Perceived disrespect and abuse among women delivering at a tertiary care center in Nepal

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22 Of the children born every year in Nepal, 57.4% are delivered in health facilities. Disrespect and 23 abuse of women during maternity care are problems that can significantly impact women’s 24 willingness to seek out life-saving maternity care. However, evidence suggests ongoing 25 disrespectful maternity care worldwide. This study aims to identify perceived disrespect and 26 abuse during labor and delivery among postnatal women delivering at Bheri Hospital, Nepal. 27

28 A cross sectional study was conducted among 445 purposively selected women admitted in 29 postnatal ward of Bheri Hospital, Nepal from February to March 2020. Ethical approval was 30 obtained from Nepal Health Research Council. Informed written consent was obtained from each 31 participant and a face-to-face interview was conducted for data collection. A semi-structured 32 questionnaire consisting of demographic information and a pre-validated Respectful Maternity 33 Care (RMC) tool was used. The information was then checked, coded, and entered in SPSS for 34 descriptive and inferential analysis. 35

36 In this study, the participants perceived very high friendly care, abuse-free care and 37 discrimination-free care but moderate timely care only. Timely care was found to be significantly 38 associated with age, ethnicity, occupation, monthly income, gravida, type of delivery, and 39 complications. On multinomial regression, monthly income and type of delivery were the only 40 factors found to be significant. Those mothers who had spontaneous vaginal delivery were 2.07 41 times more likely to have neutral RMC, and those who earn less than twenty thousand Nepalese 42 rupees per month were likely to perceive high timely RMC. 43 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 3

44 This study concludes that disrespectful or abusive maternal care is not perceived among women 45 delivering at Bheri Hospital in terms of friendly care, abuse-free care and non- discriminatory 46 care. However, timely care is less reported. Appropriate interventions to provide timely care to 47 delivering women must be instituted. 48 Key words: Delivery; Disrespect and abuse; Labor; Maternal health services; Respectful 49 maternity care; Midwives 50 51 52 53 54 55 56 57 58 59 60 61 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 4

62 With Maternal Mortality Ratio (MMR) at 239 per 100,000 live births in 2016- higher than its 63 South Asian neighbors- maternal mortality remains a formidable challenge in Nepal. Although 64 the country has witnessed considerable decline in MMR by 55% from 1996 to 2016 [1] , it still 65 needs to go a long way to achieve the target of 70 per 100,000 live births as set out in the 66 Sustainable Development Goals (SDGs) [2]. 67 Ensuring access to quality skilled care before, during, and after childbirth is vital in reducing 68 maternal mortality [3]. In low resource settings such as Nepal the lack of availability of skilled 69 care services, mistreatment during childbirth, including abusive, neglectful, or disrespectful care 70 may result in compromised quality [4]. Women have experienced disrespect and abuse (D &A) 71 all over the world in various forms ranging from physical or verbal abuse, stigma or 72 discrimination [4], detention of babies [4], being shouted at [5], threatening comments [5], 73 withholding procedure related information and providing non-consented care [5]. For instance, a 74 study in Ghana revealed that only a few clients were encouraged to ask questions and explained 75 what to expect during labor [4]. Non-confidential care has also been reported [6], as identified in 76 a study conducted in India. Similarly, evidences suggest that women have also experienced poor 77 quality care in the form of restriction in their choice of birth position and movement, and 78 restriction of liquid drinks during delivery [7]. 79 Although a growing body of evidence paints a disturbing picture of women’s experience of care 80 during pregnancy and child birth, health care providers justify such acts on the grounds of 81 punishment for non-cooperation from women and good outcomes to babies[4]. Analyzed from 82 the perspective of health service delivery system, difficult circumstances in health facilities 83 under which maternity staffs work, system failures, and inadequate human resource management 84 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 5 have been found as important reasons for D&A during delivery [8]. However, justifying 85 disrespectful care and abuse based on these factors is a violation of women’s human rights. 