Introduction

Globally, disrespectful, and abusive maternity healthcare is reported as violating women’s rights. The evidence depicts the negative consequences of disrespect and abuse of women seeking maternity healthcare services and poor quality of care [1–4]. This contradicts efforts directed toward the human rights agenda and universal health coverage.

Respectful maternity care (RMC) is a basic human right entitled to every childbearing woman, including the right to dignified and respectful care during pregnancy and childbirth [5]. Respectful care includes providing safe, evidence-based care that is provided in a supportive and friendly manner in a conducive environment with the involvement of women and their partners [6]. Evidence shows an association between respectful maternity care, improved quality of care, and utilization of maternity healthcare services [3, 6].

Disrespect and abuse vary in the types and extent of the mistreatment between countries [1, 7]. In Tanzania and other African countries, the common forms of disrespect and abuse include physical and verbal abuse, abandonment, soliciting of payment for service, retention in the facility for not being able to pay the bills, unconsented care, and the violation of privacy and confidentiality (of both physical and personal information) [1, 8–12]. A study to measure the prevalence of disrespect and abuse in Kenya revealed a rampant existence of this problem, including women who are left unattended, retained in the facility when they failed to settle bills, discriminated against, lack information and involvement in care provision and, their privacy and confidentiality violated [13, 14].

Disrespectful and abusive care is associated with women stopping seeking maternal health services from health facilities. In Tanzania, only 50% of childbirth in 2010 [15] and 62% in 2016 [16] utilized maternity healthcare services, and disrespect and abuse are highlighted among the reasons [17]. Women in rural Tanzania have declared that they would deliver at a health facility if maternity healthcare providers would use positive language and welcoming approaches [17].

Despite the growing anecdotal evidence in Tanzania, which sheds light on understanding disrespect and abuse, studies, and interventions to explore the root causes and solutions are limited. Our experience of working in the context and encountering several disrespectful and abusive cases in maternity services (e.g., use of harsh language, negligence of care, unconsented care, stereotyping and abandonment of patients) formed a basis for designing and conducting the study with healthcare providers, used as an avenue to explore potential problems and solutions.

Methods

This study used a descriptive qualitative design to explore maternity healthcare providers’ perspectives on the disrespect and abuse experienced by women attending maternity services at health facilities in the Dar es Salaam region. Qualitative research usually focuses on how and why enquiries, which allows a deeper understanding of the phenomena, situations, and encounters [18].

We conducted a series of three workshops of 20–30 participants each (30 from Ubungo and Temeke, 30 from Kigamboni and Kinondoni, and 20 from Ilala district); the workshop duration was three days,’ which was used to generate detailed data from participants. Workshops are increasingly applied where researchers wish to explore the challenges arising from complex phenomena and to identify solutions creatively and with stakeholders [19, 21] Various approaches are used to design workshops, including the use of cookbooks and guidelines, the use of conceptual format with pre-designed activities, and the use of open format [19]. In the present study, we used an open format workshop, which allowed participants and facilitators to negotiate and influence the workshop as unanticipated phenomena emerged. The design of the workshops was guided by the existing evidence, anecdotal data, and inspired by the authors’ experiences. Researchers believe that disrespectful and abusive care is sometimes hidden or accepted as a culture or a normal practice by both the provider and the consumer of maternal healthcare services. Therefore, various approaches were utilized to grasp details and nuances from front liners maternity healthcare providers.

Data collection

This study used different strategies to obtain in-depth information from healthcare providers during the workshop. First, the participants were asked to reflect on their practice individually. Second, they were asked to write anonymously about any incident that mirrors disrespect and abuse witnessed, experienced, or committed by themselves and stick this on the notice board. The participants were provided with descriptions to guide their reflections (Table 1).

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Table 1. The guide for individual reflection of practice.

https://doi.org/10.1371/journal.pone.0281349.t001

The short lectures on respectful maternity care and disrespect and abuse were conducted. This was followed by watching a video on “Why Mrs X. died” [22]. The RMC training material was developed by Aga Khan University using evidence-based materials, including the national and WHO guidelines and the White Ribbon Alliance Respectful Maternity Care Framework on RMC.

