Study ethics approval

Before commencing the study, the Aga Khan University’s (AKU’s) Ethics Review Board and the National Commission for Science, Technology, and Innovation (NACOSTI) approved the study (ref NACOSTI p/17/1475/16146). In addition, approval to commence data collection was also provided by the respective County offices at both sites.

Methods

The data came from two target locations for the AQCESS project in Kenya’s rural Kilifi and Kisii Counties.

Study sample participants

To ensure that the data are representative within and across the two communities and their respective health systems, participants were selected through a recruitment process involving support from the AQCESS project implementation teams and local community leadership. The recruitment process was successfully implemented by a combination of health facility liaisons and community health outreach workers. First, the researchers conducted 24 Key Informant Interviews (KIIs) distributed equally across the two sites. KIIs were purposively sampled with the support of the Kisii and Kilifi AQCESS project implementation teams, identifying potential respondents with key information related to the assessment areas of inquiry. They included health care providers, community health care workers, religious leaders, local government representatives, Ministry of Health representatives, and representatives of local women’s organizations.

Second, 16 Focus Group Discussions (FGDs), 8 in each county, were facilitated to include a broad representation of community members and community health committee members. FGDs were stratified to include 2 each for adult males; adult females aged 20–49, and adolescent females ages 16–19. The separate adolescent female FGDs were conducted to ensure that the specific experiences among female adolescents were captured. To allow for full and unrestricted participation, FGD participants were also purposively recruited to ensure geographic representation so that 50% of the FGDs were with participants living less than 5km from a facility and 50% of FGDs were with participants located more than 5kms from a facility. This criterion is based on past evidence indicating that distance plays a major role in decision-making around the use of services about whether to seek care and to actually access care. The final two FGDs for each county included both male and female members from the community health committees (CHCs).

Data management and analysis.

Audio recordings needing translation from Kiswahili or local dialects to English were translated for analysis. The process entailed listening to the recordings and typing the content and translating into English as required. A transcription supervisor checked all submitted transcripts and translations before they were stored for coding. Transcribed data were coded, encrypted, and saved securely in accordance with the AKU’s Ethics and Data Protection Act.

All qualitative data were analyzed using a continuous iterative process[26]. Each transcript was coded independently by two analysts and reviewed by a study investigator who was the chief data analyst. Where coding discrepancies occurred, at least two analysts re-examined the transcripts and discussed all possible meanings associated with the text in question until agreement was achieved. The current analysis relied on the users’ own report of their experience of disrespectful maternity care services. The coding of key themes is presented in Table 1 below.

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Table 1. Codes, categories and themes of disrespectful care.

https://doi.org/10.1371/journal.pone.0214836.t001

1. Neglectful care

Data from both research sites provided evidence in which patients’ basic rights to care were violated and where healthcare workers were inattentive or ignored patients’ requests for assistance. For example, speaking of her own personal experience with maternity healthcare workers, one of the adult female FGD participants reported that some of the health workers refused timely help to women at the time of delivery.

…My experience with my first-born delivery was not good with a woman nurse. I told her I was in pain, and she abused me saying I should ‘stop my nonsense and wait to give birth in the morning.’ Soon after, a male nurse came and assisted me [to] give birth. He even quarreled [with the female nurse], asking her why she was treating me that way.(Adult Female FGD, Kisii).

In the following, a mother described her experience while accompanying her relative and the treatment her cousin received convinced her never again to go back to a public health care facility.

Haaa, I can’t, I better go to the private clinic … With those mockery and abuses I can’t. Like when we went at night with my cousin. There was a male doctor who we think was on drugs—chewing miraa, was sitting outside, maybe he was taking bhang. He told the girl ‘it’s not you [who can] tell us what to do!’ When the pain was too much, she went to the bed on her own, and the man came wore glove inserted his fingers and literally tore the lady… (Adolescent Female FGD, Kisii).

A key informant interview with a local politician highlights this pattern of neglectful and uncompassionate approach to care at the facility.

…I have witnessed a case at the hospital where there was a woman who came for the first time and she was told she would not be attended to until she brings her husband … she went and never came back (Women representative KII- Kisii).

In the following example, a participant in an adult male FGD speaks of his experience with staff while accompanying his relative to the hospital.

