations of respectful and disrespectful care during training, and perceptions of working conditions in the settings where clinical training was conducted. The questions specific to witnessing elements of disrespect and abuse had three response options: rarely or never, sometimes, or most of the time. When percentages are reported, they reflect the combination of ‘sometimes’ and ‘most of the time’, thus not including behaviours that were witnessed rarely. The survey was designed such that global questions (e.g. ‘do you think disrespectful care is a problem’) were asked first, before more specific questions regarding types of disrespectful care or frequency of observations. This was done to reduce the likelihood of priming the respondent with detailed questions to influence their answer to the more global question (Sudman and Bradburn, 1982). The questionnaire was administered in the computer laboratories at each participating school, and took respondents approximately 30-45 minutes to complete. Participants were given a nominal incentive ( $2US) as a token of appreciation for their time. All data were cleaned and imported into Stata 13.1 for analysis (College Station, TX). Frequencies and descriptive statistics were calculated, and bivariate analyses were conducted using Chi Square and t-tests to explore differences between those who said they believed maltreatment was a problem in Ghana and those who did not. Age was examined using Student's T-test, and gender, marital status, location of deliveries in which the trainee participated, and opinion regarding whether women were treated more respectfully in private facilities than public facilities were examined using Chi square analysis. A p value of 0.05 was taken to be statistically significant.
Findings Table 2 illustrates the demographics of the sample. Out of the 929 eligible students enroled in participating schools, a total of 853 Table 2 Participant demographics (N ¼ 853).
Age Female gender Marital status Currently Married or Cohabitating In a relationship but not living together Not in a relationship Participated in deliveries as part of training District Hospital Teaching Hospital Public Health Clinic Private Facility Maltreatment of labouring women is a problem Yes No Women are treated more respectfully in private facilities than public facilities Yes No
Mean (95% CI)
Relationship to belief about maltreatment being a problemn
25.03 (24.8–25.3) N (%) 849 (99.6%)
t¼ 1.12, p ¼0.26
161
(19.1)
488
(57.9)
193 848
(22.9) (99.4)
734 92 86 45
(86.1) (10.8) (10.1) (5.3)
614 239
(72.0) (28.0)
χ2 ¼ 2.61, p¼ 0.27 χ2 ¼ 2.66, p ¼0.26
χ2 ¼0.34, p ¼ 0.56 χ2 ¼0.62, p ¼ 0.43 χ2 ¼0.97, p ¼0.32 χ2 ¼ 1.34, p ¼0.25 –
χ2 ¼ 76.25, p o 0.001
660 193
(77.4) (22.6)
n Means compared using Student's t-test, categorical comparisons made using Pearson's χ2.
41
students completed the questionnaire, yielding a 91.8% response rate. Most respondents (99.6%) were women, the mean age of study participants was 25.3 years, and 14.6% of respondents were currently married. Most students (99.4%) participated in deliveries as part of their training, with the vast majority (86.1%, N¼734) working in a district hospital at some point in their training. Nearly three-quarters of respondents (72.0%, N ¼614) said that maltreatment of labouring women is a problem in Ghana. More than three-quarters (77.4%, N ¼660) said that women are treated more respectfully in private facilities than in public facilities in Ghana. In addition, 86.6% said they thought how women are treated during labour and childbirth influences whether women choose to deliver in facilities, and 79.9% said that fear of maltreatment is one reason women choose to deliver their babies at home. None of the assessed demographic characteristics of the students showed a significant relationship with the belief that maltreatment during labour and childbirth is a problem in Ghana. However, the belief that maltreatment is a problem was significantly associated with the belief that women are treated better in private facilities than in public facilities (p o0.001). Fig. 1 illustrates the per cent of students witnessing various types of behaviours during training. The most commonly reported behaviours included shouting at labouring women (68.8%), telling family members to leave (76.4%) and telling labouring women to stop making noise (78.6%). Students also reported witnessing positive behaviours, including seeing providers hold the labouring woman's hand (78.3%), telling the woman she was doing a good job (95.9%), asking the woman if she needed anything (95.6%), explaining to the labouring woman what was happening to her (94.9%), asking the labouring woman if she had any questions (82.8%), and asking permission before examining the woman (94.6%). When asked about the most common ways providers encourage women to push, students reported quiet urging (36.6%) and shouting or yelling (27.6%) as the two most common means to encourage pushing during contractions. When asked how students anticipated encouraging women to push when they are the midwives in charge, students listed quiet urging (49.6%) and holding the woman's hand (39.4%) as the most common means they would employ. Only 3.1% said they intended to shout or yell at a woman to encourage her to push. Fig. 2 illustrates the number of different types of disrespectful care reported to be witnessed by respondents. Nearly half of respondents (49.0%) reported witnessing at least 5 different types of disrespectful care during their training. Four per cent reported not witnessing any disrespectful care. Students who trained in a district hospital were significantly more likely to report witnessing a greater variety of disrespectful care behaviours than those who did not train at a district hospital (t¼ 2.59, p¼ 0.01). None of the other sites (teaching hospital, public health clinic, private facility), showed significant differences between students who trained there and those who did not in terms of the number of different types of disrespectful care observed. Students also reported contextual factors that they perceived to be related to disrespectful treatment. More than half of students (61.7%) reported that providers did not have enough equipment and supplies to do their jobs, and 57.0% said that providers did not have a supportive management environment. Students also reported that providers were overworked (76.5%) and stressed (74.2%). More than two-thirds of students (69.6%) said that the resources providers have available to them influences the way they treat patients.