86 RMC has been defined by World Health Organization (WHO) as “care organized for and 87 provided to all women in a manner that maintains their dignity, privacy, and confidentiality, 88 ensures freedom from harm and mistreatment, and enables informed choice, and continuous 89 support during labor and childbirth” [9]. In this sense, RMC focuses on expanding safe 90 motherhood beyond prevention of maternal mortality and morbidity to incorporate a human-91 rights based approach, including respect to women’s autonomy, dignity, choices, privacy and 92 preferences [10]. RMC recognizes that all women need and deserve respectful care; and focuses 93 on eliminating D&A during pregnancy and childbirth. 94 Despite the existing evidences that suggest D&A during childbirth presents considerable 95 impediments to utilization of skilled birth care globally [9], only a few studies have been 96 undertaken to understand the phenomena in Nepal. The majority of these studies have used a 97 qualitative approach and only a limited number of studies have used a validated quantitative tool 98 to measure the level of D&A at the point of service provision, out of which the greater number 99 are based on health facilities in Kathmandu Valley. 100 This study aimed to identify perceived D&A during labor and deliveries among postnatal women 101 admitted at a remote hospital and also determine the factors affecting RMC. Understanding 102 women’s perspective of D&A during care is essential to identify factors that generate RMC in 103 the health facility and subsequently in the provision of RMC as envisioned in The Right to Safe 104 Motherhood and Reproductive Health Act of 2018. 105 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 6

106 Study Design, Study Setting and Sample Size 107 A cross-sectional study was done to identify the forms and associated risk factors of perceived 108 disrespect and abuse among women delivering at Bheri Hospital, Nepal. With 5083 deliveries 109 conducted in the year 2017-18 [11], Bheri Hospital in southwestern Nepal is a major referral 110 center for emergency obstetric care services for three out of seven provinces (Lumbini Province, 111 Karnali Province & Sudur Pachhim Province) of the country. 112 The sample size was calculated based on a study conducted in India, Ghana, and Kenya which 113 depicted an overall prevalence of verbal abuse to be 16% across all countries [6]. Considering 114 the prevalence of verbal abuse to be 16%, and level of significance to be 95%, the minimum 115 sample size for the proposed study was calculated to be 237. However, we were able to collect 116 the information from 445 women who delivered during the allocated period of data collection. 117 Study Participants and Recruitment 118 Purposive sampling technique was used to interview postnatal women admitted at the postnatal 119 ward of Bheri Hospital, within 24 hours of delivery. Those who were unwilling to participate in 120 the study, couldn’t understand and/or speak the Nepali language or had a stillbirth or macerated 121 birth during delivery were excluded from the study. 122 Data Collection 123 Face-to-face interview technique was used to collect data. Each interview lasted for 124 approximately 20 minutes and conducted in the Nepali language. The data were collected from 125 February to March 2020. Informed written consent was obtained before data collection. Data 126 were collected from women in postnatal ward within 24 hours of delivery to avoid recall bias. 127 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 7 A semi-structured questionnaire, divided into two parts, was used as the tool for data collection. 128 The first part included questions relating to socio-demographic factors and obstetric history, 129 details of which are presented in Table 1. The second part of the questionnaire was based on a 130 validated RMC tool with 15 items used to measure women’s perception regarding RMC. The 131 tool has four dimensions: friendly care, abuse-free care, timely care and non-discriminatory care 132 consisting of 7, 3, 3 and 2 items, respectively [12]. The construct validity of the scale is 133 confirmed by the high average factor loading of the four components ranging from 0.76 to 0.82 134 and a low correlation between the components. The scale has adequate reliability with α = 135 0.845[13]. The instrument was translated into the Nepali language and validated by a Nepali 136 language expert. The content validity of the instrument was established by consultation with 137 subject experts. Consistency of the tool was checked by pre-testing among 10% of women 138 delivering at Bheri Hospital which was not included in the final study sample. 139 Data Analysis 140 The collected data was checked, organized and coded, and entered into Microsoft excel and then 141 exported to SPSS (Statistical Package for the Social Sciences) 17.0 version for analysis. The data 142 were analyzed by using descriptive statistics like frequency, percentage, mean, standard 143 deviation, and inferential statistics: chi-square test, and multinomial logistic regression. 