title: When the baby remains there for a long time, it is going to die so you have to hit her small for the baby to come out": justification of disrespectful and abusive care during childbirth among midwifery students in Ghana.
abstract: Despite global attention, high levels of maternal mortality continue to plague many low- and middle-income settings. One important way to improve the care of women in labour is to increase the proportion of women who deliver in a health facility. However, due to poor quality of care, including being disrespected and abused, women are reluctant to come to facilities for delivery care. The current study sought to examine disrespectful and abusive treatment towards labouring women from the perspective of midwifery students who were within months of graduation.
  
  Key Messages
  
  •Midwifery students in Ghana’s public midwifery schools report witnessing and participating in many forms of disrespect and abuse during deliveries as part of their education. While they are clear as to why respectful care is important and necessary, they are able to justify and explain reasons for disrespectful and abusive care. This poor treatment of labouring women was explicitly and tacitly supported by these students’ teachers and preceptors.
  
  
  •All study materials and methods were reviewed and approved by the Ghana Health Service Ethical Review Committee, the Kwame Nkrumah University of Science and Technology Committee on Publication and Human Ethics, and the University of Michigan Institutional Review Board.
  
  
  •This research was made possible through a grant from the African Studies Center, University of Michigan.
  
  
  For this study, we conducted focus groups with final year midwifery students at 15 public midwifery training colleges in all 10 of Ghana’s regions. Focus group discussions were recorded and transcribed. A multi-disciplinary team of researchers from the US and Ghana analysed the qualitative data.
  
  While students were able to talk at length as to why respectful care is important, they were also able to recount times when they both witnessed and participated in disrespectful and abusive treatment of labouring women. The themes which emerged from these data are: 1) rationalization of disrespectful and abusive care; 2) the culture of blame and; 3) no alternative to disrespect and abuse.
  
  Although midwifery students in Ghana’s public midwifery schools highlight the importance of providing high-quality, patient-centred respectful care, they also report many forms of disrespect and abuse during childbirth. Without better quality care, including making care more humane, the use of facility-based maternity services in Ghana is likely not to improve. This study provides an important starting point for educators, researchers, and policy makers to re-think how the next generation of healthcare providers needs to be prepared to provide high-quality, respectful care to women during labour and delivery in low-resource settings.
authors.affiliation: Global REACH, University of Michigan Medical School, MI, USA
authors.forename: Sarah D
authors.initials: SD
authors.lastname: Rominski
authors.affiliation: School of Nursing, University of Michigan, MI, USA.
authors.forename: Jody
authors.initials: J
authors.lastname: Lori
authors.affiliation: Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Nakua
authors.affiliation: Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
authors.forename: Veronica
authors.initials: V
authors.lastname: Dzomeku
authors.affiliation: Department of Learning Health Sciences, University of Michigan Medical School, MI, USA.
authors.forename: Cheryl A
authors.initials: CA
authors.lastname: Moyer
mesh_terms: D001291:Attitude of Health Personnel; D036861:Delivery, Obstetric / Q000523:psychology; D005260:Female; D017144:Focus Groups; D005869:Ghana; D006801:Humans; D008880:Midwifery / Q000193:education* / Q000379:methods*; D005791:Patient Care / Q000523:psychology / Q000592:standards*; D011247:Pregnancy; D013336:Students, Health Occupations; D011795:Surveys and Questionnaires; D014754:Violence / Q000706:statistics & numerical data*