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Fig. 1. Percent of final-year midwifery students who reported witnessing midwives and nurses engage in the following behaviours either ‘sometimes’ or ‘most of the time’ when participating in childbirths as part of their training.
30 26.2
25
21.6
20.8
20 Percent
27.4
15 10 5 0
4.0 None
1 to 2
3 to 4
5 to 6
7 or more
Number of different types of disrespectful care witnessed
Fig. 2. Percent of final-year midwifery students who reported witnessing various numbers of different types of disrespectful care ‘sometimes’ or ‘most of the time’ as part of their training.
Discussion This study, which found that a majority of midwifery students in training throughout Ghana are witnessing disrespectful care as a part of their midwifery education, has several important implications for educators, policy makers, and programmatic staff. Despite students witnessing positive behaviours during their training – which suggests they can differentiate between appropriate and inappropriate practice when they see it – students witnessed a variety of disrespectful and abusive care practices during their clinical education, which has troubling implications for the future quality of maternity care in Ghana. By observing disrespect and abuse of labouring women during their training, and practicing in contexts where abusive and disrespectful care is widespread and tacitly accepted by professional and facility leadership, these students may assume these actions have at least partial support from supervisors, hospital management, and even the professional societies in the country (Kim and Motsei, 2002). In settings where abusive care has been normalised, it becomes routine, accepted, and expected (Kruk et al., 2014). To reverse the normalisation of this behaviour, the organisational, professional, and educational culture will need to be changed.
This study is one of very few to explore the role of students in disrespectful care. Nonetheless, there is a growing body of literature on disrespect and abuse during labour and childbirth, as well as its complement, respectful maternity care, due in large part to the work of the White Ribbon Alliance (WRA) (White Ribbon Alliance, 2016). The White Ribbon Alliance is an advocacy organisation that has mobilised funding, research, programmatic endeavours, policy briefs, and evaluation of efforts to improve respectful maternity care throughout the world (Hastings, 2015). As many of the projects sparked by the WRA begin to yield results, the picture of disrespect and abuse that is emerging is increasingly complex. For example, disrespect and abuse observed by researchers is universally higher than that which is reported by women or providers (Abuya et al., 2015b; Kruk et al., 2014), raising questions about whose reports are the most ‘valid’, given the subjective nature of disrespectful treatment. It is also not clear whether provider behaviour is attributable to individual provider characteristics or results from systemic failures – or both (Hastings, 2015). Research on the nurse-patient relationship provides insight into this study's findings. A seminal study by Jewkes et al. (1998) in South Africa described nurses as engaging in a continuous struggle to assert control and maintain their professional and middle-class identity, resulting in violence as a means to create social distance. This finding is supported by the data presented here, with trainees reporting witnessing their preceptors treating wealthy and educated women better than poor and less educated women, and scolding women if they didn't bring childbirth supplies. A later study exploring the role of nurses in identifying and addressing domestic violence emphasised the fact that nurses are women and community members first, and are thus subject to community norms surrounding how women are expected to be treated (Kim and Motsei, 2002). Thus in societies where domestic violence is condoned, violence in a health care setting may not be seen as unusual. According to the 2008 Ghana Demographic and Health Survey – the most recent year with domestic violence data – 20.6% of women reported experiencing physical violence at the hands of their partner at some point in their lives, with 23% experiencing violence in the past year by an intimate partner (Ghana Statistical Service, 2009). In the 2014 administration, 28% of women agreed that a man had a right to beat his wife if she did any of the following: burned the food, argued with him, went out without telling him, neglected the children, or refused sexual intercourse. Interestingly, only 13% of men agreed that it was acceptable for a man to beat his wife is she did any of the above (Ghana Statistical
C.A. Moyer et al. / Midwifery 41 (2016) 39–44
Service, 2015). The point is that behaviours that occur in a health facility do not occur in a vacuum, but instead reflect a broader societal milieu. In the case of this study, midwives may feel as though hitting or shouting at women in labour who are not complying with their instructions is perfectly acceptable, given a broader social norm that – for many – supports the idea that non-compliance can be dealt with through violence. D’Oliveira et al. (2002) described how the use of disciplinary measures to make women conform to expected behaviours has become legitimised, citing that in South Africa, nursing training has been explicitly linked to ideas of moral superiority for decades. In addition, in settings with a rigid social hierarchy, menial tasks that are associated with providing good care to women may be seen as low-class activities, and thus may not be valued by health professionals (D’Oliveira et al., 2002). This may lead to such behaviours as midwives asking women to clean up after themselves following their childbirth. In one small study in Ghana, Yakubu et al. (2014) found that the interaction between midwives and labouring women was seen as analogous to a mother/daughter relationship, including both a knowledge imbalance and the need for disciplinary action when necessary. This perception was shared by both midwives and women, with women understanding that midwives were simply trying to get them to do what they needed to do to have a healthy infant. Such normalisation means that women may not be able to distinguish between behaviour that is acceptable and that which is abnormal, illegal, or ethically wrong (Abuya et al., 2015). A recent systematic review by Filby et al. (2016) highlights the complexity of delivering