Consented maternal care and associated factors among mothers who gave birth at public health institutions in South Wollo Zone,Amhara region,Ethiopia 2022

Abstract

Introduction:

Informed consent in healthcare services is a legal, ethical, and professional requirement on the part of all treating health providers and providing person-centered care. The methods of requesting consent during childbirth have not been extensively studied. In Ethiopia, there is not at all a single study done.

Objective:

The purpose of this study is to determine associated factors among mothers who gave birth at health institutions in the South Wollo Zone, Amhara region, Ethiopia in 2022.

Methods:

Mothers who gave birth at South Wollo Zone public health institutions, from 01 March to 30 April 2022 participated in a multi-center institutional-based cross-sectional study design. Systematic random sampling was used to select 423 study participants. A validated questionnaire was used for data collection, and the data were collected through face-to-face interviews. Data were entered into Epi-Data version 4.6 and exported to SPSS version 23 for analysis. A multivariable logistic regression analysis was performed to identify factors associated with the outcome variable. The level of significance was determined using an adjusted odds ratio with a 95% confidence interval.

Result:

The study had 416 participants in total, with a response rate of 98.3%. Out of the 416 respondents interviewed, 67.1% of the women received consented care. The age group of 30–34, complications during childbirth, intended pregnancy, merchant, and primary and referral hospital were significantly associated with consented care.

Conclusion:

The level of non-consented care during delivery was high compared with other literature reflecting substantial mistreatment. Therefore, stakeholders should strengthen monitoring and assessment systems to prevent abuse, and further study is required to look for practical ways to make improvements. Key elements of consented care have also been included in Basic and Emergency Obstetric Care training sessions and given to health providers.

Keywords

Consented maternal care childbirth health institutions South Wollo Zone

Introduction

Informed consent is a process in which patients and healthcare providers discuss the nature, implications, harms, benefits, risks, and other possibilities of a proposed medical treatment^1,2 Informed consent in healthcare services is a legal, ethical, and professional requirement on the part of all healthcare provider and supports person-centered care. Informed consent is a critical issue in terms of both key quality and safety.³

Patients have the right to obtain information and ask questions regarding the care or treatment they are given.⁴ Patients’ medical autonomy is safeguarded by the informed consent code of ethics, which grants them the freedom to choose their course of treatment independently of medical advice. If a patient is competent, then she has a right to information about her treatment options and to choose in the absence of coercion.⁵

Numerous studies show that a key factor preventing facility-based births is women’s dissatisfaction with their maternity care. Treatment of women seeking obstetric care through non-consented clinical care seems to be ubiquitous and unavoidable.^6,7 If a patient does not believe that they have given their consent to an examination or procedure, they are likely to identify with assault, one of the consent’s antonyms.⁸ The most horrible episodes of obstetric violence frequently include the assault or harm of laboring women, when medical treatments are given without consent but also in spite of a clear rejection; and the UN special rapporteur on violence placed special emphasis on the importance of consent for tackling mistreatment during childbirth.^9,10

To be legitimate, consent must be provided voluntarily and freely, with no undue pressure or influence placed on the person to give permission or refuse medical care¹¹, and the patient must be competent to understand and decide, receive full disclosure, comprehend the disclosure, act voluntarily, and consent to the proposed action.¹² Informed consent is not just a signed form/document, it is a collaboration in the decision-making process between the patient and healthcare provider therapeutic encounter.¹³

The relationship between a doctor and patient must be one of trust and respect, and this is critical for providing quality patient care.¹⁴ The Miller and Wertheimer consensus states that patients have the right to complete and accurate information about their course of treatment as well as the freedom to refuse it.¹⁵ Women’s rights to make treatment decisions contend that medical professionals should respect patients’ medical autonomy even when a patient makes decisions that endanger the life of her unborn child, even if it is morally wrong to subject unborn children to unnecessary risks.¹⁶ This is especially true if a woman in labor makes a decision that puts her unborn child’s life in danger. When a woman makes a medically ill-advisable decision during labor and delivery she may act wrongfully; however, she has the right to do so. On the other hand, the mother’s medical rights would be violated by involuntary interventions during labor.

Therefore, even when women make potentially fatal decisions during labor and delivery, legal institutions should respect their choices regarding treatment.¹⁷ Even though more evidence is needed, studies have stated that enhanced communication between healthcare providers and patients leads to better patient outcomes, fewer medical errors, and lower malpractice case rates. Providing patients with simplified supplemental written materials, using the repeatback methods, decision aids, and video educational resources enhances patient perception as well as awareness of informed consent.¹

The ability to voluntarily accept an intervention after being provided with sufficient and understandable information regarding the risks and benefits is known as valid informed consent.¹⁸ Preoperative preparation is essential for all surgical procedures, including cesarean sections (CSs), which are the most common surgical interventions worldwide.¹⁹ In obstetrics, getting consent and explaining procedures are linked to better ratings of the birth experience, but receiving care without consent is thought to hinder the use of skilled birth care.^20,21

Studies reported that informed consent is underutilized. A qualitative study done in England reported that consent is not properly taken from their clients and patient refusal is ignored. Even healthcare providers do not know how they proceed when their patients cannot give consent.²²

Despite its importance, there is limited evidence showing the utilization of consent care in healthcare service delivery around the globe.²³ Spatially in Ethiopia, there is no single study done regarding the proposed problem. To assess consented care and associated factors during labor and delivery, this study is being conducted.

