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      The Mothers on Respect (MOR) index: measuring quality, safety, and human rights in childbirth

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          Abstract

          Background

          Abuse of human rights in childbirth are documented in low, middle and high resource countries. A systematic review across 34 countries by the WHO Research Group on the Treatment of Women During Childbirth concluded that there is no consensus at a global level on how disrespectful maternity care is measured. In British Columbia, a community-led participatory action research team developed a survey tool that assesses women's experiences with maternity care, including disrespect and discrimination.

          Methods

          A cross-sectional survey was completed by women of childbearing age from diverse communities across British Columbia. Several items (31/130) assessed characteristics of their communication with care providers. We assessed the psychometric properties of two versions of a scale (7 and 14 items), among women who described experiences with a single maternity provider ( n=2514 experiences among 1672 women). We also calculated the proportion and selected characteristics of women who scored in the bottom 10th percentile (those who experienced the least respectful care).

          Results

          To demonstrate replicability, we report psychometric results separately for three samples of women (S1 and S2) ( n=2271), (S3, n=1613). Analysis of item-to-total correlations and factor loadings indicated a single construct 14-item scale, which we named the Mothers on Respect index (MORi). Items in MORi assess the nature of respectful patient-provider interactions and their impact on a person's sense of comfort, behavior, and perceptions of racism or discrimination. The scale exhibited good internal consistency reliability. MORi- scores among these samples differed by socio-demographic profile, health status, experience with interventions and mode of birth, planned and actual place of birth, and type of provider.

          Conclusion

          The MOR index is a reliable, patient-informed quality and safety indicator that can be applied across jurisdictions to assess the nature of provider-patient relationships, and access to person-centered maternity care.

          Highlights

          • This paper introduces the Mothers on Respect Index (MORi) that can be used to measure women's experiences of respect and self-determination when interacting with their maternity care providers.

          • We report psychometric results separately for three samples (S1 and S2) ( n=2271), (S3, n=1613).

          • Analysis of item-to-total correlations and factor loadings indicate a reliable uni-dimensional scale (experience of respectful maternity care) for MORi, that assesses the impact of respect on woman's sense of comfort, behavior, and perceptions of racism or discrimination. Both versions of the scale exhibited good internal consistency reliability.

          • Women from vulnerable populations and women with medical or social risk factors during pregnancy had lower MORi scores. Women under the care of midwives had higher scores, and those who planned home births reported the most respectful care.

          • Implementation of MORi into institutional quality assurance systems could support quality improvement at both unit and regional levels by comparing respectful treatment across birth facilities.

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          Most cited references 29

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          Pain and women's satisfaction with the experience of childbirth: a systematic review.

           Ellen Hodnett (2002)
          To summarize what is known about satisfaction with childbirth, with particular attention to the roles of pain and pain relief. A systematic review of 137 reports of factors influencing women's evaluations of their childbirth experiences. The reports included descriptive studies, randomized controlled trials, and systematic reviews of intrapartum interventions. Results were summarized qualitatively. Four factors-personal expectations, the amount of support from caregivers, the quality of the caregiver-patient relationship, and involvement in decision making-appear to be so important that they override the influences of age, socioeconomic status, ethnicity, childbirth preparation, the physical birth environment, pain, immobility, medical interventions, and continuity of care, when women evaluate their childbirth experiences. The influences of pain, pain relief, and intrapartum medical interventions on subsequent satisfaction are neither as obvious, as direct, nor as powerful as the influences of the attitudes and behaviors of the caregivers.
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            Exploring the Prevalence of Disrespect and Abuse during Childbirth in Kenya

