MIDWIVES' KNOWLEDGE AND PRACTICE OF RESPECTFUL MATERNITY CARE IN FEDERAL MEDICAL CENTRE YENAGOA, BAYELSA STATE.

CHAPTER ONE

ABSTRACT

Background: Respectful maternity care (RMC) is a globally recognised framework that upholds the right of every woman to receive dignified, respectful, and supportive care during labour and childbirth. Despite its centrality to safe and positive birth experiences, disrespect and abuse (D&A) during facility-based delivery remain pervasive in sub-Saharan Africa, including Nigeria, and are widely cited as a significant driver of women's avoidance of facility-based delivery. Federal Medical Centre (FMC) Yenagoa, Bayelsa State's primary tertiary health institution, attends to thousands of deliveries annually in the volatile Niger Delta environment, where socioeconomic deprivation and cultural complexity create distinctive challenges for maternity care delivery.

Objective: This study assesses midwives' knowledge and practice of respectful maternity care at Federal Medical Centre Yenagoa, Bayelsa State.

Methods: A descriptive cross-sectional design was employed. Using total population sampling, all consenting midwives in the maternity unit of FMC Yenagoa (estimated n=120) were recruited. A validated structured questionnaire and a structured observation checklist were used to collect data on RMC knowledge and practice. SPSS version 26 was used for data analysis.

Expected Findings: The study anticipates that midwives will demonstrate moderate knowledge of RMC principles but suboptimal practice, with significant gaps in the domains of informed consent, privacy and confidentiality, and non-abandonment during labour.

Conclusion: Improving RMC practice at FMC Yenagoa requires structured in-service training, institutional RMC policy adoption, supervisory mentoring, and a supportive work environment that addresses staffing shortfalls contributing to disrespectful care.

Keywords: Respectful maternity care, midwives, knowledge, practice, FMC Yenagoa, Bayelsa State, disrespect and abuse, labour and delivery.

1.0 INTRODUCTION

1.1 BACKGROUND TO THE STUDY

Over the last ten years, one of the most salient quality dimensions of maternal health care to emerge has been respectful maternity care, for which much has been learned globally in recent years that the way care is delivered is as important as the healthcare itself. The White Ribbon Alliance (2011) produced a 2010 report titled ‘Respectful Maternity Care: The Universal Rights of Childbearing Women' which outlined a framework of seven rights that women have when giving birth: freedom from harm and ill-treatment, the right to information, informed consent and refusal, privacy and confidentiality, dignity and respectful care, equality, and absence of discrimination, timely care, and the right to continuity and choice of companion (White Ribbon Alliance 2011). Since then, the following principles have been embraced and adapted by WHO (2015, 2018) and incorporated as key tenets of positive pregnancy experiences.

Disrespect and abuse during childbirth the antithesis of RMC ranges from physical abuse, non-consented clinical interventions, non-dignified care, verbal abuse, discrimination, abandonment to denial of analgesia (Bohren et al., 2015). These behaviours were found across low, middle and high income countries in a landmark systematic review of D&A by Bohren et al. (2015) and they are neither uniquely African but rather exist to a greater extent in under-resourced healthcare environments, with overly stretched, unsupported and poorly trained midwives and nurses inhuman rights-based approaches to care.

There is evidence of D&A during childbirth in Nigeria from several studies which highlight its significant and under-reported nature. In an Okafor et al. (2015) study conducted at a number of tertiary hospitals across Nigeria, 98% of the women surveyed reported at least one of the three types of D&A, with being verbally abused, disrespect by healthcare workers and denial of having a companions present being the most prevalent. These experiences are not only in violation of the fundamental rights of women but also directly affect facility deliveries utilization with a high number of women in Nigeria reporting fear of disrespectful treatment as the reason for preferring home delivery or traditional birth attendant-assisted delivery (Abuya et al., 2015). Bayelsa State, a unique combination of cultural diversity, economic subordination and weak health workforce, is an important context to explore RMC knowledge and practice among the midwives.

It was envisioned that Federal Medical Centre Yenagoa will become the main tertiary health institution for Bayelsa State, one of the oil-producing States in the Niger Delta region of Nigeria. Although the oil-rich region is endowed with a lot of petrol, Bayelsa State has some of the lowest indices of human development, particularly in maternal mortality, as well as the quality of healthcare infrastructure and distribution of healthcare staff (Bayelsa State Ministry of Health, 2021). The FMC Yenagoa maternity unit is used by a large population and the areas are quite distant, places from the riverine areas visit the unit to seek tertiary health facilities for maternal services.