Methods

Study design, period, and area

In order to assess the level of consented maternal care during childbirth and associated factors among women who gave birth in the South Wollo zone Amhara Region, Ethiopia from 01 March to 30 April 2022 public health institutions, a multicenter institutional-based cross-sectional study design was employed. The study was carried out at South Wollo zone public health institutions in Ethiopia’s Amhara region. It is one of the 11 zones that make up Ethiopia’s Amhara regional state. It is bordered on the south by North Shewa, on the west by East Gojjam, on the northwest by South Gondar, on the north by North Wollo, on the northeast by Afar Region, and the east by the Oromia Special Zone and Argobba Special district. There are 22 districts in the Zone. Located 401km north of Addis Ababa, the capital of Ethiopia, is Dessie Town, the capital city of the south Wollo zone. Data from the zonal health department show that there are 135 health clinics and 12 public hospitals in the zone. All hospitals and health institutions offer delivery services around the clock.

Source population and study population

The source population was all mothers who gave birth in the South Wollo Zone Public Health institutions. All mothers who gave birth in the South Wollo zone throughout the study period were included in the study population; participants were selected by systematic random sampling from public health institutions.

Sample size and sampling procedure

Sample size determination

Under the following assumptions, the sample size was established using a precision approach that is based on a single population percentage formula: 50% proportion of PRA, 95% level of confidence, and 5% margin of error.

n = \frac{{(Z α / 2)}^{2} * p (1 - p)}{d^{2}} = \frac{{(1.96)}^{2} * 0.5 (1 - 0.5)}{{(0.05)}^{2}} = 384

Where, n = required sample sizes, α = level of significance, z = standard normal distribution curve value for 95% confidence level = 1.96, p = proportion of PRA, and, d = margin of error. Finally, by adding a 10% non-response rate, the required minimum size of the sample was 423.

To choose the Dessie referral hospital, Haik Primary Hospital, Mekane Selam Primary Hospital, and 27 health Centers, a simple random sampling procedure was applied. The sample was distributed proportionately among all the public health institutions that were chosen, taking into account the average number of women who gave birth in each institution during 2 months in 2021.

Study participants were selected from among the mothers who gave birth in South Wollo zone public health facilities using a systematic random sampling technique, continuing until each public health facility had the necessary sample size. In each of the selected healthcare facilities, data was collected from every third woman who gave birth during the study period. The sampling interval k = 3 was calculated by dividing the source population by the total sample size and this interval was used in all health institutions to select study participants. For each of the public health institutions, the constant number K was also calculated, and it was the same K = 3. This interval was used in all public health institutions to select study participants. The first sample was selected randomly by lottery method among the first three participants (1 randomly selected) then every third unit was taken to get the required sample size from each institution (Figure 1).

Figure 1.

Sampling procedures to assess consented maternity care and associated factors among women who gave birth in public health institutions of south Wollo Zone, Northwest Ethiopia, 2022.

Operational definition of variables

Friendly care: The care that includes care in a kind and friendly approach, using polite words, call by name, speaking language the mother understands, and measured by using seven requirements a woman who responds “Yes” to all seven friendly care questions, considered she was receiving friendly care at the time of labor and delivery.^24–27

Data collection tools and procedure

A validated quantitative data collection technique was used by using through face-to-face interview administered questionnaire as part of their respectful maternity care tool kit.²⁸

The instrument initially was arranged in English, then translated into Amharic, and finally back into English to ensure uniformity. The tool is divided into four sections: Respondents’ sociodemographic information is found in Part I; Participants’ obstetric information is found in Part II; Provider-Related Factors are found in Part III; and Categories of consented maternity care (CMC) that women received during facility-based childbirth are found in Part IV. To aid in the data collection procedure, 21 data collectors with BSc in midwifery professionals and three MSc midwifery specialists supervisors were engaged.

Women who were giving birth at the facilities participated in a postpartum exit interview. Private conversations were held with each qualified woman on hospital property, in a room apart from the maternity unit. Supervisors collected and signed the completed questionnaires after verifying that no information was missing and that they were accurate. Aside from this, the primary investigator continuously monitored and supervised the data collection process.

