A grounded-theory study on the impact of disrespectful maternal and newborn care on stillbirth experiences, in Zambia and Tanzania

A grounded-theory study on the impact of disrespectful maternal and newborn care on stillbirth experiences, in Zambia and Tanzania

Tina Lavender (1), Rose Laisser (2), Chowa Tembo (3), Carol Bedwell (1)

(1) Division of Nursing Midwifery and Social Work, The University of Manchester, Manchester, UK, (2) The Catholic University of Health Sciences, Mwanza, Tanzania, (3) Ministry of Health, Lusaka, Zambia

Background
Most stillbirths occur in low income countries. In Tanzania and Zambia the rates are 22.5 and 20.9 per 1000 live births, respectively. Despite the huge burden of stillbirth in these countries, health care facilities do not have programmes in place to support those affected. The limited available evidence suggests that, following a stillbirth, women do not receive the respect they deserve. We, therefore, mapped our data onto the 12 respectful care principles, identified by Shakibazadeh, to gain insight into the important elements of respectful care and to identify areas for improvement. Aim:
To explore the intrapartum views and experiences of women, partners, health providers and stakeholders on stillbirth care

Methods
A Straussian Grounded Theory approach was adopted using in-depth interviews (n=166) and non-participant observations (n=32). Data collection took place in 6 facilities (3 in Zambia and 3 in Tanzania), representing primary, secondary and tertiary levels of care. Purposive and theoretical sampling was used, the sample size being determined by data saturation. Following consent, interviews were audio-recorded, transcribed verbatim and translated (and back-translated) from local language into English. Data analysis followed grounded theory principles of constant comparison and included open, axial and selective coding. Ethical approval was received from the partner universities, Ministries of Health and health facilities involved.

Results
Although positive examples of care were reported, participants’ narratives were dominated by examples of disrespectful intrapartum care. A failing in all of the 12 respectful care domains was evident. Despite having the trauma of losing their baby, women were refused care until they gave health care workers payment; were publicly scolded when they asked questions; were left not knowing why their baby had died; and placed in inappropriate environments next to women with live babies. Partners were generally unsupported and health providers were ill-equipped to provide women with optimum care.

Conclusion
Existing systems and processes are not meeting the needs of women following stillbirth, with disrespectful care being a key element within this. Disrespectful care impacts on physical wellbeing, adds to women’s psychological burden and influences their future health care decision-making. Whilst health providers are aware of disrespectful care they need support to practice differently in order to provide women with timely, effective and respectful care.

Ethics Statement
Ethical approval for this study was obtained from University of Manchester (UREC 2018-4446-6653), The Catholic University of Health Sciences, Tanzania (CREC/287/2018) and the Independent Research Board (IRB), Zambia (2018-Jun-029). For the qualitative element parent participants were identified and approached via clinical teams, for consent for contact by the research team. Following, verbal and written explanations and time to consider, written (or thumb print) consent was obtained. Interviews were conducted at a venue of participants choice with pseudonyms used to protect identity. A study-specific distress policy was adhered to at all times. All data were managed securely and adhered to GDP regulations.

Funding:
NIHR Global Health Group for the Prevention and Management of Stillbirth in Sub Saharan Africa


International Stillbirth Alliance, Annual Conference on Perinatal Mortality and Bereavement Care, Madrid, Spain. October 5-6th, 2019.

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