Quantitative.

The respondents were all midwives (n = 201), who work in maternity sections of public hospitals in Enugu metropolis at the time of the study. All the midwives were eligible and included in the study (total sampling). Inclusion criteria was working in the maternity section of the hospitals for at least one year preceding the survey and willingness to participate in the study.

Qualitative.

We purposively selected 56 focus group participants from among the survey respondents reflecting different types of facilities, all LGAs and demographic characteristics of midwives. The midwives must have worked in maternity section of the public hospital for at least one year and willing to participate in the study.

Quantitative.

Data were collected from the midwives from February to May 2019 using pre-tested, self-administered questionnaire. The questionnaire consists of socio-demographic characteristics and PCMC scale made up of 30 items measuring dignity and respect (6 items), communication and autonomy (9 items), and supportive care (15 items). Each item was measured on a 4-point response scale—0: “no, never,” 1: “yes, a few times,” 2: “yes, most of the time,” and 3: “yes, all the time.” For each midwife, responses from the PCMC scale were summed up into one composite PCMC score. The possible score on the PCMC scale ranges from 0 to 90, with a lower score implying poorer PCMC. The range of possible scores on the sub-PCMC scales are: 0–18, 0–27 and 0–45 for respect and dignity, communication and autonomy, and supportive care correspondingly. The PCMC scale has been validated in similar low-resource context [2, 18]. Among our sample of midwives, Kaiser-Meyer-Olkin measure of sampling adequacy was 0.864 (X² = 2088.38, ρ = 0.000). All 30 items yielded adequate communalities (≥ 0.4) on exploratory factor analysis [50]. The cumulative variance was 60.9%. Oblimin rotation with Kaiser Normalization showed that all 30 items loaded ≥ 0.4 and were retained since a rotated factor loading of 0.32 is considered significant [50]. The reliability coefficient of the PCMC scale was 0.845. The pre-test of the PCMC scale on 10 midwives, working in similar setting, indicated that the questionnaire was easy to understand and took about 30 minutes to complete. Five trained research assistants facilitated administration and collection of questionnaires. We collected 177 (88.1%) questionnaires, of which 168 were appropriate for analysis, resulting in 83.6% net response rate. During the data collection, 11.9% of midwives were unavailable due to leave, training, or shift work.

Qualitative.

We conducted seven focus group discussions (FGDs) with 56 midwives to gain a detailed understanding of experiences of PCMC and its associated factors. Each focus group comprised 6 to 10 midwives. The FGDs were held at a venue within the hospital and at a time chosen in consultation with the midwives. A topic guide, developed based on the PCMC framework, was used to facilitate the FGDs (Additional file 1). Discussions, which were held in English language and audio recorded with midwives’ consent, lasted 60–90 minutes. Data were collected from February to May 2019 until thematic saturation was reached [51]. We transcribed the audiotapes verbatim, de-identified transcripts and stored them in password protected computer.

Quantitative.

Data were analyzed using SPSS (version 20, IBM, New York, USA). Characteristics of respondents were presented using frequencies and percentages. We recoded “no, never and a few times” together and “yes, most of the time and all the time” together to transform the four-point frequency responses to binary responses. The binary responses were analyzed using table, frequencies, and percentages. We categorized full PCMC and each sub-scale into “low, medium and high”. Low was defined as scores in the approximate lower 25th percentile and scores in the top 75th percentile defined as high [52]. Full PCMC and sub-scale scores in each category were also presented using table, frequencies, and percentages. Next, we tested the association of PCMC and sub-scale categories with socio-demographic characteristics of midwives using chi-square. Generalized Linear Models for ordinal scale was used to test relationship between PCMC and the parameters that were significant on bivariate analysis. Statistical significance was set at p < 0.05 level.

Qualitative.

Characteristics of focus group participants were presented using descriptive statistics. Transcripts were imported into NVivo 11 software and analysed using a thematic framework approach, which involved coding, mapping and organising the data under themes and interpretation [53]. Two persons generated a codebook, read the transcripts, coded the data independently and resolved inter-coder differences by consensus. The themes were largely deduced from dimensions of PCMC, but some sub-themes were generated inductively. Emergent sub-themes reflected factors affecting PCMC. We used excerpts and illustrative quotes to ground our findings in the data.