Subsequently, these sessions were followed by an interactive discussion with the larger group. Finally, participants were randomly organized into smaller groups and worked on a real-life scenario. This scenario (Table 2) constructed by one of the facilitators based on the case encountered in the health facility was used as a departure to a detailed discussion regarding real issues in the current practice. The group members nominated a chair who facilitated the discussions and a note taker who ensured that all the key points were captured. The discussions were also recorded using a digital recorder after verbal consent from the participants.

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Table 2. Scenario.

https://doi.org/10.1371/journal.pone.0281349.t002

Results

Eighty (80) healthcare providers from various health facilities, including dispensaries (n = 25), health centres (n = 2), and hospitals (n = 3) located in Dar es Salaam, attended the workshop. The age of participants ranged from 25 to 45 years. All had more than two (2) years of working experience in maternity care services. Most of the participants were female.

Four main themes were identified from the data: Physical and verbal abuse; Lack of professional ethics and integrity; a Vulnerable working environment; and disrespectful women and relatives, see details on Table 3.

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Table 3. Presents the major themes and sub-themes.

https://doi.org/10.1371/journal.pone.0281349.t003

Discussion

The present study explores maternity healthcare providers’ perspectives on the disrespect and abuse experienced by women attending maternity services at health facilities in the Dar es Salaam region. The key findings reveal the apparent existence of disrespectful and abusive care in maternity services. As a result, four main themes were identified from the data: Physical and verbal abuse; Lack of professional ethics and integrity; a Vulnerable working environment; and Abuse and disrespect to care, providers.

These findings correspond with the evidence from various studies which assert the prevalence of disrespect and abuse of facility-based maternal healthcare services, hindering the achievement of positive maternal health outcomes [10, 12, 24]. Surprisingly, the findings in the current study indicate that some healthcare providers associate disrespect and abuse with positive birth outcomes, such as beating/pinching/and threatening women in the second stage of labor to help push the baby out. Unfortunately, the notion is accepted by some women as help believing they would not have made it if the midwife did not intervene. From these findings, the researchers do not undermine the fact that providers may lack awareness of women’s rights in the services they provide [25], and that sometimes they disrespect and abuse them unknowingly. On the other hand, it is also apparent that most women and their families do not understand their rights in reproductive health services. Therefore, we engaged with participants to clarify areas that felt unclear as they emerged. For instance, we discussed basic human rights in reproductive health and explored different strategies for dealing with various situations. As a result, most participants spontaneously and, as a shock, learned what they do as a normal practice violates women’s rights. Notably, the incidents of lack of awareness of the patient’s rights have been reported in other studies [22, 25].

Similar to this study, several global studies have widely reported physical and verbal abuse [4, 7, 13, 26]. For instance, a recent study conducted in India and Iraq reported that shouting, scolding, and yelling is the most common form of abuse women experience, which deters women from utilizing maternity services [26, 27]. In addition, the primary concern raised by women in Iraq was the lack of privacy. At the same time, physical and verbal abuse was pointed out in the present study as a major problem.

Unlike the previous studies, this study revealed that senior midwives often abuse and disrespect junior colleagues the same way they would clients. Yelling and slapping were commonly happening to these professionals during their early days in practice. Participants believe that junior maternity providers who encounter disrespect and abuse are likely to learn and inherit the practice from their mentors. Disrespectful care and abuse may become a generational problem if not addressed appropriately. The implication stated here resonates with the pedagogy of the oppressed theory [28]; when a person is oppressed by their superior is likely to behave the same if the opportunity arises.

Participants described the practices that reflect a lack of professional ethics and integrity, including lack of confidentiality and privacy, poor provider-client communication, and none consented care/procedures. In addition, to a lack of courtesy, poor interpersonal skills, negligence of care and women’s needs, and delayed care. Several studies globally have reported similar findings to the present study [4, 29, 30]. Accordingly, participants believe these actions are committed knowingly since professional ethics and integrity is among the core courses in all healthcare professions, which is also emphasized in the professional code of conduct. Evidence from global perspectives agrees with this study’s findings in most cases described here; despite receiving professional training, many incidents of unprofessional care are reported [2, 3, 31]. For example, a study in Sweden reported that women felt excluded in decisions made about measures taken by staff during childbirth and were given unclear and incomplete information. In several cases, they received no information at all [4]. A study in Ethiopia also reported that women often receive non-confidential, unconsented, and delayed care [29].