            Background Poor quality of care including fear of disrespect and abuse (D&A) perpetuated by health workers influences women’s decisions to seek maternity care. Key manifestations of D&A include: physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination, abandonment, and detention in facilities. This paper describes manifestations of D&A experienced in Kenya and measures their prevalence. Methods This paper is based on baseline data collected during a before-and-after study designed to measure the effect of a package of interventions to reduce the prevalence of D&A experienced by women during labor and delivery in thirteen Kenyan health facilities. Data were collected through an exit survey of 641 women discharged from postnatal wards. We present percentages of D&A manifestations and odds ratios of its relationship with demographic characteristics using a multivariate fixed effects logistic regression model. Results Twenty percent of women reported any form of D&A. Manifestations of D&A includes: non-confidential care (8.5%), non-dignified care (18%), neglect or abandonment (14.3%), Non-consensual care (4.3%) physical abuse (4.2%) and, detainment for non-payment of fees (8.1). Women aged 20-29 years were less likely to experience non-confidential care compared to those under 19; OR: [0.6 95% CI (0.36, 0.90); p=0.017]. Clients with no companion during delivery were less likely to experience inappropriate demands for payment; OR: [0.49 (0.26, 0.95); p=0.037]; while women with higher parities were three times more likely to be detained for lack of payment and five times more likely to be bribed compared to those experiencing there first birth. Conclusion One out of five women experienced feeling humiliated during labor and delivery. Six categories of D&A during childbirth in Kenya were reported. Understanding the prevalence of D&A is critical in developing interventions at national, health facility and community levels to address the factors and drivers that influence D&A in facilities and to encourage clients’ future facility utilization.
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              Prevalence and predictors of women's experience of psychological trauma during childbirth.

              The increased acceptance of the prevalence of trauma in human experience as well as its psychological consequences has led to revisions of diagnostic criteria for the disorder. The three purposes of this study were to examine the rates at which women experienced psychological trauma in childbirth, to explore possible causal factors, and to examine possible factors in the development of the disorder. One hundred and three women from childbirth education classes in the Atlanta metropolitan area completed a survey in late pregnancy and a follow-up interview approximately 4 weeks after the birth. The childbirth experience was reported as traumatic by 34 percent of participants. Two women (1.9%) developed all the symptoms needed to diagnose posttraumatic stress disorder, and 31 women (30.1%) were partially symptomatic. Regression analysis showed that antecedent factors (e.g., history of sexual trauma and social support) and event characteristics (e.g., pain in first stage of labor, feelings of powerlessness, expectations, medical intervention, and interaction with medical personnel) were significant predictors of perceptions of the childbirth as traumatic. The pain experienced during the birth, levels of social support, self-efficacy, internal locus of control, trait anxiety, and coping were significant predictors of the development of posttraumatic stress disorder symptoms after the birth. These findings suggest several intervention points for health care practitioners, including careful prenatal screening of past trauma history, social support, and expectations about the birth; improved communication and pain management during the birth; and opportunities to discuss the birth postpartum.
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                Author and article information

                Contributors
                Journal
                SSM Popul Health
                SSM Popul Health
                SSM - Population Health
                Elsevier
                2352-8273
                19 January 2017
                December 2017
                19 January 2017
                : 3
                : 201-210
                Affiliations
                [a ]Birth Place Research Lab, Division of Midwifery, University of British Columbia, 5950 University Boulevard, Vancouver, BC, Canada V6T 1Z3
                [b ]School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, Canada V6T 1Z3
                [c ]Department of Global Health Sciences, University of California San Francisco, Mission Hall Building, 550 – 16th Street, 3rd Floor, San Francisco, CA 94158, USA
                [d ]Department of Obstetrics and Gynecology, University of California San Francisco, Mission Hall Building, 550 – 16th Street, 3rd Floor, San Francisco, CA 94158, USA
                [e ]Human Rights in Childbirth, 6312 SW Capitol Highway St, 234 Portland, OR 97239, USA
                [f ]Midwives Association of British Columbia, 2-175 E. 15th Avenue, Vancouver, BC, Canada V5T 2P6
                Author notes
                [* ]Corresponding author. saraswathi.vedam@ 123456ubc.ca
                [1]

                Changing Childbirth in BC Steering Council, c/o Birth Place Lab at UBC Midwifery.

                Article
                S2352-8273(17)30017-4
                10.1016/j.ssmph.2017.01.005
                5768993
                © 2017 The Authors

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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