I took my sister in-law to hospital, and after assessing her, they left her alone in bed. She called for assistance, but they said, ‘It’s not yet time.’ She pushed and delivered on her own, that’s when the health workers came running wiping the child…at times they can beat you because you gave birth on the floor, as if the mistake is yours. Yet they don’t respond when called (Male FGD, Kisii).

This neglectful behavior by healthcare staff was further demonstrated by a general inattentiveness and disregard toward patients. Some healthcare staff who neglected patients were reading newspapers. As well, healthcare workers sometimes left the facility altogether, going for long lunch “hours” and leaving patients for hours on end, waiting to be attended to:

I can add that medical providers are very… abusive especially for young ladies and adolescents. Some medical staff decide to go for early lunch. Some read newspapers while patients are waiting for services (Male FGD, Kisii).

It happened that since she declined going to theatre the health workers ignored her and told her to deliver on her own, but God intervened [by chance]. So the nurse’s attitude, Ignorance could be one of the things that contributes to this. (Male FGD, Kisii)

The above vignettes demonstrate some of the ways in which women were treated while under the care of health care workers. These vignettes also demonstrate a lack of professionalism and compassion among some health workers.

2. Adolescent women get the brunt

While some of the adult women reported that they experienced different kinds of incivility and poor care, the adolescent women focus groups reported that they were more likely to experience verbal and physical abuse by healthcare workers in both Kisii and Kilifi. A focus group discussion among adolescent women in Kisii confirmed that some doctors also share this prejudice. In this case, a doctor used harsh and humiliating language when speaking to a young pregnant women during the delivery process.

… During the pain, they [doctors] abuse you and tell you to deliver. Yet you don’t know anything. They tell you to push, and you don’t know how.” (Female Adolescent FGD, Kisii).

…We (adolescents) are attended to, but harshly. For example, me, I’m young and they told me, ‘Young as you are, you went opening your legs to men.’ (Female Adolescent FGD, Kisii)

Some adolescent women reported being slapped and disrespectfully interrogated about the father of the child during the labour process. One was so upset by abusive nature of some staff, she contemplated killing the child.

She [the nurse] was slapping me. I said, ‘I’ll kill the baby and give birth to a dead baby,’ but the lady who escorted me went and called for a male doctor, who assisted me… (Female Adolescent FGD, Kilifi)

… Some doctors are harsh because you’re a girl, during the pain they abuse you and tell you…’Young girl, when you were loitering looking for that pregnancy, were we there?’Imagine! Instead of helping you… (Female Adolescent FGD, Kisii).

… They ask you questions, ‘When did you get pregnant? Who gave you this pregnancy?’ You don’t know what to answer them. If you don’t answer, they leave you there unattended, and say ‘Till you answer …’ (Female Adolescent FGD, Kisii).

As the following discussion from one male FGD particpant illustrates, this kind of poor treatment appears to stem from social disapproval, leading to disrespect for adolescent girls who become pregnant.

Respondent: Our young wives, usually they encounter a lot of problems.

Moderator: Oh, young wives? Ha!

Respondent: Yes, the young ones. You know us. We have been, ah, so

(laughter) … when they go there, and especially because they are young, they complain that they are harassed and asked: ‘You! As young as you are you …,’ [and] such like harassment.

Moderator: Why such harassment?

Resondent: Because they are young and are already pregnant. And what are they expected to do, and it has already happened?

oderator: Okay. So how is she harassed? (Group reaction)

Respondent: She gets uncomfortable.

Respondent: They begin to think ‘this young girl has already conceived,’ so when she goes there to be served, she feels out of place and fearful, hence feel she has not been served well. She feels like she has been isolated (Male FGD, Kilifi).

While some women generally suffer abuse from maternity facility caregivers, levels of physical abuse were reported to be greater for younger women during the actual delivery.

Respondent: Actually, it is during delivery that there are usually a lot of difficulties.

Moderator: Kindly mention all.

Respondent: Some of [the women] are slapped, and that story became a talk of the town some time back, yeah. Some of the doctors [show] that behavior. (Okay). ‘You did it willingly, and you want to cause us trouble now.’ You see, that’s bad to tell somebody. She might decline to come back again, when she is pregnant in the future, and will prefer to home delivery. … Yeah, there is such a one [who slaps the women] here, only that I cannot disclose, but they are there. Very short-tempered, even tells you not to come back to that hospital (Male FGD, Kisii).