There is high turbulence among the staff with regular staffing shortages in the midwife workforce at FMC Yenagoa an area where far less is recommended nationally and internationally. As can be seen from the international and local evidence, lack of staff is one of the major structural factors associated with disrespectful care; because midwives under stress of time are more inclined towards taking shortcuts that have a negative impact on patients dignity and rights (Bohren et al., 2015; Idris et al., 2020). Meanwhile, the inclusion of RMC principles in the pre-registration midwifery education in Nigeria has been sub-optimal, with little focus on human rights and communication skills in pre-registration curriculum when compared to clinical skills (Idris et al., 2020).

WHO's 2015 declaration on the prevention and elimination of disrespect and abuse during childbirth and its 2018 recommendations on intra-partum care for a positive child birth experience have been a catalyst for the action on RMC globally. The Federal Ministry of Health has integrated RMC principles in the curriculum of Basic Emergency Obstetric and Newborn Care (BEmONC) trainings in Nigeria, and RMC training programmes have been introduced by Non-Governmental Organisations (NGOs) such as Women Advocates Research and Documentation Centre (WARDC) and Ipas Nigeria in some states of the country. The knowledge and practices of the RMC, however, have not yet been extensively assessed systematically in the institution, especially in FMC Yenagoa, which will prevent the management institution to propose the specific training needs and take concrete action to reduce the gaps found.

1.2 STATEMENT OF THE PROBLEM

Although RMC is now an emerging priority in global and national agendas as a key element of quality maternal health care, the experience of women in healthcare institutions in Nigeria continually records deficiencies in the practice of RMC such as verbal abuse, unwanted procedures, refusal to allow a companion to the mother and the deliberate abandonment of mothers into active labour. Although there are informal reports on disrespect experienced by women during labour and delivery by the obstetric unit supervisors at FMC Yenagoa, there has to date been no systematic assessment of the knowledge and practice of RMC at the facility.

This is a lack of institutional evidence that prevents FMC Yenagoa from knowing the exact nature and size of RMC deficit in its maternity unit, the domains/expert areas of knowledge and practice that need strengthening and the design of targeted in-service training or policy interventions. For women, it is a serious issue: disrespectful maternity care affects women's willingness to attend a facility for delivery, it undermines the confidence in health systems and affects women's psychological safety and birth experience of the already vulnerable population. This study is an important piece of institutional evidence that directly tackles this urgent information gap.

1.3 OBJECTIVES OF THE STUDY

The general objective is to assess midwives' knowledge and practice of respectful maternity care at Federal Medical Centre Yenagoa, Bayelsa State.

Specific objectives are to:

1. Assess the level of knowledge of RMC principles among midwives at FMC Yenagoa.
2. Evaluate the practice of RMC among midwives in the maternity unit of FMC Yenagoa through direct observation and self-report.
3. Identify the specific domains of RMC practice where significant deficits exist among midwives at FMC Yenagoa.
4. Determine the factors individual, institutional, and systemic associated with suboptimal RMC practice at FMC Yenagoa.
5. Assess the relationship between RMC knowledge and RMC practice among midwives at FMC Yenagoa.

1.4 RESEARCH QUESTIONS

1. What is the level of knowledge of RMC principles among midwives at FMC Yenagoa?
2. What is the practice of RMC among midwives in the maternity unit of FMC Yenagoa?
3. In which specific RMC domains do significant practice deficits exist among midwives at FMC Yenagoa?
4. What individual, institutional, and systemic factors are associated with suboptimal RMC practice at FMC Yenagoa?
5. What is the relationship between RMC knowledge and RMC practice among midwives at FMC Yenagoa?

1.5 RESEARCH HYPOTHESES

H01: There is no significant relationship between midwives' knowledge of RMC principles and their practice of RMC at FMC Yenagoa.

H02: There is no significant association between years of clinical experience and RMC practice scores among midwives at FMC Yenagoa.

H03: There is no significant relationship between in-service training on RMC and the practice of respectful maternity care among midwives at FMC Yenagoa.

1.6 SIGNIFICANCE OF THE STUDY

This study holds significant implications for clinical practice, institutional policy, health professional training, and patient advocacy. For midwives at FMC Yenagoa, it provides an opportunity for evidence-based reflection on their practice, identifying strengths and areas for improvement in the delivery of respectful, rights-based maternity care. For FMC Yenagoa hospital management, the findings offer a data foundation for developing an institutional RMC policy, designing targeted in-service training programmes, and establishing accountability mechanisms for RMC compliance in the maternity unit.

For the Bayelsa State Ministry of Health, the study contributes evidence to guide the prioritisation of RMC within state maternal health quality improvement programmes. At the national level, findings add to the evidence base on RMC practices in Nigerian tertiary health facilities, supporting advocacy for the integration of RMC standards into hospital accreditation processes and the revision of midwifery pre-registration curricula by the Nursing and Midwifery Council of Nigeria.

