Skip to main content

Main menu

  • Content
    • Current Issue
    • Advance Access
    • Archive
    • Supplements
      • The Challenge Initiative Platform
      • Call for Abstracts
      • The Responsive Feedback Approach
    • Topic Collections
  • For Authors
    • Instructions for Authors
    • Submit Manuscript
    • Publish a Supplement
    • Promote Your Article
    • Resources for Writing Journal Articles
  • About
    • About GHSP
    • Editorial Team
    • Advisory Board
    • FAQs
    • Instructions for Reviewers
  • Webinars
    • Local Voices Webinar
    • Connecting Creators and Users of Knowledge
    • Publishing About Programs in GHSP
  • Other Useful Sites
    • GH eLearning
    • GHJournal Search

User menu

  • My Alerts

Search

  • Advanced search
Global Health: Science and Practice
  • Other Useful Sites
    • GH eLearning
    • GHJournal Search
  • My Alerts

Global Health: Science and Practice

Dedicated to what works in global health programs

Advanced Search

  • Content
    • Current Issue
    • Advance Access
    • Archive
    • Supplements
    • Topic Collections
  • For Authors
    • Instructions for Authors
    • Submit Manuscript
    • Publish a Supplement
    • Promote Your Article
    • Resources for Writing Journal Articles
  • About
    • About GHSP
    • Editorial Team
    • Advisory Board
    • FAQs
    • Instructions for Reviewers
  • Webinars
    • Local Voices Webinar
    • Connecting Creators and Users of Knowledge
    • Publishing About Programs in GHSP
  • Alerts
  • Visit GHSP on Facebook
  • Follow GHSP on Twitter
  • RSS
  • Find GHSP on LinkedIn
Original Article
Open Access

Applying the COM-B Model to Understand the Drivers of Mistreatment During Childbirth: A Qualitative Enquiry Among Maternity Care Staff

Muhammad Asim, Waqas Hameed, Bushra Khan, Sarah Saleem and Bilal Iqbal Avan
Global Health: Science and Practice February 2023, 11(1):e2200267; https://doi.org/10.9745/GHSP-D-22-00267
Muhammad Asim
aDepartment of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Waqas Hameed
aDepartment of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Bushra Khan
bDepartment of Psychology, University of Karachi, Karachi, Pakistan.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Sarah Saleem
aDepartment of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Bilal Iqbal Avan
cDepartment of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: bilal.avan@lshtm.ac.uk
PreviousNext
  • Article
  • Figures & Tables
  • Supplements
  • Info & Metrics
  • Comments
  • PDF
Loading

Key Findings

  • One of the major drivers of mistreatment during childbirth includes the lack of staff training on interpersonal skills and psychosocial support, which resulted in providers lacking the understanding that patients’ rights also include equity, respect, and satisfaction—and not only the right to high-quality clinical care.

  • Providers restricted the presence of birth companions, particularly males, based on providers’ own cultural preferences and comfort, thus denying women a source of support during childbirth.

  • Provider’s physical and verbal abuse, neglect, and abandonment of patients, particularly of those from lower castes and minority ethnic groups, in response to patients’ lack of cooperation and compliance was common and justified. Stronger performance monitoring systems and patient feedback mechanisms would help hold staff accountable for mistreatment and contribute to improving respectful maternity care.

Key Implications

  • These findings call for a comprehensive intervention that enhances staff members’ knowledge of and positive attitude toward respectful and rights-based maternity care.

  • At the health facility level, interventions are needed to strengthen governance, performance monitoring and supervision, accountability mechanisms, and integration of feedback to continually improve maternity care and services.

ABSTRACT

Introduction:

Respectful maternity care (RMC) during childbirth is an integral component of quality of care. However, women’s experiences of mistreatment are prevalent in many low- and middle-income countries. This is a complex phenomenon that has not been well explored from a behavioral science perspective. We aimed to understand the behavioral drivers of mistreatment during childbirth among maternity care staff at public health facilities in the Sindh province of Pakistan.

Methods:

Applying the COM-B (capability–opportunity–motivation that leads to behavior change) model, we conducted semistructured in-depth interviews among clinical and nonclinical staff in public health facilities in Thatta and Sujawal, Sindh, Pakistan. Data were analyzed using thematic deductive analysis, and findings were synthesized using the COM-B model.