Poor treatment of young women was also reported in some of the Key Informant Interviews. In the following vignettes, two Ministry of Health (MOH) representatives observe:

…the way they [staff] handle these mothers, somebody may harass the mothers and next time… or even when she goes back she will go with a bad picture and says,’ I cannot go back to that facility, they do not handle people properly, they call us with very abusive words …. (MOH representative KII–Kisii).

…“I guess once again I would say the adolescents are quite disadvantaged because even the stigma is within the medical care providers, so in terms of the MCH, it is very difficult for the adolescent mothers because they need to seek health care, yet providers’ attitude is the worst when dealing with adolescent mothers.” (MOH representative -Kisii).

These vignettes illustrate the differential experience of maternity care among adolescents with respect to disrespectful and abusive health care. Moreover, the similarity among the vignettes from both the FGDs and key informants show a consensus regarding the greater level of disrespectful care that these adolescent mothers must tolerate.

3. Patients’ differential gender experience of health workers

The data showed that some women in Kenyan maternity care facilities generally found that female healthcare workers were more likely to be disrespectful and abusive compared to male healthcare workers. Some participants in the focus groups expressed their preference for male healthcare workers who they indicated treated them better and were more willing to help when asked. Adolescent women, as a group, were the most vocal in expressing their negative opinion of female staff and their preference for male health care workers.

…especially ladies, they are so harsh; they think they dropped from heaven [special than everyone] and us were collected. Men are better; they can tell you to push while assisting you. But females will slap you, yelling at you to open your legs while shouting ‘I want to see the child!’ with abuses. She tells [me] ‘I am waiting to hold the child! (Female Adolescent FGD, Kisii).

… Especially female doctors are the worst. Men don’t have problems. If you come with a Range Rover or a [Mercedes] Benz, they will wheel you to the ward. But if brought with a wheelbarrow, you’ll be told to move from here to there—they don’t mind the pain you have. You’ll be locked inside a room, and be told to yell there. I was locked [in] and told go for long call there (Female Adolescent FGD, Kisii).

While participants interviewed for this study generally reported the preference of male attendants as they provided more respectful care, Muslim patients’ desire for male caregivers was tempered by cultural and religious beliefs. One Muslim participant in the adult male focus group reported how his wife resisted being assisted by a male worker.

I think the most interesting thing is that the women prefer to be served by male health workers rather that the females…Yes that is the truth but not so for us as Islamic. My wife declined totally to be assisted by a male nurse. Even during the clinic, she forbids the male nurse to even touch her when she is to be injected…Actually, it happened that the baby’s head was already out before she could even be assisted. The only person that was available was a male nurse. You know in our religion we prefer not to show the nakedness of a woman—it is sacred… (Male FGD, Kilifi).

Female healthcare workers were reported to be verbally and physically abusive resulting in patients generally preferring to be attended by male health workers.

Moderator: So, you are saying that women prefer the male health workers to the female?

Respondents: Yes! (Chorus answer)

Respondent: Yes, because the male nurse has a patient heart. He will even try to console the mother, unlike the female nurse, who can inflict slaps. Then she goes about her businesses, leaving the mother behind without even caring (Female Adult FGD, Kisii).

Participants reported that women who gave birth to children with disabilities were likely to be humiliated by some female staff who blamed the mother for the child’s disability.

They are women and maybe they’ve also given birth. They should know the pain they went through … If you give birth to a disabled child, they ask you when coming to the clinic, ‘Were you moving with men when pregnant?’ Or, ‘Your man did fix you well’ (hakuingisha [penetrate] vizuri [good or satisfactory]) so the child didn’t reproduce properly. The man didn’t have energy.’ (Female Adolescent FGD, Kisii).

…female health workers have contempt. When we went with my cousin, who is also young, we brought a disabled child. Another lady nurse abused us, till we also abused her back. . . . We looked for another doctor, the nurse abused her saying: ‘She was sleeping with men while pregnant, that’s why she gave birth to a disabled child!,’ and we reported the case to the senior doctor…We don’t know if she was reprimanded. My cousin wanted to kill the child, saying she is abused because of her child status. We later took the child to my grandmum, who took care of the child (Female Adolescent FGD, Kisii).