Supervisors and data collectors received a half-day instruction regarding the goals of the study and data collection methods. Throughout the data collection process, the skilled data collectors received supervision. Pretest was done on 5% of the sample size (21 women) before the actual data collection at Boru Hospital and Woged Health Center. The collected data were reviewed and checked for completeness, clarity, and consistency, and on-spot corrective measures were taken by both data collectors and supervisors

Data processing and analysis

Epi-Data version 4.6 was utilized to enter the data, which were then cleaned for inconsistencies and missing values before being exported to SPSS version 23 for analysis. Analytical and descriptive statistical techniques were employed.

To determine how each independent variable is associated with the outcome variable, bivariable logistic regression was used. A variable with a p-value of <0.2 was a candidate for a multivariable logistic regression model. Then, to identify a statistically significant association, the multivariable analysis’s p-value of less than 0.05, adjusted odds ratio (AOR), and its 95% confidence interval (CI) were taken into account. In the end, the data were collated, shown, and discussed using texts, tables, and graphs. The odds ratio and 95%.

Result

Sociodemographic characteristics of the respondent

The study had 416 participants in total, with a response rate of 98.3%. Among the individuals involved in the study, 35.6% were within the age group of 25–29 years; with an interquartile range of (IQ of 21–30) years and a median age of 27. Of all responders in total, 389 (93.5%) were Amhara by ethnicity, and 327 (78.1%) were Orthodox Christianity religion followers. Considering the mother’s marital status, 374 (89.9%) of them were married and 145 (34.9%) were housewives. Of the total respondents, 234 (56.2%) made less than 2282 Ethiopian birr per month as a family 228 (54.8%) of the total respondents lived in rural areas (Table 1).

Table 1.

A sociodemographic characteristic of mothers who gave birth at public health institutions in the south Wollo Zone, Amhara region, Ethiopia, 2022 (N = 416).

Characteristics	Categories	Frequency	Percentage
Age in groups	15–19	34	8.2
	20–24	101	24.3
	25–29	148	35.6
	30–34	72	17.3
	35 and above	61	14.7
Place of residence	Rural	228	54.8
Place of residence	Urban	188	45.2
Religion	Orthodox	327	78.1
	Muslim	77	18.5
	Protestant	14	3.4
Marital status	Single	31	7.5
	Married	374	89.9
	Others^a	11	2.7
Ethnicity	Amhara	389	93.5
	Tigre	15	3.6
	Other ethnicity^b	12	2.9
Educational status	Unable to read and write	114	27.4
	Able to read and write	67	16.1
	Primary (1–8) completed	33	7.9
	Secondary (9–12) completed	106	25.5
	Collage and above	96	23.1
Mothers occupation	Housewife	145	34.9
	Private employee’	47	11.3
	Government employee	54	13
	Merchant	65	15.6
	Student	47	11.3
	Farmer	58	13.9
Average monthly income	Less than 2282	234	56.2
	More than 2282	182	43.8

Divorced and widowed.

Oromo and gurage.

Obstetric-related characteristics of women

According to the study’s findings, 287 (69%) of the respondents were multiparous and 380 (91.3%) had ANC follow-up. Of the total respondents, 316 (76%) gave birth with spontaneous vaginal delivery and 42 (10.1%) were given birth by CS. Of the total respondents, 393 (94.5%) were live births, and 325 (78%) participants were attended by Midwife healthcare professionals. Not having companions when giving birth for 118 (27.9%) of childbirth women and staying at health facilities for 12 h or less for 333 (80%) (Table 2).

Table 2.

Obstetric characteristics of mothers who gave birth at public health institutions in the south Wollo Zone, Amhara region, Ethiopia, 2022 (N = 416).

Characteristics	Categories	Frequency	Percentage
Number of parity	Primi-para	129	31
	2–3	194	46.6
	⩾4	93	22.4
Pregnancy intended/wanted	Yes	360	86.5
Pregnancy intended/wanted	No	56	13.5
Antenatal care follow-ups	Yes	380	91.3
Antenatal care follow-ups	No	36	8.7
Place of antenatal care follow-ups	Health center	252	66.4
	Primary hospital	64	16.8
	Referral hospital	34	8.9
	Private clinic	30	7.9
Number of ANC follow-ups	Once to twice	116	30.5
	Three times	152	40
	Four and above	112	29.5
Current place of delivery	Public health center	134	32.2
	Primary hospital	99	23.8
	Public referral hospital	183	44
Provider conducting delivery	Nurse	2	0.6
	Midwife	325	78
	Doctor	30	7.2
	Emergency surgeon	59	14.2
Sex of provider	Male	250	60.1
Sex of provider	Female	166	39.9
The current mode of delivery	SVD	316	76
	Cesarean section	42	10.1
	AVD	58	13.9
Outcomes of delivery	Alive	393	94.5
Outcomes of delivery	Stillbirth	23	5.5
Facing complications during labor and delivery	No	370	88.9
Facing complications during labor and delivery	Yes	46	11.1
Type of complication	Hemorrhage	13	28.3
	Hypertensive disorders	15	32.6
	Other complication^©	28	39.1
Time of delivery	Day time	202	48.6
Time of delivery	Nighttime	214	51.4
Total hours of stay at health facilities	12 h or less	333	80
	13–24 h	28	6.7
	25 h and above	55	13.3
Companions during delivery	No	300	72.1
	Yes	118	27.9

SVD: spontaneous vaginal delivery; AVD: assisted vaginal delivery; ^©: infection, obstructed labor, premature rupture of membrane.

