An in-depth analysis of midwives’ understanding and practice of respectful maternity care in Ghana: a focused ethnographic study
Publication Date
December 15, 2022
Creator
Abstract
Background:
Research that explored women’s experiences of maternity care in lower-middle income countries including Ghana over the past decade has, unfortunately, highlighted the mistreatment that women suffer during childbirth which may be partly responsible for the low uptake of skilled birth attendants in these settings. This has resulted in the focus on respectful maternity care (RMC). The emphasis on RMC has increased research attention to the conceptualisation of RMC and strategies for its promotion. The research evidence indicates that RMC has mostly been conceptualised as the ‘absence’ of abuse, the lack of RMC viewed as a behavioural problem of providers, and providers’ concerns about systemic contraints partially interpreted as a justification for the mistreatement of women. This has influenced the use of human rights approach and the training of providers as predominant strategies for promoting RMC. Therefore, these strategies, though necessary, have had limited effect on promoting RMC because they do not address constraints that hinder the provision of RMC in these settings. The current conceptualisation of RMC also does not reflect contextual nuances and the needs of providers. Furthermore, there is limited attention to the identification of causal mechanisms and an investigation of how these mechanisms interplay to influence the agency of providers. This research, therefore, sought to elicit midwives’ (who form the majority of provders in maternity care) beliefs and experiences to facilitate the conceptualistion of RMC in a manner that refelcts local nuances not captured within universal frameworks. Additionally, this research sought to identify causative mechanisms and establish how they interplayed to influence midwives’ agency during the provision of RMC.
Aim of the study:
To understand midwives’ views and beliefs about RMC in the Ghanaian context and how RMC was enacted, influenced, and experienced in practice by addressing the following specific objectives:
• To understand what RMC meant to midwives working in a maternity unit
• To explore the factors that influenced the provision of RMC
• To explore the facilitators and barriers for the provision of RMC
Methodology and methods:
A focused ethnographic approach with a critical realist philosophical underpinning. Data collection was carried out in three phases, in three different facilities, and using three different methods: (i) audio-taped focus group discussions with midwives (ii) participant observations at the labour wards, and (iii) audio-taped interviews with other stakeholders including directors of health facilities whose contribution to the care provided by midwives were identified by the researcher. Ethical approval was obtained from the Ghana Health Service Ethics Review Committee (Reference number GHS-ERC: 013/10/2018) and the University of Nottingham Faculty of Medicine and Health Sciences Ethics Committee (reference number: 154-1811). Informed consent was obtained from all participants prior to data collection. Recorded data was transcribed verbatim and coded. NVIVO software was used to facilitate the data analysis process. Thematic analysis of data was carried out using a realist-informed inductive and iterative process. The analysis was deepened by incorporating critical realist principles of abduction and retroduction to enable the identification of causative mechanisms influencing RMC.
Findings:
Three main themes emerged:
1. Reciprocal respect and mutual satisfaction: establishing a value-based midwife-woman relationship
2. Causal connection between structural deficiencies and inequalities on care and women’s agency and autonomy
3. A fractured midwife-woman relationship
The core feature of RMC was the midwife-woman relationship with principles that are focused on reciprocal respect and mutual satisfaction for both women and midwives but underpinned by woman-centred care. Midwives utilised embodied values involving spirituality and notions of kinship attachment to develop a supportive relationship with women and to ensure the presence of RMC. The values of reciprocity, mutuality, spirituality, and kinship attachment inherent in this concept facilitated the creation of a culturally sensitive and context specific concept of RMC. This is a novel finding from the study which extends the existing concept of RMC beyond the ‘absence’ of abuse. The initial approach utilised by midwives when the woman first reported in labour also emerged as highly significant in shaping the nature of the relationship. Ensuring the preservation of women’s dignity, privacy, and confidentiality were also considered aspects of the RMC concept. Based on these findings, a conceptual framework for RMC was developed which established the connection between these elements. Observational data revealed that this idealised concept, however, did not always manifest in practice. The research found that resource constraints, lack of interprofessional collaboration, lack of concern for midwives’ wellbeing, and midwives’ fear of adverse outcomes and subsequent blame resulted in the lack of enactment of the idealised RMC concept. To enable the identification of deeper structures that had stronger causal connection with midwives’ agency, the themes were further analysed using the critical realist principle of retroduction. This resulted in the postulation of five causative mechanisms and explanation was given on how these mechanisms interacted to influence midwives’ agency, the midwife-woman relationship, and thus the provision of RMC which had been unrecognised. For instance, structural and gender-based violence and risk aversion arising from the fear of adverse outcomes and blame were causative mechanisms with deeper causal powers to influence midwives’ paternalistic approaches care to ensure safe outcomes. The identification of these underlying mechanisms are key contributions of this study that extend the knowledge on factors influencing the provision of RMC. A conceptual model was developed to highlight the regularities and mechanisms that shaped the nature of agencies and influence the provision of RMC.
Conclusion:
This study has presented novel contributions to the RMC discourse globally and in Ghana specifically and addressed some gaps within the global RMC concept. The study has highlighted that RMC is underpinned by a value-based midwife-woman-relationship which though woman-centred, was reciprocal, focusing on women’s unique experiences of care and midwives’ experience of care provision. The identification of causative mechanisms through critical realism illuminated the real mechanisms that shaped the nature of RMC provision. The findings have demonstrated that the current discourse around RMC which positions care providers as perpetrators of mistreatment and women as victims needs to be broadened to include the systemic complexities that shape the agency of providers and the nature of care delivery. Ensuring RMC, therefore, requires a broader approach which addresses not just the safety of women, and the training and skill needs of midwives (both of which are common in the current literature) but also prioritises the creation of an enabling environment in terms of midwives’ professional recognition, interprofessional collaboration, resources, and leadership.
Recommendations for future policy, practice, and research:
The midwife-woman relationship has been the locus of interest in this study with regards to RMC. Strategies are, therefore, required to mitigate the challenges within this relationship. Development of a model of care that is context specific, recognises and acknowledges the realities of care yet inculcates the tenets of woman-centred care is required. This will facilitate the translation of the idealised value and relationship-based woman-centred approach to RMC into practice. The initial approach/interaction within the midwife-woman relationship when a woman reported to the facility in labour emerged as highly significant in this study. Hence, there is the need for further research to establish approaches that will enhance this initial encounter. Policies and guidelines which are woman-centred, context specific, and culturally sensitive and integrate both the views of women and midwives through robust research must be developed. A study that targets the wider health system stakeholders is also needed to gain an in-depth understanding of how the dynamics of power, management of risks, and the distribution of resources are contributing to creating the culture within the health care system and how care is provided. Further research into Interprofessionalism and shared decision-making in maternity care within the Ghanaian context will be necessary to test best practice approaches to determine models for practice that will promote interprofessional collaboration and teamwork.
Item Type
ethesis
Thesis Type
PhD
Supervisors
Subjects (LC)
Associated Schools / Departments
School of Health Sciences
eprints ID
69787
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