These vignettes illustrate some of the gendered differences among healthcare workers as reported by patients. These vignettes also illustrate some of the attitudes and beliefs associated with giving birth to a child with disabilities, an area that has not been addressed in research or policy in the Kenyan context.

4. Structural factors as a barrier to respectful maternity care

Our analysis confirms that, in both Kisii and Kilifi, public prenatal and maternity health care failed to treat some women with dignity and respect. However, respectful care is also contingent on the availability of structural resources to support women on their journey through maternity. Findings from this study reveal that some maternity health centres may lack basic resources and supplies such as water, beds, or readily fueled vehicles and ambulances to transport patients that are referred to larger facilities (see S3 and S4 Appendices). For example, participants reported that in some cases women carried water along with them to the hospitals for their delivery.

…You can find a woman who is in labour carrying a jerrican of water on her head going to the hospital. Simply because she knows there is no water at the hospital… (Male FGD, Kilifi).

..I saw a woman groaning in pain she had come to deliver and there was no water. Usually there is scarcity of water in this area. It happened that that day the care provider present was not supposed to be on duty that night. So it happened as I was talking with her that is when that mother came in but she had to be send elsewhere because the hospital was not functioning to the lack of water… (Male FGD, Kilifi).

Spaces and beds were not adequate to meet the demand of the number of pregnant women seeking care at some facilities.

The beds in the labour ward should be added. The wards are also small. Some women are usually waiting to give birth while lying down on the floor because the beds are occupied. When I was delivering, I gave birth while lying on the floor because the beds were occupied and there was nowhere to deliver. I knelt and the baby came… (Female Adult FGD, Kilifi).

The lack of availability of beds for mothers may be discouraging the uptake of maternity services. For some women, other structural barriers including poor road systems and inadequate means of transportation and lack of available healthcare staff hindered their access and use of the facilities. Participants in the male FGDs in both Kisii and Kilifi reported the difficulties that some women face in getting to the facilities which can have an extremely tragic effect on maternal outcomes.

…I come from a place called Ibencho, roads are in bad condition. There is a woman who wanted to deliver and was carried using a bed and because of the distance, she died before reaching the hospital…this was less than five years ago. From Ibencho, people are only carried using beds or wheelbarrows to Sengera …Things are not different with Riokindo.” (Male FGD, Kisii)

… I have always witnessed women suffering and having a rough time in accessing the facilities due to long distances that they have to cover. And if it is a must they get to hospital the only available means of transport is the motor bikes. So you can imagine a pregnant mother being rode on a motorbike, it is usually a hard task. This is a challenge. So that is what I have been able to witness also sometimes it happens that some due to that they end up having complications and some even may die before getting to the health facility. This I have witnessed many times and secondly, when they get to the hospital you find that midwives are not available (Male FGD, Kilifi)

These vignettes demonstrate that on a woman’s journey through pregnancy and delivery, there are many structural barriers that she must navigate both at the micro and the macro levels. Disrespectful care is not confined solely to how healthcare workers treat women but must consider additional factors such the availability of resources required to provide access to and the availability of respectful and appropriate care.

Study limitations

This study reported views from focus group discussions and interviews from a broad range of people with respect to maternal health care service delivery. This multifaceted approach strengthened the data quality and trustworthiness through the convergence of reports by these different groups and can be used to inform future work and potential areas for intervention in the Kenyan context. These findings are not intended to be generalizable in terms of statistical significance, but provide insight into the challenges with promoting facility prenatal, delivery and antenatal care in these two counties as well as across Kenya more generally.

Although data were collected from two research sites (Kisii and Kilifi), more data on the experience of disrespectful maternity care was reported by the participants from the Kisii context. While reports of disrespectful treatment were similar across both sites, women in Kilifi, a historically and culturally more Muslim community, were less forthcoming with providing stories detailing their experiences. In addition, religious leaders in both Kisii and Kilifi did not provide reports of disrespectful maternity care. Finally, in selecting participants for focus groups, male adolescents were not included which may limit the gender inclusivity of the overall study. We acknowledge that to have a more complete understanding on this topic, future work will also need the views of male adolescents and health care workers in these contexts regarding disrespectful maternity care.