144 Mean score (M) of four broad components i.e. friendly care, timely care, abuse free care, and 145 non- discriminatory care was used to describe the level of respectful maternity care experienced 146 by the postpartum women during childbirth in each component separately. To determine the 147 participant’s degree of respectful maternity care, the following Likert- range conversion and 148 qualitative interpretation were used: 4.20- 5.00-Very High, 3.4- 4.19 -High, 2.60- 3.3 - Moderate, 149 1.80- 2.5 -Low and 1- 1.78 Very Low [12]. 150 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 8 Ethical Approval 151 Ethical approval was obtained from the Nepal Health Research Council (Ref #1953, 18 March 152 2020). Written permission from Bheri Hospital administration was also obtained. Informed 153 written consent was obtained from the respondents. Participants were also assured that their 154 participation/non-participation would have no bearing on their treatment. Confidentiality of the 155 participants was maintained by assigning unique identification code to each participant. 156

157 Table 2 depicts the socio-demographic information of the participants. The majority of them 158 (74.4%) were aged 20- 30 years, belonged to the Janjati ethnic group (46.1%), and most of them 159 (91.2%) followed the Hindu religion. The majority (86.7%) were educated. However, almost half 160 (50.8%) were unemployed. Approximately fifty-three percent of respondents were from joint or 161 extended family. Regarding the spouse’s background, most of them (91.7%) were educated and 162 were involved in a non-formal occupation (71.5%). 163 Table 3 illustrates the obstetric history of participants. The majority of participants had less than 164 two gravidae (75.7%), were multiparous (64.7%) and most of them (95.7%) had term pregnancy. 165 Almost half of the participants (51.5%) delivered via spontaneous vaginal delivery (SVD) while 166 remaining delivered via augmented labor and/or lower section cesarean section. One third of 167 respondents (33.3%) had complications during labor. 168 Table 4 shows the perception of participants regarding RMC on a 5 points Likert scale. The 169 components of RMC are presented in four broad categories of Friendly Care, Abuse-free Care, 170 Timely Care, and Non-discriminatory Care. 171 Regarding Friendly Care, very few respondents disagreed that the health workers cared for them 172 with kind approach (0.9%), treated them in a friendly manner (2.6%), talked positively about the 173 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 9 pain and relief measures (2.0%), showed concern and empathy (0.2%), treated them with respect 174 as an individual (1.5%), and spoke in understandable language (10.5%). Of note, almost half of 175 the participants (47.2%) disagreed on being called by their name. 176 The table also presents the perception of participants towards Abuse-free Care. Nearly 32.6% 177 disagreed with the statement that health workers responded to their needs whether or not asked. 178 Also, 5.6% reported being slapped during delivery for different reasons, and a similar number of 179 participants (4.7%) reported being shouted at for not doing what they were told to do. 180 Regarding Timely Care, more than a quarter of participants (27.8%) agreed to being kept waiting 181 for a long time before receiving care, but a higher number of participants were not allowed to 182 practice cultural rituals (62%). Some agreed that service was delayed due to health facility’s 183 internal problems (18.7%). 184 Perception towards Discrimination-free Care shows that few respondents (3.3%) agreed that the 185 health workers did not treat them well because of personal attributes. Also, 2.9% of participants 186 agreed that some health workers insulted them and their companions due to personal attributes. 187 The mean score shows that the participants’ perceptions of Non-discrimination Care (4.67), 188 Friendly Care (4.42) and Abuse-free Care (4.29) were very high, whereas perception of Timely 189 Care (3.10) was comparatively moderate. 190 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 10 Table 4 presents the findings of the association between selected demographic and obstetric 191 characteristics and the Friendly Care component of RMC. This table shows that there is a 192 significant association between timely care and monthly income (p<0.05), gravida (p<0.05), para 193 (p=0.004), and week of gestation (p=0.026). 194 Table 6 reveals the association between Abuse-free Care and selected demographic and obstetric 195 characteristics. This table shows that there is a significant association between Abuse-free Care 196 and spouse’s occupation (p=0.002), para (p=0.010), type of delivery (p<0.05). 