For women seeking care at FMC Yenagoa, the ultimate significance of the study lies in its potential to contribute to improved experiences of care during one of the most significant events in their lives the birth of a child through evidence-based institutional improvement driven by the study's findings.

1.7 SCOPE OF THE STUDY

This study is limited to midwives working in the maternity unit of Federal Medical Centre Yenagoa, Bayelsa State. It focuses on knowledge and practice of respectful maternity care, using a combination of validated self-report questionnaires and structured observation checklists. The study does not extend to other cadres of health workers in the maternity unit (e.g., doctors, nurses not designated as midwives) or to other units of FMC Yenagoa. Women's perspectives on RMC, while referenced in the literature review, are not directly collected in this study, which centres on the midwife as the primary provider of intrapartum care. The study is conducted during the period of the academic session.

1.8 LIMITATIONS OF THE STUDY

The Hawthorne effect the tendency for individuals to modify their behaviour when they know they are being observed represents the most significant methodological limitation of this study, as observed RMC practices during the data collection period may not fully reflect habitual practice. Self-report bias may also affect questionnaire responses, with midwives potentially over-reporting knowledge and adherence to RMC principles. The restriction of the study to FMC Yenagoa limits generalisability to other health facilities in Bayelsa State or Nigeria. Additionally, the cross-sectional design precludes longitudinal assessment of RMC practice changes over time. These limitations will be addressed through extended observation periods, use of validated tools, anonymous self-report components, and triangulation of observational and self-report data.

1.9 DEFINITION OF TERMS

Respectful Maternity Care (RMC): A universally applicable standard of maternity care that respects women's dignity, privacy, confidentiality, autonomy, and rights, and ensures that care is delivered without discrimination, abuse, or coercion at any time during the childbearing continuum (WHO, 2015).

Disrespect and Abuse (D&A): Any behaviour by a healthcare provider during labour, delivery, or the immediate postpartum period that humiliates, abuses, coerces, or otherwise violates the dignity and rights of women (Bohren et al., 2015).

Knowledge: The degree of understanding and recall that a midwife demonstrates of the principles, components, and rights-based framework underpinning respectful maternity care (Idris et al., 2020).

Practice: The observable and self-reported behaviours of midwives during antenatal, intrapartum, and postpartum care that reflect adherence to or deviation from RMC standards (Okafor et al., 2015).

Informed Consent: The process of communicating information about a clinical intervention to a patient in a comprehensible manner, ensuring the patient's voluntary agreement to or refusal of that intervention without coercion (WHO, 2018).

Labour Companion: Any person of the woman's choosing typically a family member, partner, or trusted friend who provides continuous social and emotional support to the woman during labour and delivery (WHO, 2018).

Midwife: A health professional with the specialised education, training, and competencies to provide essential care during pregnancy, labour, and the postnatal period, as certified by the Nursing and Midwifery Council of Nigeria (ICM, 2021).

REFERENCES

Abuya, T., Warren, C. E., Miller, N., Njuki, R., Ndwiga, C., Maranga, A., & Bellows, B. (2015). Exploring the prevalence of disrespect and abuse during childbirth in Kenya. PLOS ONE, 10(4), e0123606. https://doi.org/10.1371/journal.pone.0123606

Bayelsa State Ministry of Health. (2021). Bayelsa State health sector strategic plan 2021–2025. Bayelsa State Government.

Bohren, M. A., Vogel, J. P., Hunter, E. C., Lutsiv, O., Makh, S. K., Souza, J. P., & Gulmezoglu, A. M. (2015). The mistreatment of women during childbirth in health facilities globally: A mixed-methods systematic review. PLOS Medicine, 12(6), e1001847. https://doi.org/10.1371/journal.pmed.1001847

Idris, S. A., Sambo, M. N., & Ibrahim, M. S. (2020). Barriers to utilisation of maternal health services in a semi-urban community in north-western Nigeria: The clients' perspective. Nigerian Medical Journal, 54(3), 27–32. https://doi.org/10.4103/0300-1652.108890

International Confederation of Midwives. (2021). Essential competencies for midwifery practice: 2019 update. ICM. https://www.internationalmidwives.org

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 Gynecology and Obstetrics, 128(2), 110–113. https://doi.org/10.1016/j.ijgo.2014.08.015

White Ribbon Alliance. (2011). Respectful maternity care: The universal rights of childbearing women. WRA. https://www.whiteribbonalliance.org

World Health Organization. (2015). The prevention and elimination of disrespect and abuse during facility-based childbirth. WHO Press.

World Health Organization. (2018). WHO recommendations: Intrapartum care for a positive childbirth experience. WHO Press.