Women’s perceptions of consent requests by type of clinical procedure

The women stated that the frequency of requests for consent differed according to the type of clinical procedure. Women were generally requested for their agreement before having maternity operations rather than newborn procedures. The greatest percentage of consent requests for maternal procedures (90.5%) was reported for CS, with the lowest being for PPH prophylaxis (29.1%) after spontaneous birth or Instrumental vaginal delivery. Women stated that low rates of consent requests for neonatal procedures had been obtained during childbirth among these neonatal conjunctivitis prophylaxis, and neonatal hemorrhagic disease prophylaxis (12.7%) presenting the lowest rate among the nine procedures that were investigated (Table 3).

Table 3.

Consent request by type of clinical procedure according to women’s perception during childbirth at public health institutions in the south Wollo Zone, Amhara region, Ethiopia, 2022 (N = 416).

Variable	Yes	No
Vaginal examination during labor (N = 416)	351 (84.4%)	65 (15.6%)
Fundal pressure during the second stage of labor as perceived by women (N = 30)	11 (36.6%)	19 (63.4%)
Episiotomy (N = 131)	60 (45.8%)	71 (54.2%)
Instrumental vaginal birth (N = 58)	27 (46.6%)	31 (53.4%)
Cesarean section (N = 42)	38 (90.5%)	4 (9.5%)
PPH prophylaxis (N = 416)	121 (29.1%)	295 (70.9%)
Neonatal conjunctivitis prophylaxis (N = 416)	53 (12.7%)	363 (87.3%)
Neonatal hemorrhagic disease prophylaxis (N = 416)	53 (12.7%)	363 (87.3%)
Neonatal screening for metabolic diseases (N = 118)	106 (89.8%)	12 (10.2%)

Category of consented maternity care

In about 385 (92.5) of women, provider responds to your question with politeness and truthfulness, and 373 (89.7%) they were given the freedom of being birth in the position they want. For about 384 (92.3%) of women, providers explain What was going on and what to anticipate during labor and delivery, and 325 (78.1%) providers introduce themselves and greet you and your companion. Among the participants, a significant number of women 91 (21.9%) complained that some healthcare professionals did not introduce themselves and greet them and their companions. About 385 (92.5%) of women’s care providers answered their inquiries with promptness, politeness, and truthfulness. Additionally 384 (92.3%) of them gave explanations on what is happening and what to expect during childbirth (Table 4).

Table 4.

Category of consented maternity care reported by mothers during childbirth at public health institutions in the south Wollo Zone, Amhara region, Ethiopia, 2022 (N = 416).

	Category of consented care	Yes (%)	No (%)
Consented care	Providers introduce themselves and greet you and your companion	325 (78.1%)	91 (21.9%)
	Providers encourage you and your companion to ask questions	379 (91.1%)	37 (8.9%)
	Provider responds to your question with politeness and truthfulness	385 (92.5%)	31 (7.5%)
	Providers explain what was being done and what to expect throughout labor and delivery	384 (92.3%)	32 (7.7%)
	The provider gives periodic updates on the status and progress of your labor	382 (91.8%)	34 (8.2%)
	Providers allow you to choose a birth position as you want	373 (89.7%)	43 (10.3%)
	Healthcare providers obtain permission/consent from you before any procedure	381 (91.6%)	35 (8.4%)

Status of consented care

Among the 416 responders who were interviewed, 67.1% (95%; CI: 62.5, 71.6%) of the women received consented care, but a large number of women 32.9% had not received consented care during childbirth with (95% CI: 28.4–37.5).

Factors associated with consented maternity care during childbirth

As the bivariable analysis’s result showed the respondent’s age, occupation, pregnancy intended/wanted, number of parity, time of delivery, place of delivery, delivery outcome, and facing complications during labor and delivery were factors found to be associated with consented maternity care at a p-value of 0.25 or less. The five variables in a multivariable logistic regression analysis are: age, occupation, pregnancy intended/wanted, place of delivery, and facing complications during labor and delivery were significantly associated with consented maternity care at a p-value of <0.05.

The odds of consented maternity care were 3.57 (1.10–11.59) and 5.24 (1.36–20.18) times higher among women in the age group of 30–34 and 35 and above, respectively. According to this study, women who intended their current pregnancy were 3.2 (1.61–6.36) times more likely to receive consented maternity care than those who were not.