Basic characteristics of study survey respondents.

The mean age of midwives was 41.8 years ±9.6 years. Table 1 shows that all midwives were female and Christians. Most midwives were married and Igbo. About 40% were senior midwives while 53% have worked ≥ 10 years. Almost 66% of respondents had bachelor’s degree.

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Table 1. Basic characteristics of study survey respondents.

https://doi.org/10.1371/journal.pone.0261147.t001

Distribution of dignity and respect items.

Most midwives reported that they treated women with respect, friendly, never abused women verbally or physically, ensured visual privacy and confidentiality of women’s health record (Table 2).

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Table 2. Distribution of dignity and respect items among midwives.

https://doi.org/10.1371/journal.pone.0261147.t002

Distribution of communication and autonomy items.

As shown in Table 3, the proportion of midwives who reported good communication and autonomy practices ranged from 53.0% to 86.3%.

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Table 3. Distribution of communication and autonomy items among midwives.

https://doi.org/10.1371/journal.pone.0261147.t003

Distribution of supportive care items.

Table 4 shows a wide variation in the proportion of midwives who reported good supportive care practices (range,19.0% to 86.3%).

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Table 4. Distribution of supportive care items among midwives.

https://doi.org/10.1371/journal.pone.0261147.t004

Distribution of total person-centred maternity care and subscale.

Table 5 shows that few midwives had high perception of PCMC and its subscales. The mean perception of person-centred maternity care is 54.06 (10.99).

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Table 5. Total person-centred maternity care and sub-scale scores.

https://doi.org/10.1371/journal.pone.0261147.t005

Socio-demographic factors associated with PCMC.

As shown in Table 6, there was no socio-demographic differences in total person-centred maternity care and across the sub-scales.

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Table 6. Socio-demographic factors associated with midwives’ perception of person-centred maternity care.

https://doi.org/10.1371/journal.pone.0261147.t006

Predictors of person-centred maternity care among midwives.

Table 7 shows that midwives’ perception of PCMC was not significantly related to socio-demographic factors.

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Table 7. Predictors of midwives’ perception of person-centred maternity care.

https://doi.org/10.1371/journal.pone.0261147.t007

Basic characteristics of focus group participants.

Table 8 shows that all participants were female, Igbo, and Christians. Most midwives were age ≤ 40 years, married, employed in state government hospitals and tenured for ≤10 years. Almost 54% of were junior midwives.

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Table 8. Basic characteristics of focus group participants.

https://doi.org/10.1371/journal.pone.0261147.t008

Dignity and respect.

Most midwives stated that they treated all women alike irrespective of their personal attributes. Few midwives, however, noted that government officials and wealthy people get preferential treatment from providers as a mark of respect, or in anticipation of pecuniary benefits. “If you look wealthy, everybody will flood your bed even when they do not have any role in your care, but if you look poor, nobody will come to you. Even when you come to the nursing station to ask for something, nurses may shout at you” (M1 FGD4, TH). One midwife remarked “If her excellency [wife of the governor] comes here to deliver, … junior nurses will stay clear and let older nurses attend to her” (M6, FGD7, GH). Equally, persons living with HIV expect to be discriminated: “They watch us with critical eye to see whether there is an atom of discrimination, but here we treat all women alike” (M7, FGD3, TH)

Most midwives observed that they treated women in a friendly manner by “creating a therapeutic environment” (M6 FGD4, TH) through care that is “individualised, appropriate, acceptable and safe” (M7 FGD4, TH). Midwives attributed unfriendliness to quacks, who are not trained: “every woman sees anybody on white as a nurse and green, as a midwife. So, any ill treatment they have received, they think it is from the midwife” (M6, FGD1, TH).

All midwives acknowledged that verbal abuse is common. However, many midwives viewed it as “verbal encouragement because though what you say to the women may sound harsh, it will spur them to take action that leads to a positive outcome” (M6, FGD3, TH). Midwives identified five factors that precipitate verbal abuse. First, some women come to the hospital without any birthing materials. Secondly, when women refuse to disclose their HIV status, midwives normally frown at that. Thirdly, midwives are unhappy with women who default after antenatal care registration and re-present during labour. Fourthly, some women lack good personal hygiene: “some women come to the hospital without taking their bath. It’s annoying” (M3, FGD5, GH). Finally, non-adherence to midwife’s instructions by women or their relatives. Midwives explained that they scold women to elicit their co-operation for a positive birth outcome: “if the woman gets up or closes her legs when they head of the baby is already out, you must use a harsh tone to bring the woman down” (M9, FGD2, TH).