Participants in the present study feel that disrespect and abuse are complex and may be caused by an individual provider who lacks professional ethics and integrity. However, several systemic problems exaggerate the problem. They cited lack of resources and poor leadership as contributing to the bridging of professional ethics and integrity, e.g., lack of screening curtains and private rooms affect privacy and confidentiality during care. Studies in other areas have reported similar findings [9, 17, 32]. These findings imply that environmental factors are essential components that may influence the client’s care.

It will be interesting to find out what factors contribute to the lack of professionalism and what can be done to overcome the situation from the health care professional’s perspective.

Concerning the work environment, this study’s findings revealed dissatisfaction with the work environment among healthcare providers. Participants felt that their working environment and the system-related issues directly or indirectly expose them to the risk of committing disrespectful and abusive care. The main areas of concern were; lack of working equipment and supplies, space constraints, unclear processes, high workload, lack of commitment from leadership, vague and unfulfilled policies (e.g., free treatment for pregnant women and under-five children), and shortage of qualified staff. These findings are similar to those in several studies from within and in other countries [17, 26, 30, 32, 33]. For example, a study in Tanzania reported a lack of partitions between beds and that women shared beds [32]. It implies that even if one wanted to provide respectful care in such a situation, it would be hard to do so. As a result, women/families will continue complaining of poor care. In contrast, the health care providers remain frustrated and unhappy, which may inversely affect the care and health outcomes for the mother and the child.

On the contrary, findings in the current study revealed that although the emphasis is on addressing disrespect and abuse against women, healthcare providers are also disrespected and abused Participants wanted to know how and who would address disrespect and abuse from women and their families, asking, “what about disrespectful women and relatives?” Previous studies have reported clients abusing healthcare providers verbally and physically due to emotional reactions and stress [34]. The participants also cited unsupportive systems, and judgmental communities. A lengthy discussion ensued following this question, insisting that some healthcare providers suffer silently from disrespect and abuse experienced from women and their relatives, supervisors, and the challenging work environment. Furthermore, they think disrespected, and abused professionals will likely disrespect and abuse innocent clients. Finally, participants expressed their enthusiasm for understanding their rights which would balance with the discussion around disrespect and abuse of women at maternity services.

Violence against healthcare providers has been relatively reported worldwide however, there is a paucity of literature on women and relatives’ disrespect and abuse of maternity healthcare providers in Tanzania. However, a study in Tanzania reported that health providers might act disrespectfully due to the existing inequality, where they hold authority over women, though they are the victims of continuous health system challenges and poor working conditions [17].

Limitation

The researchers acknowledge that this study uses nurses, midwives, and clinical officers as prototype of providers to examine their perspectives of disrespect and abuse in maternal newborn, and child health care in Dar es Salaam. However, maternal health care is provided by a multidisciplinary team of providers; hence participants’ discernments of disrespect and abuse may mirror such communications. Conducting a similar study extending beyond nurses, midwives, and clinical officers; and in different settings than urban and semi-urban contexts may influence a significant positive change in the problem. Notwithstanding the limitation, the researchers believe that the evidence generated from this study will form a foundation for lager intervention study focusing on addressing the chronic problem of disrespect and abuse.

Conclusion

Act of disrespect and abuse is alarming in practice; it is associated with ignorance of fundamental human rights by providers and recipients of services. Conducting workshops can be useful in revealing disrespect and abuse deep-rooted in practice from provider’s perspectives and provides an opportunity to rectify the problem with providers. The findings of this study suggest the crucial need of more extensive interventional study to address the widespread actions of disrespect and abuse.

Acknowledgments

We extend our sincere appreciation to the Aga Khan University leadership for the guidance and support with running the workshops, to the Dar es Salaam Regional Medical Officer and the Reginal Nursing Officer for their cooperation and for granting permission to their staff to attend the workshop and participate in this study.