According to this study, women who experienced difficulties or faced complications during labor and delivery were 62% (AOR = 0.38, 95% CI: 0.19–0.76) less likely to receive consented maternity care as compared to those who have not faced complications during labor and delivery. The odds of receiving consented maternity care were 3.1 (AOR: 3.1, 95% CI: 1.36–7.18) times higher among women who work as a merchant than those who were a housewife. This study concluded that among the women who gave birth at primary hospitals and referral hospitals were 70% and 58% less likely to have consented to maternity care (AOR: 0.30, 95% CI: 0.16–0.58) and (AOR: 0.42, 95% CI: 0.24–0.76) as compared to those women who gave birth at Health center respectively (Table 5).

Table 5.

Factors associated with consented maternity care during labor and childbirth at public health institutions in the south Wollo Zone, Amhara region, Ethiopia, 2022 (N = 416).

Variables	Received CMC service		COR (95% CI)	AOR (95% CI)
Variables	Yes	No	COR (95% CI)	AOR (95% CI)
Age
15–19	16 (47.1%)	18 (52.9%)	1	1
20–24	64 (63.4%)	37 (36.6%)	1.95 (0.88–4.27)	1.56 (0.47–2.84)
25–29	106 (71.6%)	42 (28.4%)	2.84 (1.33–3.58)	2.32 (0.90–5.95)
30–34	50 (69.4%)	22 (30.6%)	2.56 (1.11–5.92)	3.57 (1.10–11.59)*
35 and above	43 (70.5%)	18 (29.5%)	2.68 (1.13–6.41)	5.24 (1.36–20.18)*
Occupation
Housewife	100 (69%)	45 (31%)	1	1
Private employee’	37 (78.7%)	10 (21.3%)	1.66 (0.76–3.64)	2.1 (0.87–5.05)
Government employee	34 (63%)	20 (37%)	0.76 (0.39–1.47)	0.68 (0.32–1.47)
Merchant	51 (78.5%)	14 (21.5%)	1.64 (0.82–3.26)	3.1 (1.36–7.18)**
Student	28 (59.6%)	19 (40.4%)	0.66 (0.33–1.31)	1.87 (0.75–4.68)
Farmer	29 (50%)	29 (50%)	0.45 (0.24–0.84)	0.37 (0.18–0.76)
Pregnancy intended/wanted
No	25 (44.6%)	31 (55.4%)	1	1
Yes	254 (70.6%)	106 (29.4%)	2.97 (1.67–5.27)	3.2 (1.61–6.36)**
Parity
Primi-para	75 (58.1%)	54 (41.9%)	1	1
2–3	142 (73.2%)	52 (26.8%)	1.96 (1.23–3.15)	1.66 (0.86–3.21)
⩾4	62 (66.7%)	31 (33.3%)	1.44 (0.83–2.51)	0.73 (0.25–2.06)
Time of delivery
Day time	144 (71.3%)	58 (28.7%)	1	1
Night time	135 (63.1%)	79 (36.9%)	0.68 (0.45–1.04)	0.64 (0.40–1.02)
Place of delivery
Health center	105 (78.4%)	29 (21.6%)	1	1
Primary hospital	58 (58.6%)	41 (41.4%)	0.39 (0.22–0.69)	0.30 (0.16–0.58)**
Referral hospital	116 (63.4%)	67 (36.6%)	0.47 (0.28–0.79)	0.42 (0.24–0.76)*
Delivery outcome
Live birth	269 (68.4%)	124 (31.6%)	1	1
Stillbirth	10 (43.5%)	13 (56.5%)	0.35 (0.15–0.83)	0.42 (0.15–1.14)
Facing complications during labor and delivery
No	257 (69.5%)	113 (30.5%)	2.48 (1.28–4.0)	1.61 (1.23–4.16)**
Yes	22 (47.8)	24 (52.2%)	1	1

AVD: assisted vaginal delivery; PEC: primary education (1–8) completed; SEC: secondary education (9–12) completed.

Significant at p-value < 0.05, **Significant at p-value < 0.001.

Discussion

This is the first inquiry regarding consent supplication practices around the time of childbirth in Ethiopia based on women’s point of view for nine key clinical procedures and mothers during childbirth reported seven types of consented maternity care at public health institutions in the south Wollo Zone, Amhara region, Ethiopia. In this study, there is evidence of a widespread absence of patient information processes or consent requests by type of clinical procedure according to women’s perception during childbirth in many settings, such as PPH prophylaxis, neonatal conjunctivitis prophylaxis, and neonatal hemorrhagic disease prophylaxis

This finding shows only 67.1% of the women received consented care at public health institutions in the South Wollo Zone, Amhara region, Ethiopia.

This result is higher than the studies conducted in Enugu, southeastern Nigeria where consented care services were provided at a rate of 45.5%.²⁹ This variation might be the difference in sociodemographic characteristics and healthcare professionals practice.

