perspectives found that while women rarely questioned medical interventions despite their discomfort and embarrassment, they were vocal in expressing the importance of good interactions with their carers (Kabakian-Khasholian et al. 2000). A diverse group of 117 women were interviewed by Kabakian-
Khasholian and colleagues. They came from rural, remote rural and urban areas and represented different levels of education and class. Although they had different opinions regarding the presence of their husbands or family
members at the birth, and whether they preferred a midwife or doctor to care for them, women of all groups agreed that their satisfaction with care was ‘highly dependent on their interactions with care providers.’ The women appreciated
kind doctors and midwives who treated them humanely, praised or encouraged them, listened to their concerns and answered their questions. It appears (although the authors do not clarify) that private providers cared for all of the women in the study. The competitive nature of private care helps to explain some of the caring behaviours described but this does not detract from the importance women placed on the psychosocial aspects of care, especially when choosing their healthcare provider.
Exit interviews from health services of 1913 persons in rural Bangladesh (Aldana et al. 2001) found that politeness, respect and privacy was more important to them than the technical competence of the staff (characterised for example by physical examination or explaining the nature of the problem). Although this quality assessment study examined general health services it was one of a few larger studies in the region that, in addition to endeavouring to ensure rigour and reliability throughout the process, included multiple questions regarding client expectations, quality, satisfaction and the behaviour of
providers. Aldana and colleagues highlighted differences between professional and lay notions of quality and the need to address both. They recommended more in-depth research on determinants of client satisfaction in respective cultures.
In the context of a high maternal mortality ratio and 64% home birth rate, a qualitative study in Rakai district, Uganda, explored the psychosocial factors that influenced decisions regarding the place of birth (Amooti-Kaguna and Nuwaha 2000). Eight focus group discussions (FDG) were held with groups of men and groups of women. Semi-structured interviews were held with 211 women who had given birth to a baby during the preceding year. The use of male moderators in this study might have affected the women’s willingness to express themselves though the authors considered that the women talked openly. “Fear of being ridiculed by health workers” explained Amooti-Kaguna and Nuwaha, was one reason the women did not utilise public health units for antenatal care or childbirth. Some midwives were perceived as “rude, proud, negligent and vulgar” and were quoted as “using demeaning words to the
women”(p.208). Mothers who had not attended antenatal clinics or who had had many previous pregnancies were particularly abused by some young midwives. Mothers felt uneasy giving birth in the health unit due, they said, to health worker harassment or rudeness. They preferred traditional birth attendants (TBAs) who were said to be kind, caring, culturally acceptable and always available. Abrahams et al. (2001) reported from South Africa that staff-patient interactions made clinic attendance an unpleasant experience that discouraged women from attending. D’Ambruoso and colleagues (2005) reported that
humane, professional and courteous treatment was very important for women in Ghana. Health professionals’ attitudes were a critical element of care. They did not only affect women’s satisfaction and future use of maternity services but also affected whether they would recommend those services to others. Women in Ghana recounted both positive and negative encounters with staff. Some women experienced kindness, reassurance, politeness, help with caring for their babies and prayers, others cried when they relived their experiences of being threatened, shouted at, humiliated and unsupported as they gave birth. Despite the shouting and unfriendly behaviour, a number of women said that they would recommend the facility to women experiencing problems in childbirth because “to have your baby and be alive is the most important” (D'Ambruoso et al. 2005, p.6). Studies from many other settings including Cambodia, Zimbabwe and Benin reported that unfriendliness, lack of respect, shouting, rudeness, beatings and neglect of pregnant women by healthcare providers was not acceptable to women and that such behaviour discouraged them from
accessing maternity services or using a skilled attendant for antenatal care and childbirth (Grossman-Kendall et al. 2001; Mathole et al. 2004; Matsuoka et al. 2010).
Kempe et al. (2010) highlighted the importance of authority for women in Yemen. In a country where women are routinely disempowered, the authors noted that women’s personal empowerment at birth was very important to them. According to Yemeni childbirth tradition it is important that the labouring woman has power and authority during childbirth that their questions are answered and requests met. This is central to the experience of becoming a mother. The majority of Yemeni women gave birth at home, maternal mortality ratios were
high and the government was endeavouring to increase the use of professional care during childbirth (Kempe et al. 2010). This study revealed, however, that the higher the level of training of professional staff, the less respect and consideration the women experienced. It was the TBAs who shared authority, cared with empathy, created solidarity and support amongst women as they laboured at home. The authors concluded that attracting women to institutional care required a better understanding of people in the community, the
involvement of traditional carers and fundamental changes to make health service provision culturally appropriate.
Women in focus groups and semi-structured interviews in Uganda could explain the merits of having their babies at the health facilities but for varied reasons including lack of transport, poor quality of care and rude staff, 61% gave birth outside the health facilities where 40% of births were supervised by TBAs (Amooti-Kaguna and Nuwaha 2000). The authors concluded that it was not health education for women that was needed but a change in staff attitudes to make the health units more user-friendly, improve the quality of care and increase the proportion of women giving birth with a trained health worker. The focus on cultural barriers, poverty and ignorance when discussing the
underutilisation of services, Thaddeus and Maine (1994) contended, obscured the role that institutional inadequacies play.
These studies indicate that it is not sufficient to just provide clinical services; they must also be socially and culturally acceptable. Women’s choices regarding ante-natal attendance, place of birth, the use of biomedical or traditional healthcare services are strongly influenced by their experiences of healthcare providers, or the reputation of health facility staff. The effect on the uptake of services, it could be argued, has an indirect effect on maternal mortality and morbidity.
Next, I wanted to ascertain if there was evidence of a direct link between healthcare provider behaviour and maternal mortality.