Most midwives mentioned that they would strongly pat uncooperative women on the laps to open their legs when “the baby is about come out and the woman is persistently closing her legs” (M5, FGD1, TH) because “when things go wrong, the person that is usually blamed is the birth attendant” (M8, FGD1, TH). Moreover, “for a midwife, to have a stillbirth is a dilemma that one lives with all through one’s life” (M3, FGD3, TH). In contrast, few midwives insisted that “beating or spanking a woman in labour is an abuse as there are so many ways one can assist a woman to deliver her baby” (M2 FGD4, TH). It is also an abuse “when a midwife uses needle to prick an unmarried adolescent” (M6 FGD2, TH) during childbirth.

Almost all midwives reported that visual privacy was achieved using screens and curtains; and patients’ records are kept strictly confidential. Even for HIV positive woman, when a woman says, “I do not want my husband to know about this” (M4 FGD4, TH), the midwife will not disclose her HIV status to her husband.

Communication and autonomy.

While many midwives said that they introduced themselves appropriately to women, some midwives indicated that “as for introducing ourselves, we do not always do that” (M3 FGD4, TH). It was explained that “we are conversant with them. We live with them. We are familiar with them. We know ourselves. They will even call you on the phone before coming to the hospital” (M6, FGD7, GH). Also, “some midwives do not like women to know their names” (M8, FGD1, TH) or assume that “once the woman sees me on white, she knows am the nurse on duty” (M1, FGD5, GH) or introduction are limited by workload.

Many midwives also stated that they called women by their names. Even though “it is a taboo for you not to call a woman by her name” (M8, FGD1, TH), “some midwives addressed women as “Madam” (M2, FGD1, TH). Also, high workload constrained midwives from calling women by their name: “we do not usually call them by their names due to high workload” (M6, FGD5, GH).

Midwives were divided on involvement of women and their relatives in decisions around their care. Although some midwives mentioned that “we give individualized care and respect their autonomy as long as mother and baby are safe” (M4, FGD3, TH), others noted that “in this part of the world, it is mostly healthcare providers that make delivery decisions. Even with some enlightened women, after educating them, they will still come back to you with ‘nurse what do you want me to do’?” (M3 FGD4, TH). Women involvement was limited when midwives consider women’s requests as unnecessary. For instance, when a woman says, “I do not give birth without hot drip” (M3, FGD 7, GH), but there is no clinical indication for augmenting the labour. Also, some women greeted the news of assisted delivery with such notions as “God forbid” (M3, FGD 7, GH), “not my portion” (M2, FGD7, GH) and “no, my pastor said I must give birth like a Hebrew woman” (M1, FGD3, TH). In such circumstances, midwives do not wait “for the woman and her spirituality” (M7, FGD1, TH) to take appropriate actions.

Most midwives noted that women were not always involved in decisions about their birthing position: “No, you are the one who will tell them the position. I want you to stay like this, so that proper decent will be attained during labour” (M1, FGD7, GH). Even when “there are people who like to stand up at labour because they feel less pain doing so. We cannot leave them to give birth standing up. So, we force them to bed” (M10, FGD1, TH). Conversely, some women insisted on their birthing position: “despite all our pleas, a Hausa woman refused to lie down. She squatted until she had her baby” (M5, FGD6, GH). Similarly, a nurse preferred to give birth while standing up: “She stood on the bed and she gave birth standing up” (M8, FGD2, TH).

Most midwives elicited consent from women, based on questioning by and explanations of care processes to women in the language the women understood. Midwives explained that when a woman signs consent on admission, she “agrees to all procedures that will be done to her during labour and childbirth” (M7, FGD3, TH). Yet, “whatever procedure we are carrying out, we explain it to the woman and get her go-ahead” (M3, FGD6, GH). However, some midwives remarked that “we do not usually explain the procedure to the woman and most times we do not even wait for them to respond. We just say: madam, I want to do this, and we just go ahead” (M2, FGD1, TH).