Results:

We identified several behavioral drivers of mistreatment during childbirth: (1) institutional guidelines on RMC and training opportunities were absent, resulting in a lack of providers’ knowledge and skills; (2) facilities lacked the infrastructure to maintain patient privacy and confidentiality and did not permit males as birth companions; (3) lack of provider performance monitoring system and patient feedback mechanism contributed to providers not feeling appreciated or recognized. Staff bias against patients from lower castes contributed to patient abuse and mistreatment. The perspectives of clinical and nonclinical staff overlapped regarding potential drivers of mistreatment during childbirth.

Conclusions:

Addressing mistreatment during childbirth requires improving the knowledge and capacity of maternity staff on RMC and psychosocial support to enhance their understanding of RMC. At the health facility level, governance and accountability mechanisms in routine supervision and monitoring of staff need to be improved. Patients’ feedback should be incorporated for continuous improvement in providing maternity care services that meet patients’ preferences and needs.

INTRODUCTION

Respectful maternity care (RMC) is rooted in a woman-centric approach based on the ethics of and respect for universal human rights. RMC prioritizes the needs of women and newborns during childbirth in every health system.1,2 The 7 universal rights of childbearing women are freedom from harm, consented care, privacy and confidentiality, dignified care, timely and high-quality care, equitable care, and autonomy.3

However, a plethora of literature has highlighted a global prevalence of mistreatment during childbirth, particularly in low- and middle-income countries.4–7 In a study in Pakistan, 97% of women reported experiencing at least 1 incident of disrespectful or abusive behavior during childbirth.8 Mistreatment during childbirth is likely to have a detrimental effect on the woman-provider interaction and lead to women’s poor childbirth and postpartum experiences.9,10 Short-term adverse consequences of mistreatment may include pain and suffering, a feeling of dehumanization, and fear of childbirth,11,12 while in the long term, a reinforcement of mistrust toward institutional birth may instill in women a preference for home-based births.1,13–15

Research has tended to focus on women’s experiences of mistreatment during childbirth. However, a growing body of evidence has focused on providers’ perspectives of mistreatment during childbirth and its underlying causes.16–21 Studies have also examined the health system perspective to identify systemic factors of mistreatment during childbirth.19,22–24 Such studies25 have identified several complex, multifaceted factors of mistreatment during childbirth, which can be classified broadly as: individual (prejudice, ensuring compliance for positive outcomes, and stress); sociocultural (normalization of mistreatment and power dynamics); and structural (workload and lack of accountability). It is worth noting that studies investigating reasons for patient mistreatment in general health care identified similar underlying behavioral drivers.26,27

Behaviors are acquired through interaction with the environment; our responses to environmental stimuli shape our actions.28 Studies have shown that a lack of health-system support for health care providers reduces their inclination to provide supportive care to patients.29–31 Hence, bringing the insights of behavioral science to bear on mistreatment during childbirth may reveal the psychological dimensions of providers’ behavior, such as perceived notions of what mistreatment is, an instinct to justify mistreatment, and how environmental (social and health system) stimuli influence actions.32 Identifying these and other precursors of behavioral manifestations could provide opportunities to design an innovative intervention to address mistreatment during childbirth. An intervention capable of understanding and addressing this complex public health issue requires a behavioral framework.33 Moreover, evidence suggests that theory-driven interventions are more likely to be able to change human behavior.34,35

Bringing the insights of behavioral science to bear on patient mistreatment during childbirth may reveal the psychological dimensions of providers’ behavior.

Since patient mistreatment is a behavioral act, likely driven by individual and environmental factors, it needs to be investigated through a behavioral lens. To the best of our knowledge, few studies have adequately explored this complex phenomenon using a behavioral science lens.21,36,37 Although RMC interventions implemented thus far have shown promising results, concerns remain about their sustainability within the health system.38 Efforts to understand the complexity of mistreatment during maternity care should be situated in a defined theoretical framework that can ultimately inform the development of effective interventions for sustainable impact.

The theories of behavior change can be categorized as process models, determinants frameworks, classical theories, implementation theories, and evaluation frameworks.39 Given the nature of our project to develop a comprehensive intervention package to promote RMC within public health facilities, we wanted to understand the behavioral drivers of mistreatment during childbirth among maternity care staff using the COM-B (capability–opportunity–motivation that leads to behavior change) model because it lends itself to understanding and/or explaining what influences implementation outcomes. According to the COM-B model, to perform a particular behavior, one must feel both psychologically and physically able to do it, have the social and physical opportunity to do it, and want or need to carry out that behavior more than other competing behaviors.40 The COM-B model has been widely used globally, particularly to understand the behavior of health care staff.41,42 Unlike other frameworks, COM-B is relatively simple, yet it allows researchers to distinctively and comprehensively capture the physical, psychological, and social factors that lead to behavioral outcomes43 of health care staff providing supportive care to women during childbirth.39,44,45

In this study, we aimed to understand the behavioral drivers of mistreatment during childbirth among maternity care staff at public health facilities in the Sindh province of Pakistan.