197 Table 7 shows the association between Timely Care and selected characteristics which reveals 198 that there is a significant association between Timely Care and age (P<0.05), ethnicity (p=0.002), 199 occupation (p=0.001), monthly income (p<0.05), gravida (p<0.05), type of delivery (p=0.002), 200 and complications (p=0.002). However, there is no significant association between Timely Care 201 and educational status, spouse’s occupation, or week of gestation (P>0.05). 202 As mentioned in Table 4, among the four components, women’s perception of Timely Care was 203 found to be moderate whereas other dimensions of RMC were perceived very high. To determine 204 the factors resulting in moderate perception of Timely Care, multinomial logistic regression was 205 done. Table 8 shows that those who had SVD were 2.07 times as likely to have neutral RMC for 206 Timely Care. Similarly, those who earn less than twenty thousand Nepalese Rupees per month 207 were 2.36 (1.30-4.23) times as likely to have high Timely RMC in Nepal. We did not observe 208 any significant effects between gravida, complication during the delivery, and the number of 209 living children (P>0.05). 210

211 This study aimed to identify perceived Disrespect & Abuse and its associated factors during 212 labor and delivery among postnatal women at a busy referral hospital in western Nepal. D&A are 213 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 11 evaluated based on four different dimensions of RMC i.e. Friendly Care, Abuse-free Care, 214 Timely Care and Discrimination-free Care. Very high degree of Friendly Care, Abuse-free Care 215 and Discrimination-free Care was identified, however, only moderate Timely Care was 216 perceived by the participants which is in contrast to the study in Egypt where only 217 Discrimination-free Care was perceived to be high and other dimensions to be moderate [12]. 218 The reason for high rating of Abuse-free Care in this study could be normalization of the abuse 219 in the health care setting [14], where delivering women think that it is normal to be abused 220 physically and/or verbally for better labor outcomes. Also, despite the knowledge of principles of 221 RMC among health care providers, this knowledge may not translate to an improvement in 222 actual respectful care at the bedside [14]. 223 Most of the women (91.3%) perceived that they were treated in a friendly manner which is 224 consistent with a direct observation of RMC in health facilities of five countries in East and 225 Southern Africa (86%) [7]. Talking positively about the pain and relief measures was one of the 226 components of Friendly Care where very few respondents (2.0%) disagreed with the statement. 227 The reasons for not addressing pain may be due to the lack of availability of a doctor [14] and/or 228 the shortage of health workers persistent in the country [15]. The shortage, however, might have 229 been more pronounced at the time of data collection due to the ongoing staff adjustment process 230 undertaken as part of implementing Federalism in the country [16]. 231 WHO recommends communication between maternity care providers and women in labor, using 232 simple and culturally acceptable methods [17]. Evidence suggests that language barrier is a 233 critical factor that hinders effective communication and can also pose considerable risk to patient 234 safety and quality of care [18]. More than two third of the participants (84%) in this study 235 confirmed that the health worker spoke in a language understandable to them. A study conducted 236 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 12 in Egypt found that nearly 61% of the health workers did not communicate in an understandable 237 language. This suggests that language barrier was less common in our context. To ensure 238 respectful attitude and supportive environment during delivery, it is required to continue 239 emphasizing the importance of health care provider-client communication and client-centered 240 care [19]. 241 One of the critical elements affecting patients’ perception of RMC is the way in which a patient 242 is addressed by a name of her/his preference. Patients’ preferred mode of address by healthcare 243 workers, to large extent, is influenced by ethnic and cultural factors. For instance, a study on 244 non-English speaking Australians shows that patients preferred to be called by their informal 245 name [20]. On the other hand, patients in countries like Iran [21] and Israel [22] preferred formal 246 address by title and surname. In this study, 47.2% respondents agreed that they were called by 247 their preferred name, which is similar to the study from Egypt [12]. However, with limited 248 evidence on Nepalese patients’ preference of address by healthcare workers, the present study is 249 unable to provide contextual interpretation of the figure. Therefore, we recommend further study 250 on Nepalese patients’ preferred mode of address by healthcare workers. 