Supportive care.

Most midwives stated that they pay attention to women, empathise with them, provide psychological support and control women’s pain most time. Constant reassurance, counselling, encouraging women to take deep breathing exercises, walking and massaging were common approaches midwives employed to control pain during labour. Additionally, asking women “to call their pastor, reverend or imam to pray or talk to them helped to allay their anxiety” (M3, FGD5, GH). However, some midwives noted “lack staff to attend to many women needing attention at the same time” (M6, FGD3, TH) as a constraint.

Most midwives revealed that allowing labour and childbirth support was not the norm because “there are other mothers in labour and sometimes when you advise a woman on what to do, the relation will tell the woman a different thing” (M9, FGD2, TH) or “they start teaching you your job” (M4, FGD5, GH). Nonetheless, relatives of women were allowed into labour or birthing room under exceptional circumstances. First, lack of manpower: “when you are alone conducting childbirth and the support person is an experience woman, you can allow her to be around and assist you” (M2, FGD7, GH). Secondly, to avoid blame for a poor childbirth outcome: “when the woman is not co-operating during childbirth, we bring in the relative, even the husband, to talk to her and to bear witness in case the childbirth ends negatively” (M3, FGD2, TH). Thirdly, to facilitate referral of women who experience complications. Fourthly, to provide needed items that are unavailable in the health facility. However, “many times women do not want their husband to be around” (M6, FGD3, TH).

Midwives did not consider the maternity section clean, safe and health always. In some hospitals, “the wards are very dirty. We had a case where the relative of a woman in labour was bitten by scorpion one night” (M6, FGD7, GH). Epileptic power supply, poor water supply and inadequate toilet facilities were common problems in maternity sections: “one major problem this hospital is facing is lack of toilet facility. If you go to the labour ward, we have only one toilet” (M9, FGD1, TH). Where toilets exist, midwives blamed women for not keeping them clean: “some dispose their pads in the toilets, while others simply mess up the place” (M4, FGD6, GH). Yet, hospitals lacked staff responsible for cleaning toilets: “we have only one staff, she cannot run three shifts for seven days in a week” (M4, FGD5, GH).

Midwives believed that women trusted them and that they took the best care of women. However, labour wards are crowded, and hospitals lack enough staff. In tertiary hospitals doctors and midwives work as a team, but in general hospitals midwives seem to bear higher burden of the high workload as doctors were not always available when needed: “Am not going to talk about doctors who are supposed to be around. Here, it is only midwives all the time” (M5, FGD7, GH). Another midwife corroborated, “the midwife belongs to every department. She finds card; she admits the patient; she is the doctor; she is the pharmacist; and she is the midwife” (M3, FGD5, GH). Furthermore, in state-owned hospitals, exit of junior midwives due to inadequate compensation exacerbate the workload of remaining midwives.

Most midwives observed that the cost of maternal care is high: “The cost of everything in this hospital is very high, considering that many people that patronize us are poor people” (M8, FGD2, TH). It was explained that “most things have been commercialized and patients must provide the necessary things needed for their care” (M1, FGD1, TH). Women also pay for drugs that were covered by free care policy. Many midwives revealed that women who are unable to pay their bills are detained in tertiary hospitals for several weeks until they pay. Detained women are usually un-booked patients who are brought as emergencies and needing surgery. Often, “these women are operated on loans–drugs on loan, blood on loan, everything on loan–and there is no money to pay for them” (M5, FGD3, TH). Midwives involve security men in monitoring women “because if you are on duty and a woman absconds, the hospital management will query you” (M5, FGD2, TH). Few midwives observed that in some cases, midwives engage with social workers to assist detained women pay the bills. For women who attend antenatal care, midwives link high-risk women to national health insurance scheme: “if we check the history and there is a possibility of delivering via Caesarean section, we do advice the mother to enrol into national health insurance” (M4, FGD2, TH). Additionally, midwives use drugs from emergency drug cupboards in labour and post-natal wards and get refund from women. Midwives reported that women often misconstrued these cash payments as under-the-table payments. Furthermore, midwives occasionally mobilise private funds to help poor women.