METHODS

Study Design and Setting

We used a qualitative descriptive exploratory research design22 to carry out this formative study using semistructured in-depth interviews. This study is part of a larger project that aims to develop and test the feasibility of a service-delivery intervention model to promote a culture of support and respect during childbirth in public health facilities.46 We conducted the study in all 6 secondary-level public health facilities that provided basic emergency obstetric and newborn care services in 2 districts adjacent to Aga Khan University Karachi: Thatta and Sujawal from Sindh province, Pakistan. These predominantly rural districts report the highest maternal and neonatal mortality due to poor socioeconomic conditions and health system factors. Women are engaged in the informal economy such as working in agriculture fields and in informal domestic labor. Moreover, these districts are categorized in the low human development index strata, where only 17% of women are literate.47 The population in both districts combined is about 1.7 million, and 90% of people live in rural areas. The inhabitants are largely Muslim (97%), and 60% of births take place in health facilities.48

Study Participants

A typical maternity team at a secondary-level hospital comprises an obstetrician/gynecologist, who is the in-charge of the department; 1 or more other doctors for each shift; and other clinical staff, including nurses, midwives, or lady health visitors (LHVs). Nonclinical staff include aayas (traditional birth attendants), sweepers, and ward boys (in district headquarters hospitals).

To get a broader perspective, we included 2 categories of participants to interview (N=38): clinical staff (n=23) (including obstetrician/gynecologists, midwives, LHVs, nurses, and technicians) and nonclinical staff (n=15) (aayas, security guards, cleaners, and janitorial staff). We included nonclinical staff because of their involvement in childbirth processes to support clinical staff.22 Health facility staff who were working in the maternity wards during the data collection were eligible to participate in the study. The research team conducted individual in-depth interviews to minimize the issue of courtesy bias and concerns regarding a breach of confidentiality by disclosing poor maternity practices.

After receiving permission from provincial and district health authorities and the in-charge of health facilities, the research team approached clinical and nonclinical staff from the obstetrics and gynecology section. The participants were selected purposively according to a predetermined quota from each health facility and cadre according to the designation of providers (Table 1).

View this table:
  • View inline
  • View popup
TABLE 1.

Participants Interviewed on Respectful Maternity Care in Sindh, Pakistan

Interview Guide Development

The semistructured interview guides were developed based on the COM-B model,41 the World Health Organization (WHO) framework of health system building blocks,49 and relevant literature.50 Owing to the distinct responsibilities and comprehension levels between clinical and nonclinical staff, we developed 2 separate semistructured interview guides (Supplement 1). The interview guides included questions on the health facility structure, quality assurance mechanisms, staff understanding of supportive and respectful care, the patient-provider relationship, and perceptions regarding disrespectful care. Moreover, the interview guides had some open-ended questions and scenarios related to disrespectful care during childbirth at health facilities. These open-ended questions and scenarios were developed based on relevant literature review.20,21,36,51–53 Moreover, we used 2 tools of participatory reflective practices—a timeline and a flow diagram54—to collect data on the staff’s daily routine as well as job challenges and mechanisms to address challenges for providing RMC (Supplement 2). The semistructured interview guides were pilot tested on clinical and nonclinical staff at different public health facilities.

Data Collection

From February 2020 to June 2020, data were collected, but collection was temporarily suspended from March to May 2020 due to the COVID pandemic and lockdown. A total of 38 semistructured in-depth interviews were conducted. All the interviews were conducted in person by 2 trained female sociologists who had prior qualitative research experience related to maternal and child health. The interviewers were trained on research objectives and qualitative data collection before field activities. Thirty-four interviews were conducted in health facilities and 4 interviews were conducted at participants’ homes at their request. Interviews were conducted in a separate room where only the research team and interviewee were present. The interviews were conducted in the local Sindhi language and were audio-recorded after participants gave their written consent. After each interview, the research team debriefed to reflect on the participant’s responses. On average, each interview lasted approximately 45–60 minutes. The data collection concluded when the research team collected no new information. The research team discussed the data saturation point during the analysis of interview notes of 38 interviews. When the researchers did not find new information and themes from the data, the researchers decided to conclude the further data collection.