251 Neglect or abandonment during labor and delivery has been reported in varying degrees in 252 countries like Kenya (14.3%) [23] and Tanzania (3.45%)[24]. This neglect could be in form of 253 health workers not being present at the time of birth, not providing medications or not 254 communicating the progress of labor. More than a quarter of women in this study responded that 255 the health workers did not respond to their need whether or not asked, which is quite a large 256 figure compared to those reported previously. The reason for not responding to needs could be 257 the heavy workload of midwives and health care workers[25]. In an overburdened Nepali health 258 care system where patient to healthcare workers ratio is unimaginably high [26]. In a 259 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 13 communication with Shanti Kandel, RN (January 2021), six thousand delivery in Bheri Hospital 260 is attended by a group of only eleven staffs for the fiscal year 2076/77. Silence can be a way in 261 which a system defends itself against the many needs of patients. Silence from a care provider 262 can cause neglect, resulting to avoidable complications during delivery [25], negative impact on 263 the health of mother and / or baby [27] and also unwillingness to return or recommend others to 264 the health facility for next delivery [28]. Respondents with complications are generally more 265 likely to report D & A during delivery[29]. Although a third of respondents in this study had 266 complications, rates of D & A remained low. 267 Women, during the process of delivery, are vulnerable to being abused by health workers 268 whether it might be physical or verbal [28,30,31]. Such abuses are likely to result in a high rate 269 of traumatic birth experience for women [32]. Different forms of abuse like being slapped (5.6%) 270 or being shouted at (4.6%) has been reported in this study. Women experiencing physical and 271 verbal abuse was found to be dramatically higher in another study conducted in central Nepal, 272 which reported physical and verbal abuse to be 18.7% and 30% respectively [33]. The difference 273 in reported abuse thus requires extensive research to identify the prevalence and institute 274 appropriate interventions. A study has demonstrated that midwives feel a strong sense of 275 accountability and responsibility for labor and delivery outcomes and tend to do whatever it 276 takes to deliver a live baby to a healthy mother [34]. In addition, the midwives/ nurses ratio per 277 population for Nepal is lesser (31.08/10,000 population) than the recommended by WHO 278 (40/10,000 population) leading to overburden for health workers [35]. WHO recognizes that D 279 & A not only violate the rights of women to respectful care, but also threaten their rights to life, 280 health, bodily integrity and freedom from discrimination [36]. However, abuse in any form, 281 whether it be physical or verbal should never be tolerated during labor and delivery. 282 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 14 Nearly half of the respondents (48.3 %) agreed that they were kept waiting for a long time, 283 which is substantially higher than the study conducted in Ghana, Guinea, Myanmar, and Nigeria 284 where 22% reported waiting for long periods before being attended by health workers [4]. The 285 delay in care (27.8%) might be due to too few staff as compared to patients as revealed by a 286 study of midwives of Malawi [8]. The situation might be similar in Nepal as shortage of staffs in 287 the hospital setting has been reported [37], further worsened by the ongoing shifts in staff 288 allocation as a part of Federalism. 289 Few participants i.e. approximately three out of a hundred, agreed that the health workers did not 290 treat them well because of personal or their companions’ attributes, which is in contrast to a 291 study conducted in Nigeria that showed a higher percentage of discrimination faced by 292 respondents at 8.1% [38]. Birth preparedness practice in Nepal tends to be higher as reported by 293 a study that denotes familiarization of pregnant women with the delivery setting. Early 294 communication and interpersonal relationship between care provider and patient could be a cause 295 for higher Discrimination-free Care [39]. 296 Women with SVD were two times more likely to have a neutral response about RMC for Timely 297 Care as compared to those who had cesarean delivery. Women experiencing caesarian delivery 298 could have ultimately perceived the urgency of services for delivering a healthy baby, thus 299 women with SVD would be more likely to report neutral Timely Care. Similarly, those who earn 300 less than twenty thousand Nepalese Rupees were twice as likely to feel they had a high level of 301 timely RMC. Women of lower economic status may be more tolerant of a long wait in order to 302 receive care in a government facility with higher case load as opposed to delivering at home. 303 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 15