This finding also supported a study conducted in Pakistan in which the majority of service providers do not provide care with consent.³⁰ In a study done in London, healthcare professionals also have concerns about consent practices, and more work is urgently needed to promote autonomy in laboring women.³¹

This study was also lower than the research findings in Bangladesh Consent (not informed consent) was taken from 95% of the mothers before proceeding with normal vaginal delivery and postpartum care in the tertiary-level hospital in Bangladesh.³² According to a study conducted in Italy, 83.5% of the procedures requested informed consent.²³ The explanation might be the status of the participant’s level of understanding about the service, service quality, and the ability of participants to report consented care might be different, and the difference may be infrastructure.

The odds of consented maternity care were 3.57 (1.10–11.59) and 5.24 (1.36–20.18) times higher among women in the age group of 30–34 and 35 and above respectively.

This finding is supported by research done in adjusting for countries (Ghana, Guinea, Myanmar, and Nigeria) younger, unmarried women were more likely to have without consent vaginal examinations.³³ The likely reason may be that healthcare providers interact and treat teens differently simply because they are younger than the providers themselves, or the providers may perceive teens as too young to become a mother. Many qualitative research and reviews have indicated that younger women, especially those in their teens may be the targets of discrimination and may receive less consented care.^34,35

According to this study, women who were intended with their current pregnancy were 3.2 (1.61–6.36) times more likely to receive consented maternity care than those with an unwanted pregnancy. The reason that might be pregnancy is desired and planned; the mother receives continuous emotional support from her husband, family, and community, which improves the outcome of childbirth and consented care.

This study revealed that the women who have not faced complications during labor and delivery were 1.61 (AOR = 1.61, 95% CI: 1.23–4.16) times received consented care compared to those who faced complications during labor and delivery. This study supported a study that was conducted in Australia and New Zealand experienced complications during childbirth, 20% of interviewees said informed consent was lacking or insufficient, 25% of participants suggested policy change in favor of a formal informed consent process and 55% of participants recommended changing the policy to improve awareness of complications and increased birth preparedness.³⁶

The odds of receiving consented maternity care were 3.1 (AOR: 3.1, 95% CI: 1.36–7.18) times higher among women who work as a merchant than those who were a housewife. Study results from Western Ethiopia support this finding³⁷ and in Central Tigray, Ethiopia.³⁸ The possible explanation may be that merchant women are more likely to report abuse because they are better aware of their rights and very likely to report non-consented care.

This research revealed that the women who gave birth at Primary hospitals and Referral Hospital were 70% and 58% less likely to have consented care (AOR: 0.30, 95% CI: 0.16–0.58) and (AOR: 0.42, 95% CI: 0.24–0.76) as compared to those women who gave birth at Health center, respectively. This is consistent with the study conducted in the West Shewa zone, Central Ethiopia, and Addis Ababa that indicated there was a notable difference between hospitals and health centers between the health centers and hospitals.^39,40 The most plausible explanation may be due to the presence of larger caseloads compared to the available number of human resources at hospitals than in health centers.

Strength of the study

The study was carried out in a multi-center study in a rural and urban area to control the potential source of confounding using an adjusted logistics regression model.

Limitations

This study has some essential limitations, the most effective way to investigate consenting care was by using the observational data collecting method. Finally, this study used only a quantitative approach, but the qualitative inquiry is important to capture robust data in determining factors affecting consented maternal care services.

Conclusion

This study reveals the significant amount of non-consented care during delivery, and there is an immediate need for action in this area, so this study finding verifies and enhances the previous evidence showing gaps in consented maternal care requests during childbirth are prevalent. Factors like age group of 30–34 and 35 and above, complications during labor and delivery, planned pregnancy, merchant and Primary hospitals, and Referral hospitals were the factors that are significantly associated with those consented maternal care during childbirth. However, although there is a lack of unanimity on how to better improve this practice in regular women-consented care, it is important to recognize the possible role of systemic factors (e.g., low quality of standard forms, and the timing of requests). More research and action are needed to investigate practices and explore the impact of different strategies of improvement. We recommended that the government of Ethiopia consider integrating key elements of consented care has also been included in Basic and Emergency Obstetric Care training sessions.

Focused on increasing awareness of family planning methods to prevent unplanned pregnancy. Additionally, it creates awareness in the community about complications during childbirth if not choosing to have care in a hospital.

Consented care is improved when patients have rights to information, informed consent, and the ability to refuse treatment, as well as privacy, confidentiality, and respect for their preferences. Besides this, public health institutions and other stakeholders must strengthen monitoring and assessment systems to prevent abuse, and further study is required to investigate effective strategies for improvement.