Data Analysis

All the recorded interviews were transcribed directly into English language by linguists who had command of Sindhi and English languages and had experience translating health-related interview transcriptions. To ensure data quality, 2 authors reviewed (WH, MA) all transcripts using both written notes and audio recordings. A deductive content analysis approach55 was used based on the COM-B model. After several deliberations within the research team, the model was contextually adapted in accordance with the issue of RMC. We first outlined the operational definitions of the broader framework components (capability, motivation, and opportunity) and their subcategorization (Figure). Thereafter, we reviewed the transcriptions and made minor adjustments to the definitions where necessary. The data analysis process included an intensive review of all transcripts by 2 authors (MA, WH). Moreover, field notes were also reviewed for in-depth understanding and contextualization of the participant’s quotes. The data were sorted and analyzed through NVivo version 11.0 software. Two authors (MA, WH) generated an exhaustive list of relevant codes of corresponding themes and subthemes by using a COM-B model. These themes were used to develop a theoretical matrix that all authors reviewed and from which subthemes emerged. The authors (MA, WH, BK, BIA) discussed the interpretation of themes and subthemes before reaching a consensus. Similar codes or recurring participant statements were omitted during article preparation.

FIGURE
  • Download figure
  • Open in new tab
  • Download powerpoint
FIGURE

Adaptation of the COM-B Model in the Context of Mistreatment During Childbirth and Emerging Subthemes

Abbreviation: COM-B, capability-motivation-opportunity that leads to behavior change.

Ethical Approval

The Aga Khan University Ethics Review Committee (Reference ID: 2019-1683-5607) and the London School of Hygiene and Tropical Medicine Institutional Review Board (Reference ID: 17928) provided ethical clearance for this study.

RESULTS

Nearly all the participants (95%) were female. Participants’ mean age was 39 (standard deviation ±7.3) years. Almost two-thirds of the participants (61%) were clinical staff. Most of the staff worked morning or evening shifts (Table 2).

View this table:
  • View inline
  • View popup
TABLE 2.

Characteristics of Study Participants

We categorize our findings into the 3 COM-B components: capability, opportunity, and motivation.

Capability

Capability refers to both the physical capability, which includes providers’ skills and capacity to provide RMC, and the psychological capability, which includes providers’ knowledge, understanding, and decision-making processes to provide RMC.

Physical Capability

We defined psychosocial support as staff providing psychological and social resources to the pregnant woman to help her overcome the physical, mental, and emotional challenges she may face during labor and childbirth. Not all the clinical staff knew about the importance of providing psychosocial support during childbirth. When asked about providing psychosocial support to patients, some clinical staff equated this to speaking politely with patients.

We speak softly with patients and try to provide optimal care during the stay of patient at the facility. —Nurse, Thatta

When asked about providing psychosocial support to patients, some clinical staff equated this to speaking politely with patients.

The clinical staff reported that nonclinical staff usually misbehave with patients and that they need orientation on interpersonal communication skills.

Lower staff doesn’t even have a common sense to talk with the patients. They misbehave and scold the patients all the time … They even degrade the patients by pointing out that you smell so bad and sit outside because you are bleeding. They should not treat patients in this way. —LHV, Thatta

However, when we interviewed the nonclinical staff, they leveled accusations that clinical staff misbehaved with patients. It is evident that the entire staff misbehaved with patients, and no one took responsibility for their disrespectful behavior.

We also found that almost all participants reported that they did not receive specific trainings on interpersonal behavior and RMC. A few clinical staff reported that they attended trainings that focused on clinical care, patient safety, and family planning. Because more focus is given to providing standard clinical practices for improved health outcomes, trainings related to providing supportive care and psychosocial support are largely not offered at childbirth health facilities.

Refresher courses related to clinical care are conducted occasionally at our health facilities. However, training on behavioral change is never provided since I joined public service. There is no mechanism on providing supportive care during childbirth in our health facilities. However, all service providers have their own ways of doing things. —Nurse, Sajwal

Some nonclinical staff mentioned that they never received specific training to improve their interpersonal and supportive care skills.

Ever since I am in service, I never had any training. I have requested many times to my seniors so that if we are lacking in anything, it can be improved by training. Our seniors, doctors, and nurses have trained us from starting to prepare trolley and how to clean instruments. We never had training on supportive care and how to behave with maternity patients. —Aaya, Thatta

In contrast, a clinical staff member with more than 10 years’ experience reported that they do not need any training related to supportive care because they are qualified physicians and do not need any further training on supportive care of patients.

