Table 5 Gender analysis framework to understand how gender dynamics and power relations contribute to women’s experiences of mistreatment during childbirth (Additional file 1 for extended version). In Myanmar facilities, women are first admitted to the labor ward when they come for childbirth but not ready for birth. Women are moved to the waiting room when they are experiencing contractions and in the early stage of labor, and to a separate delivery room when they are in advanced labor. After birth, women are either moved to a separate postnatal room, or back to the labor ward (if no separate postnatal room)
From: A qualitative study on acceptability of the mistreatment of women during childbirth in Myanmar
Access to resources | Financial resources | – Facility-based childbirth care free-of-charge – Informal costs (gate attendants, lower-level health workers, food/gifts to providers to express gratitude for care – Indirect costs medicines, consumables and equipment |
Access to information | – Women with lower health literacy may not understand explanations/instructions from healthcare providers, leading to misunderstanding. – When women arrive for childbirth with no antenatal care, without early/regular antenatal care, or without medical records, there may be conflict with providers | |
Support from family companions | – Intermittent support from female family companions only in labor ward and only for essential tasks in waiting room. – Male companions allowed only in labor ward and only during visitor hours (up to 4 h per day) – No family companions allowed in delivery room | |
Human resources | – High patient-to-provider ratios limit interaction time between women and providers – Insufficient salaries for providers for long hours, overtime, and additional tasks (clerical work, management) – Insufficient number of lower-level hospital staff (cleaner, gate keeper), and not trained as a professional cadre | |
Health facility structure & conditions | – Multiple beds in the same room (labor ward, waiting room, delivery room, and postnatal rooms) with no curtains or partitions – Insufficient number of beds in the labor ward, and the waiting room to accommodate the patient load – Separate rooms for waiting room, delivery room, and postnatal ward; women move between rooms throughout labor and birth – Need for clean and reliable bathrooms, water supply, and electricity | |
Division of labor | Woman-level | – Women expected to attend antenatal care, arrive at the facility “on time” for the birth, for their personal hygiene (before examination, and understand and “obey” the rules of the health facility and the instructions from the providers |
Family-level | – Family companions expected to care for women (food, drinks, change of clothes, prayer, and encouragement), clean up after the birth, listen to explanations from providers, communicate this information to other family members, and obey the rules of the health facility | |
Provider-level | – Community-based midwives and public health staff expected to educate women before arrival at health facility – Providers expected to provide emotional support and clinical care, and effectively communicate with women and their families about care provided, how family companions can support, and any additional fees – Nurses expected to supervise cleaners and lower-level providers, control the flow of family companions to prevent crowdedness – Providers expected to work in unity according to the roles of their cadre; human resource constraints can make this challenging – Supervisors responsible for decision-making about care (as needed), continuous supply of medicine and equipment, managing workloads, and supervision of staff and trainees – Administrators expected to resolve inconveniences hindering work of providers, and smooth functioning of facility | |
System-level | – The Ministry of Health and Sports expected to provide a reliable supply of medicines, equipment, and health workforce | |
Social norms | Choice of birthplace | – Most women prefer home birth because of the convenience, lower cost, and easier arrangements – Some women prefer hospital birth because it is perceived as safe, responsive to complications, and positive view of doctors and medicine – Women may choose hospital birth if they have higher risk health conditions, or for their first birth but not subsequent births |
Mode of birth | – Some women prefer vaginal birth as it is considered normal and safe. – Some women prefer caesarean birth to avoid labor pain | |
Companionship | – Many women preferred female family companions, and preferred companionship continuously throughout labor and childbirth. | |
Acceptability of mistreatment | – Most women view mistreatment was unacceptable, as it made them feel sad, worried and scared. Some women believed that it is acceptable as a method of encouragement or protection, or if it was done for the woman’s sake. – Most providers believe that mistreatment was unacceptable, but some felt that it was acceptable if used for the sake of the women. – Women and providers suggest that mistreatment may happen when women do not follow the hospital rules or provider instructions. | |
Relationship with staff | – Relationships between women and the lower level staff were negative, but more positive with the doctors and nurses – Women and family companions may not understand the challenges faced by healthcare providers | |
Rules and decision-making | Factors influencing decision-making | – Most women reported that they decided where they would give birth; some influenced by family, providers during antenatal care, or by their health condition, financial situation or the distance to the hospital. |
Compliance & obedience | – Women attending antenatal care early/regularly treated with more respect as they are perceived to be prepared for the birth – Women who “comply” with the rules of the hospital and with the providers’ instructions may have better experiences – Nurses/low-level hospital staff responsible for enforcing rules (e.g. asking family companions to leave labor ward) and may become frustrated with repeatedly enforcing the same rules | |
Organization of services and care | – Formal cost of facility-based childbirth is free, but informal payments are sometimes needed; women who make these informal payments may have better experiences – Males allowed on the labor ward only during visitor hours; females allowed on labor ward and waiting room intermittently; no one allowed in delivery room – Women allowed to give birth in lithotomy position, as this is how providers are trained and delivery beds are designed – Women allowed to mobilize while in the labor ward and waiting room but not delivery room – Women allowed to eat and drink in the labor ward and waiting room but not delivery room. |