Supplemental Material

sj-docx-1-smo-10.1177_20503121241227083 – Supplemental material for Consented maternal care and associated factors among mothers who gave birth at public health institutions in South Wollo Zone, Amhara region, Ethiopia 2022

Supplemental material, sj-docx-1-smo-10.1177_20503121241227083 for Consented maternal care and associated factors among mothers who gave birth at public health institutions in South Wollo Zone, Amhara region, Ethiopia 2022 by Wassie Yazie Ferede, Besfat Berihun Erega, Fillorenes Ayalew Sisay, Abeba Belay Ayalew, Yismaw Yimam Belachew and Tigist Seid Yimer in SAGE Open Medicine

Footnotes

Acknowledgements

We have gratitude to Debre Tabor University for its ethical letter. Our gratitude is also great to all data collectors and study participants.

Author contributions

WYF: Conception and design, acquisition of data, analysis, and interpretation of data, drafting the article, critical revision of the article, and final approval of the version to be published. BBE: Conception and design, acquisition of data, analysis, and interpretation of data revised the subsequent drafts of the manuscript, final approval of the version to be published. FAS: Conception and design, acquisition of data, analysis, and interpretation of data revised the subsequent drafts of the manuscript, final approval of the version to be published. ABA: Conception and design, acquisition of data, analysis, and interpretation of data revised the subsequent drafts of the manuscript, final approval of the version to be published. TSY: Conception and design, acquisition of data, analysis, and interpretation of data, drafting the article, critical revision of the article, final approval of the version to be published. YYB: Conception and design, acquisition of data, analysis, and interpretation of data, drafting the article, critical revision of the article, final approval of the version to be published.

Availability of data and material

All available data are in the manuscript.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research was supported by a grant from the Debre Tabor University, College of Health Science. The granting agency did not have a role in the design, collection, analysis, and interpretation of data or in the writing of the manuscript.

Ethical approval

Ethical approval for this study was obtained from Debre Tabor University’s Research and Ethical Review Committee granted ethical approval; the letter’s reference number was DT/091/21/1861/14. Additionally, a letter of support was obtained from the South Wollo Zone Health Office.

Informed consent

Written informed consent was obtained from all subjects before the study age above 18-year-old participants and legally authorized representatives before the study under 18-year-old participants. The participants in the study received no financial compensation or benefit whatsoever. The study participants were identified using codes to protect data confidentiality, and participants have been informed that they have the right to withdraw at any time.

Trial registration

Not applicable.

ORCID iDs

Wassie Yazie Ferede

Abeba Belay Ayalew

Tigist Seid Yimer

Supplemental material

Supplemental material for this article is available online.

References

Cordasco

KM.

Chapter 39 obtaining informed consent from patients: brief update review. Los Angeles, CA: VA Health Services Research Center for the Study of Healthcare Innovation, Policy and Practice.

Standard of care: lack of informed consent; what is informed consent? https://www.standardsofcare.org/medical-malpractice/types/lack-informed-consent/

Australian commission on safety and quality in health care: Home/Our work/Partnering with consumers/informed consent, https://www.safetyandquality.gov.au/our-work/partnering-consumers/informed-consent

AMA: Ethics; Informed Consent; Code of Medical Ethics Opinion 2.1.1, https://www.ama-assn.org/delivering-care/ethics/informed-consent

Dolgin

JL.

The legal development of the informed consent doctrine: past and present. Camb Q Healthc Ethics 2010; 19(1): 97–109.

World Health Organization. The prevention and elimination of disrespect and abuse during facility-based childbirth. Geneva: World Health Organization, 2015.

Bohren

Hunter

Munthe-Kaas

, et al. Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reprod Health 2014; 11: 71.

Tillman

Consent in pelvic care. J Midwifery Womens Heal 2020; 65(6): 749–758.

Simonovic

A human rights-based approach to mistreatment and violence against women in reproductive health services with a focus on childbirth and obstetric violence (Report of the special rapporteur on violence against women, its causes and consequences). New York, NY: UN, for example, Section III.B.14, 2019.

10.

Beck

CT.

A secondary analysis of mistreatment of women during childbirth in health care facilities. J Obstet Gynecol Neonatal Nurs 2018; 47(1): 94–104.

11.

Care Quality Commission. Supporting note: consent to care and treatment. Care Qual Comm 2011: 1–2.

12.

Varkey

Principles of clinical ethics and their application to practice. Med Princ Pract 2021; 30(1): 17–28.

13.

Rawlings

Sillin

Shadduck

, et al. Informed consent: a shared decision-making process that creates a new professional obligation for care. Surg Endosc 2020; 34(11): 4713–4716.

14.

Gillon

Ethics needs principles—four can encompass the rest—and respect for autonomy should be first among equals. J Med Ethics 2003; 29: 307–312.

15.

Miller

Wertheimer

Facing up to paternalism in research ethics. Hastings Cent Rep 2007; 37: 24–34.

16.