Guidelines, manuals, and training are for unqualified [quacks] health care providers. I am a qualified physician, and I am very clear in my work… I know what to do during the job. Consultants don’t need the trainings for such purposes. —In-charge, Thatta

Psychological Capability

The lack of understanding of patients’ rights, respect, and support was the major factor in mistreatment during childbirth. Clinical staff reported that they consider patients’ rights to be providing high-quality care, including having available doctors at health facilities, performing proper examinations, and having adequate stock of drugs and other clinical supplies. However, providers’ respectful behavior toward patients, equity, privacy, politeness, and patient satisfaction were not considered core components of patients’ rights.

The medicine which we receive should reach to the patients… that are the patients’ rights. —Midwife, Thatta

Clinical staff considered patients’ rights to be having available doctors at health facilities, performing proper examinations, and having adequate stock of drugs and other clinical supplies.

However, a consultant shared a similar viewpoint that the availability of doctors for timely care at health facilities is the primary right of patients.

The most important thing is the availability of doctors at health facilities. Patients come to hospitals to seek treatment from physicians and usually physicians do not attend and see the patients in many public hospitals. That’s the main thing for patient right if physician attend the patients at health facilities. —In-charge, Thatta

We found that clinical staff define respect as speaking courteously and showing respectful behavior to patients. However, most clinical staff members expected respect to be reciprocated between staff and patients.

Respect is necessary and a bilateral phenomenon between provider and patient. As care providers, we should respect patients and they [patients] should respect us to get back more respect. —Nurse, Thatta

Clinical staff considered patients’ rights to include taking care of them and fulfilling their material needs with integrity. Moreover, they viewed patient support as providing clinical information to motivate and guide patients.

In meeting patients’ differential needs, most clinical staff reported that they understood patients’ needs and provided support based on their past experiences. Furthermore, they explained psychosocial support in terms of providing medicine or giving money to those who cannot afford care.

Participants reported that physically and mentally disabled women usually delivered their babies at home. However, a few providers shared that they were equipped to fully support disabled women during pregnancy.

Most of disabled women deliver babies at home. However, some dumb and deaf patients come for delivery in our hospital. In such situation, we invite their attendants in the labor room. Because we can’t understand their ambiguous language and gestures. —In-charge, Thatta

Some patients have problem with their hands or legs, and they need help during delivery and childbirth. We ask their attendant to come and hold their legs and give them support. —Nurse, Thatta

Opportunity

Opportunity refers to external factors that influence mistreatment during childbirth. These could include physical opportunities, such as lack of resources and infrastructure, and social opportunities, such as unclear social norms, pressures, and lack of peer relationships that cause mistreatment during childbirth.

Physical Opportunity

The absence of mechanisms to maintain privacy and confidentiality because of a lack of physical infrastructure and essential equipment was a major concern at health facilities.

We have 1 labor room that has 10 beds without separators. Moreover, we have 1 operation room with 3 beds and all surgeries are being conducted without separators. —Aaya, Thatta

Moreover, a shortage of beds in the labor room was also common. An LHV raised her concern about the lack of physical infrastructure to provide quality care.

We have 1 labor room with 3 beds. We manage almost 100 deliveries every month and sometimes it is difficult to allocate beds to the patients. —LHV, Thatta

Both clinical and nonclinical staff highlighted that guidelines related to RMC were not available at health facilities. Some facilities had educational posters mounted on the walls that explained standard procedures for clinical care; however, guidelines related to RMC were missing.

We have posters about eclampsia, postpartum hemorrhage, and COVID-19 in wards and operation theaters. The main thing is to protect ourselves from infection. During surgery, I repeat the procedure to mentor juniors and tell them standard procedure to control the infection. —Nurse, Thatta

Staff mentioned that guidelines related to RMC were not available at health facilities.

Moreover, clinical staff mentioned that the limited supply of drugs in the health facility is a major barrier to providing care to all patients.

We have limited supply of drugs and patients who came to our facility demand medical supply from us. Most of drugs get out of stock immediately and we cannot give drugs to patients to satisfy them. —LHV, Thatta

Social Opportunity

A birth companion is a trustworthy person (e.g., her husband, family member, or friend) who provides support to women during labor and childbirth. Participants reported that they perceived the birth companion’s role was to support women in tasks, such as preparing admission/discharge documents, accompanying them for medical tests (e.g., ultrasound), and getting prescription medicines if they were not available in the hospital. Both clinical and nonclinical staff highlighted that managing birth companions was a major challenge because they cause a lot of problems and delays in providing care to patients. However, clinical staff have a duty to be respectful of the supportive and companion care. Clinical staff pointed out that companions sometimes become aggressive and commit violence at the facility.

