Respectful Maternity Care: Optimizing the quality of care for women with hypertensive disorders of pregnancy in Ghana

Hypertensive disorders of pregnancy (HDPs) constitute a global health challenge, especially in low- middle-income countries where they account for a significant proportion of maternal and perinatal severe morbidities and mortalities. In Ghana, the proportion of maternal deaths attributed to HPDs has doubled over the past decade (from 9% in 2007 to 18% in 2017). In addition, emerging evidence indicates women experience wide range of disrespectful care and mistreatment in health facilities which can potentially disincentivize them from seeking facility-based maternity care. This thesis assessed the quality of care for women with HDPs and explored how appropriate integration of respectful maternity care (RMC) can optimize the provision and experience of care and reduce maternal morbidity and mortality.

Chapter 2 determined the perinatal morbidity and mortality associated with HDP: NICU admission (24.7%), neonatal respiratory distress/asphyxia (15.2%), preterm birth (21.7%), low birth weight (24.7%) and perinatal mortality rate of 106 per-1000 births comprising stillbirth (6.8%) and early neonatal deaths (3.8%).

Chapter 3 determined that maternal near-miss cases occurred in 33.1% with 2.7% maternal deaths. Severe maternal outcomes occurred among 50.0% and 39.4% of women with severe preeclampsia and eclampsia respectively. The most common organ system involvement was hematologic dysfunction (38.6%), followed by respiratory dysfunction (14.8%). Stillbirth and neonatal deaths occurred in 14% and 19% of births respectively whiles NICU rate was 12.7%.

Chapter 4 explored the perspectives and lived experiences of healthcare provision among pregnant women with HDP. Women reported mixed (positive and negative) experiences of maternal care. Major health system factors influencing the women’s experiences of care included lack of logistics, substandard professionalism, inefficient national health insurance system and unexplained delays at health facilities. Patient-related factors that influenced provision of care enumerated were financial limitations, chronic psychosocial stress and inadequate awareness about HDP.

In chapter 5, health providers highlighted major challenges in the clinical management of HDPs: patient-related factors, health system-related challenges and health provider associated factors. Context-specific recommendations suggested for improving the quality of care in managing maternal hypertension include restructuring the health system to reduce delays in providing care, improving financial coverage of medical insurance, encouraging social/family support, enhancing education on HDPs and strengthening health workers’ numbers and working conditions.

Chapter 6 explored the major types of mistreatment of women: verbal abuse, physical abuse and abandonment and lack of support. Mistreatment was commonly experienced during the second stage of labour, especially among adolescents. Inability to push well during the second stage of labour, disobedience to instructions, and not bringing prescribed items for childbirth often preceded mistreatment.

In Chapter 7, healthcare providers and hospital administrators reported mixed feelings regarding the quality-of-care women receive. Almost all respondents were aware of the occurrence of mistreatment and described physical and verbal abuse and denial of preferred birthing positions and birth companionship as typical examples. Rationalizations for mistreatment provided by the health workers included limited staff capacity, high workload, perceptions of women’s non-compliance and women’s attitudes towards maternity staff.

Chapter 8 explored the prevalence of four types of mistreatment of women during vaginal examinations: non-consented care (58.9%), sharing of private information (16.4%), exposure of genitalia (27.8%) and exposure of breasts (24.9%). The observed prevalence of mistreatment during vaginal examinations varied across countries. There were country-level differences in the association between the absence of privacy measures and mistreatment. Lack of privacy measures was associated with sharing of private information, genitalia exposure, breast exposure non-consented vaginal examination. Appropriate integration of evidence-based respectful maternity care into routine maternal care at the different hierarchical levels and addressing challenges related to women’s socio-cultural dimensions, health professionals and health systems can potentially be the game changer in maternal health.