304 This study has used a standardized tool to gather quantitative information about D & A faced by 305 women during labor and delivery. However in-depth insight regarding health workers’ 306 perceptions and/or those of delivering women could not be obtained. Also, the potential for 307 generalization of the findings cannot be ascertained as only a single tertiary care center in 308 western Nepal has been included for the study. 309 Information bias and courtesy bias might have occurred as the information was collected by an 310 on- duty student nurse, although the respondents were assured prior to the study that their 311 opinion would have no impact on further treatment. 312 Recommendations 313 Any forms of D & A must be prohibited during labor and delivery so that women can enjoy their 314 experience of labor and delivery. Irrespective of the health system or staff-related issues; timely 315 care must be of priority in order to ensure quality maternity care. Timely Care is simply not 316 always possible in highly constrained settings such as Bheri Hospital, but the perception of 317 Timely Care might possibly be reduced by additional communication and explanations of the 318 cause of the delay. 319 Further studies should be conducted to determine RMC at all levels of the healthcare system 320 throughout the country, such that potential generalization of our findings and appropriate 321 interventions for improvement can be planned accordingly. 322 Sustained interaction with the health system are required to implement behavior change 323 intervention central to promoting respectful care [40]. The successful improvement in maternity 324 care environment for women and midwives needs broader interdisciplinary perspectives on the 325 wider drivers of midwives’ disrespectful attitudes and behaviors [8]. 326 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 16

327 This study concludes that RMC is practiced highly in western Nepal in terms of Friendly Care, 328 Abuse-free Care, and Discrimination-free Care. However, Timely Care is less reported. 329 Therefore, appropriate interventions to provide Timely Care to delivering women must be 330 instituted. Along with this, adequate communication and explanation of delay can reduce 331 perception of delayed care among care recipients. Physical or verbal abuse during labor and 332 delivery must not be tolerated, and while rates of abuse were shown to be low in this study, there 333 remains room for improvement. Further research on RMC in Nepal is required to clarify the 334 drivers for D & A and examine potential solutions. 335 Abbreviations 336 D&A- Disrespect & Abuse 337 LSCS – Lower Segment Caesarion Section 338 MMR - Maternal Mortality Ratio 339 NHRC- Nepal Health Research Council 340 RMC- Respectful Maternity Care 341 SDG – Sustainable Development Goals 342 SVD – Spontaneous Vaginal Delivery 343 WHO- World Health Organization 344 Declaration 345 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 17 Competing interests: The authors declare no competing interests. 346 Funding: The study was self-funded by the authors. 347 Acknowledgments: The authors are immensely thankful to the management of Bheri 348 Hospital and to the NHRC for ethical approval. We express sincere gratitude to all women who 349 participated in this study along with delivery room residents and midwives for providing support 350 during the study. At last but not the least, we are thankful to all the student nurses of Sushma 351 Koirala Memorial Hospital, Nepalgunj, Banke for their support during data collection. 352

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Available from: https://reproductive-health-497 journal.biomedcentral.com/articles/10.1186/s12978-017-0364-8. 