[Companions] do physical violence with our staff. Once a female patient was expired in the morning, her family members broke the glasses of windows of labor ward. They hit the duty doctor. They also verbally abuse us if they do not get medical supplies. [Companions] also make videos of empty counter and saying that nobody is available at labor ward to harass us. —Nurse, Thatta

Clinical staff reported that patients sometimes arrive with several companions, which poses another challenge to accommodate and manage these companions at the facilities.

A maternity patient comes at health facility with whole family including elders and children. This is a custom in our society. However, when we need a donor, then nobody donate blood. —LHV, Thatta

When asked about engaging birth companions, participants reported that only female companions were allowed to accompany women during labor and, depending on the situation, some women were allowed to have companions in the delivery room. Male companions were not allowed in the maternity ward nor in the labor room because of the privacy needs of other patients who were in the same labor room. In fact, clinical staff reported they felt uncomfortable when male companions were present while women were undressed at the time of delivery.

In my opinion every woman has a certain level of privacy that can’t be comprised. Even their husbands should not see them in that state [naked]. Moreover, I [CMW] and my support staff are also present there [delivery room] … They [male companions] are their husbands not ours… Woman is nude in front of their husband and we [female staff] are also standing there. I will not allow such unethical practices at my health facility. —Midwife, Thatta

The presence of a male companion at the time of delivery was not a norm at health facilities.

Delivery can be done without the presence of husbands. If there is any separate setup, then her husband cab shows up there. In my opinion, it is important for husband to leave the place during delivery in order to perform duty by the care providers. However, husband or male member can present during the labor. —In-charge, Thatta

The other major social issue was staff working relationships and team coordination. Participants noted that although the working relationship between colleagues and supervisors was good, there was a lack of coordination and mutual respect between nonclinical and clinical staff. Nonclinical staff expressed concerns about clinical staff’s rude behavior, particularly of senior doctors, while they cannot manage the companions at health facilities.

My duty is to manage people in [the outpatient department] so that doctors and nurses can see patients and perform their work easily. If maternity patients and attendants do not listen to us, then physician insult and abuse us…. This is not right to insult us in front of patients. —Aaya, Sujwal

Motivation

Motivation refers to the processes that influence or direct clinical staff’s decision-making behavior for RMC. Reflective motivation is the lack of provider understanding about capabilities, roles, and responsibilities that lead to mistreatment. Automatic motivation is the lack of rewards, incentives for respectful care, and lack of repercussions for mistreatment.

Reflective

Clinical staff reported that their colleague’s repeated rude behavior toward patients was accepted as their personality attribute.

There is a doctor in our shift that gets so angry on patients on their small actions. Her behavior remains rough while treating the patients at labor room. When she gets angry with patients, then we try to keep our attitude good, so the patient doesn’t get too nervous. —LHV, Sujwal

Participants reported that psychological and physical abuse was common during childbirth, particularly at secondary-level health facilities. Violence often occurred when patients did not follow instructions, patients did not cooperate, many people were at the facility, and supplies were not available. Moreover, clinical staff reported that patients only followed instructions when they dealt sternly with patients.

I have observed that if a woman has labor pain and the baby is about to out, but the push of woman is not efficient… and baby’s life may be critical. In such circumstances, staff members can shout and slap to save the life of baby. —In-charge, Thatta

Women who cry and do not cooperate… then we have no choice than to scold and beat them. We hold them [women] in the position so that they can deliver baby easily. Baby’s life must be saved in any case. Babies die in the womb of women who do not follow the instructions of providers. —Midwife, Thatta

Participants reported that providers neglected and abandoned patients who did not follow their instructions during delivery.

At the time of delivery, we counsel women and tell them how labor pain gets increase. We leave them for some time if they don’t follow our instructions. After some time, women understand that they have to deliver a baby and then we start treatment. —LHV, Thatta

Participants reported that providers neglected and abandoned patients who did not follow their instructions during delivery.

Moreover, nonclinical staff also reported that it was difficult to provide respectful care to some patients because of some patients’ physical appearance. However, clinical staff did not mention any discrimination based on patients’ physical appearance.

We pray that [retracted] caste people don’t come here. Doctor feels difficulty to give assistance to them because of bad smell from their body. They don’t come prepared for delivery. —Housekeeping staff, Sujwal

Automatic Opportunity

When the maternity teams discussed providing emotional (e.g., consoling distressed women) and instrumental support (e.g., giving money out-of-pocket), they mentioned that they did this because of the praise and prayers they received from women and their companions. This praise gave them emotional satisfaction, reenergized them, and gave them a sense of accomplishment.