Flanigan

Obstetric autonomy and informed consent. Ethic Theory Moral Pract 2016; 19: 225–244.

17.

Pérez

D’

Gregorio

. Obstetric violence: a new legal term introduced in Venezuela. Int J Gynaecol Obstet 2010; 111(3): 201–202.

18.

Appelbaum

PS.

Assessment of patients’ competence to consent to treatment. N Engl J Med 2007; 357: 1834–1840.

19.

Weiser

Haynes

Molina

, et al. Size and distribution of the global volume of surgery in 2012. Bull World Health Organ 2016; 94: 201–209.

20.

Bowser

Hill

Exploring evidence for disrespect and abuse in facility-based childbirth: report of a landscape analysis. Washington, DC: Harvard School of Public Health and University Research Co, 2010.

21.

Kambala

Lohmann

Mazalale

, et al. How do Malawian women rate the quality of maternal and newborn care? Experiences and perceptions of women in the central and southern regions. BMC Pregnancy Childbirth 2015; 15: 169.

22.

Helen

Informed consent before nursing care procedures. Nurs Ethics 2005; 12(1): 1244–1252.

23.

Valente

Mariani

Covi

, et al. Quality of informed consent practices around the time of childbirth: a cross-sectional study in Italy. Int J Env Res Public Health 2022; 19(12): 7166.

24.

Kitaw

Tessema

Respectful maternity care and associated factors among mothers in the immediate postpartum period, in public health facilities of Addis Ababa, Ethiopia, 2018. Int J Pregn Childbirth 2019; 5(1): 10–17.

25.

Wassihun

Zeleke

Compassionate and respectful maternity care during facility-based childbirth and women’s intent to use maternity service in Bahir Dar, Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 294.

26.

Asefa

Bekele

Morgan

, et al. Service providers’ experiences of disrespectful and abusive behavior towards women during facility-based childbirth in Addis Ababa, Ethiopia. Reprod Health 2018; 15(1): 4.

27.

Ferede

Gudayu

Gessesse

, et al. Respectful maternity care and associated factors among mothers who gave birth at public health institutions in South Gondar Zone, Northwest Ethiopia 2021. Womens Health 2022; 18: 17455057221116505.

28.

Reis

Deller

Carr

, et al. Respectful maternity care: country experiences survey report. Washington, DC: United States Agency for International Development, 2012.

29.

Okafor

Ugwu

Obi

. Disrespect and abuse during facility-based childbirth in a low-income country. Int J Gynecol Obstetr 2015; 128(2): 110–113.

30.

Munawar

Hassan

Ayub

, et al. Women’s perceptions about quality of maternity care at tertiary care hospital Karachi, Pakistan. Pakistan J Public Health 2017; 7(2): 109–112.

31.

Kennedy

Lanceley

Whitten

, et al. Consent on the labour ward: a qualitative study of the views and experiences of healthcare professionals. Eur J Obstetr Gynecol Reprod Biol 2021; 264: 150–154.

32.

Karim

Ahmed

Ferdous

, et al. Assessing informed consent practices during normal vaginal delivery and immediate postpartum care in tertiary-level hospitals of Bangladesh. Eur J Midwifery 2019; 3: 10.

33.

Bohren

Mehrtash

Fawole

, et al. How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys. Lancet 2019; 394(10210): 1750–1763.

34.

Bowser

Hill

Exploring evidence for disrespect and abuse in facility based childbirth: a report of a landscape analysis. Cambridge, MA: USAID-TRAction Project, Harvard School of Public Health and University Research Co., 2010.

35.

Warren

Njue

Ndwiga

, et al. Manifestations and drivers of mistreatment of women during childbirth in Kenya: implications for measurement and developing interventions. BMC Preg Childbirth 2017; 17: 102.

36.

Ely

Langer

Dietz

HP.

Informed consent and birth preparedness/complication readiness: a qualitative study at two tertiary maternity units. Aust N Z J Obstet Gynaecol 2022; 62(1): 47–54.

37.

Tekle Bobo

Kebebe Kasaye

Etana

, et al. Disrespect and abuse during childbirth in Western Ethiopia: should women continue to tolerate? PLoS One 2019; 14(6): e0217126.

38.

Berhe

Gesesew

Ward

, et al. Neglected and non-consented care during childbirth in public health facilities in Central Tigray, Ethiopia. BMC Preg Childbirth 2022; 22(1): 1–11.

39.

Bulto

Demissie

Tulu

AS.

Respectful maternity care during labor and childbirth and associated factors among women who gave birth at health institutions in the West Shewa zone, Oromia region, Central Ethiopia. BMC Preg Childbirth 2020; 20(1): 1–443.

40.

Asefa

Bekele

Morgan

, et al. Service providers’ experiences of disrespectful and abusive behavior towards women during facility based childbirth in Addis Ababa, Ethiopia. Reprod Health 2018; 15(1): 4.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.07 MB