498 499 List of Tables 500 Table 1. Distribution of variables in the study 501 Part I- Socio-demographic characteristics and obstetric history Demographic Information: Age of Mother, Ethnicity, Religion, Type of Family, Educational Status, Educational Level, Occupation, Spouse’s Educational Status, and Spouse’s Occupation Obstetric History: Gravida, Para, Week of Gestation, Type of Delivery, and Complication During Labor Part II- Perceived Disrespect & Abuse 12 Friendly Care, Abuse-free Care, Timely Care, and Discrimination-free Care 502 Table 2. Distribution of participants according to socio-demographic information (n= 445) 503 Characteristics Frequency (n) Percent (%) Age (Years) <20 20-30 30-40 88 331 26 19.8 74.4 5.8 Ethnicity Brahmin/Chhetri Janjati Madhesi/Dalit and others 136 205 104 30.6 46.1 23.4 Religion Hindu Others 406 39 91.2 8.8 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 25 Educational Status Educated Uneducated 386 59 86.7 13.3 Occupation Unemployed Employed 226 219 50.8 49.2 Family type Nuclear Joint& Extended 208 237 46.7 53.3 Monthly income 20000 263 182 59.1 40.9 Spouse’s educational status Educated Uneducated 408 37 91.7 8.3 Spouse’s Occupation Foreign employment Non-formal employment Formal employment 25 318 102 5.6 71.5 22.9 504 505 Table 3. Distribution of participants according to obstetric history (n=445) 506 Characteristics Frequency (n) Percent (%) Gravida 2 337 108 75.7 24.3 Para Primi para Multipara 157 288 35.3 64.7 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 26 Week of gestation Preterm Term 19 426 4.3 95.7 Type of delivery Spontaneous vaginal delivery Augmented Lower section cesarean section 229 63 153 51.5 14.2 34.4 Complications during labor Yes 148 33.3 No 148 66.7 507 508 Table 4 Participant reports of RMC (n=445) 509 Components of RMC SD f (%) D f (%) N f (%) A f (%) SA f (%) Mean (SE) CM (SE) Friendly care: The health worker/s Cared with a kind approach 3 (0.7) 1 (0.2) 1 (0.2) 141 (31.7) 299 (67.2) 4.64 (.027) 4.42 (.028) Treated in a friendly manner 10 (2.2) 2 (0.4) 27 (6.1) 185 (41.6) 221 (49.7) 4.36 (.038) Talked positively about pain and relief 5 (1.1) 4 (0.9) 14 (3.1) 200 (44.9) 222 (49.9) 4.42 (.033) Showed his/her concern and empathy - 1 (0.2) 38 (8.5) 187 (42) 219 (49.2) 4.40 (.031) Treated with respect as an individual 1 (0.2) 6 (1.3) 66 (14.8) 181 (40.7) 191 (42.9) 4.25 (.036) Spoke in a language that I could understand 18 (4) 29 (6.5) 24 (5.4) 174 (39.1) 200 (44.9) 4.14 (.05) . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 27 Called me by my name 113 (25.4) 97 (21.8) 46 (10.3) 130 (29.2) 59 (13.3) 2.83 (.068) Abuse free care: The health worker/s Responded to my needs whether or not I asked 51 (11.5) 94 (21.1) 89 (20.0) 90 (20.2) 121 (27.2) 3.31 (.065) 4.29 (.044) Slapped me during delivery for different reasons (R) 267 (60.0) 121 (27.2) 32 (7.2) 19 (4.3) 6 (1.3) 4.40 (0.43) Shouted at me because I hadn’t done what I was told to do (R) 249 (56.0) 125 (28.1) 50 (11.2) 17 (3.8) 4 (0.9) 4.34 (.042) Timely Care Kept waiting for a long time before receiving service (r) 98 (22.0) 117 (26.3) 106 (23.8) 78 (17.5) 46 (10.3) 3.32 (.061) 3.10 (.057) Allowed to practice cultural rituals in the facility 169 (38.0) 107 (24.0) 87 (19.6) 19 (4.3) 63 (14.2) 2.33 (.066) Service provision was delayed due to the health facility’s internal problems (r) 172 (38.7) 102 (22.9) 88 (19.8) 51 (11.5) 32 (7.2) 3.74 (.060) Discrimination- free care: Some of the health workers Did not treat me well because of my personal attributes (R) 330 (74.2) 89 (20.0) 11 (2.5) 9 (2.0) 6 (1.3) 4.64 (.036) 4.67 (.032) Insulted me and my companions due to my personal attributes (R) 316 (71.0) 112 (25.2) 4 (0.9) 5 (1.1) 8 (1.8) 4.62 (.035) SA- Strongly agree, A- Agree, N- Neutral/ Indifferent, D- Disagree, SD- Strongly disagree 510 SE- Standard error, CM- Cumulative mean 511 Table 5. Distribution of Friendly RMC by different socio-demographic and obstetric 512 characteristics (n=445) 513 Characteristics Friendly care χ 2 p- value Moderate RMC High RMC Very high RMC . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 28 f (%) f (%) f (%) Age <20 20-30 30-40 1 (1.1) 24 (7.3) 1 (3.8) 41 (46.6) 149(45.0) 16 (61.5) 46 (52.3) 158 (47.7) 9 (34.6) 8.958a .062 Ethnicity Brahmin/Chhetri Janjati Madhesi/Dalit & others 10 (7.4) 8 (3.9) 8 (7.7) 58 (42.6) 92 (44.9) 56 (53.8) 68 (50.0) 105 (51.2) 40 (38.5) 6.754 .149 Educational Status Educated Uneducated 25 (6.5) 1 (1.7) 177(45.9) 29 (49.2) 184 (47.7) 29 (49.2) 2.817a .244 Occupation Unemployed Employed 9 (4.0) 17 (7.8) 115(50.9) 91 (416) 102 (45.1) 111 (50.7) 5.529 .063 Monthly income 20000 5 (1.9) 21 (11.5) 126(47.9) 80 (44.0) 132 (50.2) 81 (44.5) 18.188 .000 Spouse’s Occupation Foreign Non-formal Formal employment 0(.0) 21(6.6) 5(4.9) 13(52.0) 146(45.9) 47(46.1) 12(48.0) 151(47.5) 50(49.0) 3.605a .462 Gravida 2 7 (2.1) 19 (17.6) 146(43.3) 60 (55.6) 184 (54.6) 29 (26.9) 49.498 .000 Para Primi para Multi para 2 (1.3) 24 (8.3) 83 (52.9) 123(42.7) 72 (45.9) 141 (49.0) 11.135 .004 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 29 Week of gestation Preterm Term 0 26 (6.1) 14 (73.7) 192(45.1) 5 (26.3) 208 (48.8) 7.302 a .026 Type of delivery SVD Augmented LSCS 10 (4.4) 6 (9.5) 10 (6.5) 100(43.7) 34 (54.0) 72 (47.1) 119 (52.0) 23 (36.5) 71 (46.4) 6.112 a .191 Complications Yes No 7 (4.7) 19 (6.4) 69 (46.6) 137(46.1) 72 (48.6) 141 (47.5) 0.504 .777 a – likelihood ratio 514 515 Table 6. Distribution of Abuse-free RMC by different socio-demographic and obstetric 516 characteristics (n=445) 517 Characteristics Abuse Free Care χ 2 p- value Very Low RMC f (%) Low RMC f (%) Moderate RMC f (%) High RMC f (%) Very High RMC f (%) Age <20 20-30 30-40 - 4(1.2) - 2(2.3) 12(3.6) 1(3.8) 13(14.8) 71(21.5) 5 (19.2) 39(44.3) 94(28.4) 11(42.3) 34(38.6) 150(45.3) 9 (34.6) 11.606a .212 Ethnicity Brahmin/Chhetri Janjati Madhesi/Dalit & others 0(.0) 1(.5) 3(2.9) 2(1.5) 8(3.9) 5(4.8) 32(23.5) 36(17.6) 21(20.2) 42(30.9) 66(32.2) 36(34.6) 60(44.1) 94(45.9) 39(37.5) 11.214 .186 .190 Educational Status . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 30 Educated Uneducated 3(.8) 1(1.7) 10(2.6) 5(8.5) 74(19.2) 15(25.4) 129(33.4) 15(25.4) 170(44.0) 23(39.0) 11.214a .190 Occupation Unemployed Employed 3(1.3) 1 (.5) 6 (2.7) 9 (4.1) 40(17.7) 49(22.4) 81(35.8) 63(28.8) 96(42.5) 97(44.3) 4.713a .318 Monthly income 20000 1(.4) 3(1.6) 11(4.2) 4(2.2) 50(19.0) 39(21.4) 79(30.0) 65(35.7) 122(46.4) 71(39.0) 5.981a .201 Spouse’s Occupation Foreign Non-formal Formal employment 0(.0) 3(.9) 1(1.0) 0(.0) 15(4.7) 0(.0) 4(16.0) 61(19.2) 24(23.5) 3(12.0) 99(31.1) 42(41.2) 18(72.0) 140(44.0) 35(34.3) 24.143a .002 Gravida 2 2(.6%) 2(1.9) 14(4.2) 1(.9) 69(20.5) 20(18.5) 103(30.6) 41(38.0) 149(44.2) 44(40.7) 6.223a .183 Para Primi para Multipara 1(.6) 3(1.0) 9(5.7) 6(2.1) 40(25.5) 49(17.0) 54(34.4) 90(31.2) 53(33.8) 140(48.6) 13.184a .010 Week of gestation Preterm Term 0(.0) 4(.9) 0(.0) 15(3.5) 7(36.8) 82(19.2) 7(36.8) 137(32.2) 5(26.3) 188(44.1) 5.592a .232 Type of delivery SVD Augmented LSCS 3(1.3) 1(1.6) 0(.0) 4(1.7) 9(14.3) 2(1.3) 50(21.8) 12(19.0) 27(17.6) 69(30.1) 25(39.7) 50(32.7) 103(45.0) 16(25.4) 74(48.4) 29.030a .000 Complications Yes 1(.7) 1(.7) 32(21.6) 45(30.4) 69(46.6) 7.391 a .117 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 31 No 3(1.0) 14(4.7) 57(19.2) 99(33.3) 124(41.8) a – likelihood ratio 518 Table 7. Distribution of Timely RMC by different socio-demographic and obstetric 519 characteristics (n=445) 520 Characteristics Timely Care χ 2 p- value Very Low RMC Low RMC Moderate RMC High RMC Very high RMC Age <20 20-30 30-40 0(.0) 38(11.5) 3(11.5) 8(9.1) 33(10.0) 1(3.8 0 37(42.0) 179(54.1) 13(50.0) 25(28.4) 73(22.1) 9(34.6) 18(20.5) 8(2.4) 0(.0) 55.822a 54.618 .000 .000 Ethnicity Brahmin/Chhetri Janjati Madhesi/Dalit & others 19(14.0) 12(5.9) 10(9.6) 13(9.6) 17(8.3) 12(11.5) 75(55.1) 101(49.3) 53(51.0) 29(21.3) 53(25.9) 25(24.0) 0(.0) 22(10.7) 4(3.8) 24.939a .002 Educational Status Educated Uneducated 38(9.8) 3(5.1) 39(10.1) 3(5.1) 198(51.3) 31(52.5) 90(23.3) 17(28.8) 21(5.4) 5(8.5) 4.089a 4.420 .394 .352 Occupation Unemployed Employed 10(4.4) 31(14.2) 29(12.8) 13(5.9) 113(50.0) 116(53.0) 61(27.0) 46(21.0) 13(5.8) 13(5.9) 18.888a .001 Monthly income ≤ 20000 >20000 18(6.8) 23(12.6) 23(8.7) 19910.4) 129(49.0) 100(54.9) 68(25.9) 39(21.4) 25(9.5) 1(.5) 20.616a .000 Spouse’s Occupation . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 32 Foreign Nonformal Formal employment 6(24.0) 25(7.9) 10(9.8) 2(8.0) 31(9.7) 9(8.8) 13(2.0) 159(50.0) 57(55.9) 4(16.0) 79(24.8) 24(23.5) 0(.0) 24(7.5) 2(2.0) 13.692a 14.218 .090 .076 Gravida 2 17(5.0) 24(22.2) 32(9.5) 10(9.3) 185(54.9) 44(40.7) 85(25.2) 22(20.4) 18(5.3) 8(7.4) 30.782a .000 Para Primi para Multi para 8(5.1) 33(11.5) 18(11.5) 24(8.3) 87(55.4) 142(49.3) 39(24.8) 68(23.6) 5(3.2) 21(7.3) 9.255a .055 Week of gestation Preterm Term 2(10.5) 39(9.2) 0(.0) 42(9.9) 10(52.6) 219(51.4) 5(26.3) 102(23.9) 2(10.5) 24(5.6) 2.703a 4.355 .609 .360 Type of delivery SVD Augmented LSCS 20(8.7) 10(15.9) 11(7.2) 14(6.1) 7(11.1) 21(13.7) 129(56.3) 32(50.8) 68(44.4) 56(24.5) 14(22.2) 37(24.2) 10(4.4) 0(.0) 16(10.5) 22.359a 24.612 .004 .002 Complication Yes No 10(6.8) 31(10.4) 22(14.9) 20(6.7) 68(45.9) 161(54.2) 33(22.3) 74(24.9) 15(10.1) 11(3.7) 16.957a .002 No. of living child ≤ 2 >2 22(5.8) 19(28.4) 37(9.8) 5(7.5) 204(54.0) 25(37.3) 92(24.3) 15(22.4) 23(6.1) 3(4.5) 35.113a 26.558 .000 .000 a – likelihood ratio 521 Table 8. Associated factors for Timely RMC during delivery (n=445) 522 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint 33 Predictors Neutral RMC High RMC OR( CI) P-Value OR(CI) P-Value Type of Delivery SVD 2.07(1.15-3.72) 0.01 1.38(0.74-2.59) 0.30 Augmented 0.99(0.47-2.10) 0.99 0.56(0.23-1.36) 0.18 LSCS 0 b - 0 b - Gravida Primi 2.28(0.92-6.29) 0.07 2.20(0.82-5.90) 0.12 Multi 0 b 0 b - Monthly income (NPR) ≤ 20000 1.33(0.78-2.24) 0.289 2.36(1.3-4.23) 0.004 >20000 0 b - 0 b Complication during delivery Yes 0.81(0.43-1.53) 0.52 0.63(0.31-1.27) 0.63 No 0b - 0 b Living Children ≤ 2 1.86(0.74-2.59) 0.048 1.52(0.52-4.39) 0.43 ≥ 2 0 b - 0 b - Model fitting information= Chi-square= 3.68,df=12 p-value=0.000, Pseudo R2 Nagelkerke=0.096 523 a. The reference category is 1.00 Low RMC, b This parameter set zero because it is redundant, 524 525 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.23.21250363doi: medRxiv preprint