Most participants knew that showing respectful care added to their reputation in the community because women shared their positive experiences with other women in the community and even mentioned maternity team members by name.

There was no patient feedback and complaint system in place at health facilities. Some clinical staff mentioned that they reported issues and complaints to senior doctors or health facility in-charges who took action and resolved the issue. There was no mechanism for patients to submit written feedback or suggestions regarding maternity care at health facilities.

The documentation of complaints and feedback from patient are unimaginable thing in our facilities… This system based on verbal communication. We resolve issues on the spot. No one knows about such existence of formal accountability system for complaints. —LHV, Sujwal

There is no proper monitoring system here. I am the only one who listens to all patients and staff. People come to me and bring up complains about the ward staff. For example, staff didn’t empty urine bag. Sweeper demands 50 rupees from the patients to empty the urine bag…. All these things disturb the patients. When they bring the complaints then I talk to the sweepers. If she didn’t understand, then I scold her. —Nurse, Thatta

Nonetheless, clinical staff felt that a patient complaint mechanism could help keep staff accountable for their behavior toward patients. Knowing that patients had an opportunity to make a formal complaint would ensure that staff would avoid any disrespectful or abusive behavior toward patients.

If we introduce a patient complaint system in health facility, it will make maternity staff more cautious about how they behavior with patients. They will have a fear that if they do something wrong with patients, they [patients] could go and lodge a complaint against them. —LHV, Thatta

Informal cash payment was common among nonclinical staff (aaya and janitorial staff) because of the lack of accountability at the health facility and staff’s lower salaries. Nonclinical staff asked for money at the delivery room from birth companions immediately after childbirth.

It is common to give cash to aaya and sweeper and they [attendants] give cash on their own will. Our staff does not ask for cash themselves. However, we sometime say that these staff workers are poor so give them some cash. —Midwife, Sajwal

Although health facility administrators visited health facilities to regularly monitor staff activities, they usually focused on the availability of medical supplies and medicine, staff attendance, and cleanliness of the health facility instead of staff behavior.

Mostly they [external monitors] come in the morning shift, such as district deputy commissioner and assistant commissioner. They put more focus on cleanliness, duty rosters, dress code of staff, and availability of medicines. —Aaya, Thatta

According to participants, a systematic mechanism to review staff performance did not exist at health facilities. Although a formal annual staff appraisal system existed, the process did not consider the clinical staff performance with respect to RMC. However, occasionally, senior staff conducted meetings to resolve issues. Most maternity team members were motivated to perform their job responsibilities, but they expressed the need for formal appreciation and recognition from administrative leadership for those who exceeded expectations at work.

Here, nobody will appreciate you; no matter how hard you work. They just want to work, work and work, and don’t ask anything… appreciation will certainly higher your morale so that you work harder. —Nurse, Thatta

Most maternity team members were motivated to perform their job responsibilities, but they expressed the need for formal appreciation and recognition from administrative leadership.

DISCUSSION

Our formative study used the COM-B framework to examine the behavioral drivers of mistreatment during childbirth at public health facilities in Pakistan. Supplement 2 presents a summary of key findings on the drivers of mistreatment during childbirth by both clinical and nonclinical staff. Our research adds to the findings of recent systematic reviews about health professionals’ understanding of mistreatment during childbirth. We systematically examined behavioral drivers of mistreatment during childbirth using an established theoretical framework and deliberated on their interconnectedness. More importantly, our study also provides additional insights concerning systemic issues that trigger mistreatment during childbirth.25

Capabilities of Maternity Care Staff and Mistreatment

Staff, particularly nonclinical staff, lacked knowledge about respect, rights, privacy, and equity with respect to patients. Patients’ rights were understood in terms of tangible items, such as the availability of drugs and supplies and the presence of a doctor at the health facility. Respect for patients was perceived as conditional and reciprocal—to be earned by the patient’s respectful attitude toward staff. This perceived notion of respect may be a precursor to the mistreatment of pregnant women. Many staff cited instances of mistreatment as a reaction to patients’ disobedience or abusive behavior.5,18 Both clinical and nonclinical staff confirmed that women were mistreated during childbirth at health facilities, but they blamed each other for the manifestations of such mistreatment.

Respect for patients was perceived as conditional and reciprocal—to be earned by the patient’s respectful attitude toward staff.