high quality midwifery care, citing social and cultural, economic, and professional barriers to quality care provision. The authors describe barriers as including gender inequality (female midwives are vulnerable to attack or seen as inviting violence when travelling to nighttime deliveries, and they are held to the same domestic expectations of wives and mothers who do not work outside the home), extremely low wages for long hours worked, poor training opportunities, and the challenges associated with working in remote regions with minimal chance for continuing education (Filby et al., 2016). These factors, while described in the context of overall quality of care, provide insight into the circumstances surrounding maltreatment. This study has several notable strengths. First, it is a national sample of all final-year midwifery students attending public educational programmes for midwifery in the country of Ghana, rather than a sub-sample. Second, study methodology ensured private, anonymous data collection to minimise the likelihood of social desirability bias influencing participant responses. Third, the study addressed several topics, including such things as respondents’ long term career goals, preferences regarding rural postings, training in family planning, and experiences with respectful care. We believe this diversity in topic areas may have minimised respondents’ sense that the researchers were looking for ‘appropriate’ answers – a finding that has been borne out by the diversity of responses seen across all topics. Finally, the order of the items on the survey ensured that respondents were asked about their global perceptions of disrespectful care before being primed by their responses to more specific questions about types of disrespectful care. This format leads to more of an instinctive response to the global question, rather than allowing a respondent to mentally tally their specific responses to inform their global judgment if the global question is asked last in the series. We believe this format is likely to lead to a more realistic assessment of students’ attitudes, unimpeded by their subsequent reporting of observations. Despite its strengths, this study has several limitations. First, the study relies upon self-reported data from students, none of which was corroborated by observational data that could verify
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what the students reported. However, given that observation often changes behaviour, self-reported data is the strongest option in this setting. Second, the measurement tool did not ask students to report events that were ‘ever’ witnessed or seen only once. Thus we may be underestimating the magnitude of the issue. The study was also not designed to count the number of occurrences of disrespectful behaviour beyond ‘sometimes’ or ‘most of the time’, both of which have subjective interpretations and may mean different things across different respondents. Nonetheless, we believe that events reported as being seen sometimes or most of the time are occurring frequently enough as to warrant attention. The study also did not include explicit questions regarding how they would address disrespectful care if it was identified as a problem. Finally, given the homogeneity of the study population in terms of age, level of education, and gender, we were not able to determine whether there were differences between individuals that might have had a relationship to their perceptions of maltreatment. We were also not able to determine differences between responders and non-responders to the survey. The results of this study indicate that adequately resourcing health systems, both with human and material resources, is imperative for ensuring adequate quality of care for women. Healthcare workers need to be well-supported if they are to be held accountable for their actions. There are very real resource limitations within the health system in Ghana, and this may negatively impact the way providers deliver care (Banchani and Tenkorang, 2014). While women have a right to high quality and respectful care, providers also have a right to the means to deliver this care (Hulton et al., 2014). The State of the World's Midwifery report from 2014 described the need to evaluate the quality of midwifery education, including such things as infrastructure, skills of the instructors, types of students matriculating, educational curricula, and influencing factors (SOWM, 2014). We would argue that midwifery (as well as nursing and medical) education must also be evaluated with an eye toward teaching, role-modelling, and rewarding positive women-provider interactions. Most midwifery and nursing cadres have a national curriculum in low and middle income countries (State of the World's Midwifery Report, 2014). The addition of thoughtful, well-designed, properly evaluated modules addressing respectful care is urgently needed. The research presented here suggests the need to improve monitoring, accountability, and consequences for maltreatment within facilities to improve the care that pregnant and labouring women receive. The challenge moving forward, however, is to create a culture of accountability on the part of providers to ensure respectful maternity care without creating a commensurate culture of blame. As the White Ribbon Alliance has made clear, while women need legal recourse when faced with disrespectful and abusive treatment, a punitive approach is not always the most effective (Hastings, 2015). And while we concur with the WRA that interventions should address as many levels of the system as possible, we believe one logical starting place is in the educational institutions teaching tomorrow's midwives.
Conflict of interest None of the authors has conflicts of interest to declare, financial or otherwise.
Acknowledgements This research was supported in part by the African Studies Center at the University of Michigan, as well as in part by research
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C.A. Moyer et al. / Midwifery 41 (2016) 39–44
grant 1 K01 TW008763-01A1 from Fogarty International, National Institutes of Health (Dr. Jody R. Lori, PI). The content is solely the responsibility of the authors and does not necessarily represent the official views of Fogarty International or the National Institutes of Health.
Appendix A. Supplementary material Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.midw.2016.07.009.
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