Psychological distress is commonplace during childbirth. Hence, WHO recommends providing emotional support during intrapartum care. Our study highlights a lack of realization among clinical staff of the importance of identifying and addressing the differential physical and mental health needs of maternity patients. Clinical staff focused primarily on clinical conditions and the clinical needs of patients to achieve improved birth outcomes, most likely because they never received training on systematically screening patients for differential needs and for psychosocial support during childbirth. Because of the high level of poverty observed among patients in the study districts, most clinical and nonclinical staff identified free medicine and financial help as constituting patients’ needs beyond physical health care. With improved knowledge and skills, clinical staff would be able to identify women’s emotional needs and determine the right psychosocial support to meet those needs, likely resulting in reduced distress and better birthing outcomes.56 There is a clear need for clinical and nonclinical staff to be trained on the integral domains of WHO’s framework for maternal and newborn care: dignity and respect, effective communication, and emotional support.57 Training maternity staff on behavioral change has shown improvements in their understanding of RMC.50

Opportunities in the Contexts of the Health Facility and System

We found that a range of systemic and broader social factors formed the foundations of mistreatment during childbirth. The presence of male companions was highly restricted at the time of delivery because of the cultural and religious values of both providers and patients in maintaining the privacy of (other) patients. Interestingly, female clinical staff voiced discomfort about their own privacy being compromised in the presence of male companions at the time of childbirth. The husband’s role is widely recognized as a source of general and emotional support to women during pregnancy and childbirth. However, different studies have pointed out that male involvement in childbirth is restricted because of facility-related constraints, an unwelcoming health system, and cultural inclinations.58–61 The engagement of companions during maternity care was further limited by negative perceptions of companions as an unnecessary interruption in care provision. Janitorial staff felt that companions were a burden on them as they created a mess on the wards that they needed to clean up. In such situations, they felt the need to assert their authority to ensure compliance with health facility rules, often resulting in mistreatment.62 Similar observations were made in studies conducted in African countries.7,18,32 However, female birth companions generally enjoyed cultural acceptance by both patients and staff and were widely permitted in health facilities.

Both clinical and nonclinical staff highlighted the unavailability of basic infrastructure, such as privacy screens/curtains in labor rooms. Various studies have pointed out that in the most resource-limited settings, many patients share labor rooms.63–65 In such environments, women experience exposure to other patients, male visitors, and staff who are not attending to them as undignified, inhumane, or shameful.7 Studies from South Asian and African countries also report that women experience compromised auditory and visual privacy, which resonates with our findings.7,65 Also, although health facilities had guidelines related to clinical procedures, they lacked guidelines or job aids related to RMC. This may explain clinical staff’s predominant concern with the technical aspects of clinical care to ensure good outcomes while neglecting the elements of RMC. Administration focused on material management, staff attendance, and facility cleanliness while giving relatively little attention to patient-provider behavioral interactions.

Clinical staff had clearly defined working relationships and coordination mechanisms in place. However, there was a gap and a degree of conflict in working relationships between clinical and nonclinical staff. This reflects the power dynamics of the existing hierarchy. A sense of inferiority, feeling of powerlessness, and lack of coordination among nonclinical staff might cause frustration and a tendency to assert what power they feel they have on the patient, which may result in mistreatment.52

Motivation and Mistreatment

Physical and verbal abuse were commonplace during childbirth, more so in cases of difficult deliveries and patients’ noncompliance with staff instructions. Clinical staff justified their abusive behavior and use of threats by claiming they acted in the interests of the mother and newborn to save their lives. In addition, clinical staff used neglect and abandonment as leverage to ensure patients’ compliance. Other qualitative5,11,18 and quantitative4 studies have found that mistreatment and abuse are commonplace during childbirth in low- and middle-income countries. The acceptance of and lack of willingness to discuss such actions are indicative of both the normalization of this behavior11,66 and a lack of any process to monitor it.53

Clinical staff justified their abusive behavior and use of threats by claiming they acted in the interests of the mother and newborn to save their lives.

Staff, particularly nonclinical staff, harbored ethnic, tribal, and caste-based prejudices resulting in patient abuse. Such behavior decreases patients’ trust in both health care providers and the health system.67 Studies from India and Pakistan reported that women who belonged to lower-caste and minority-ethnic groups were more likely to be mistreated.20 Providers’ negative attitudes and abusive behavior undermined the well-being of affected maternity patients and were a disincentive for women to seek health care.9 Patients commonly made informal cash payments to nonclinical staff to ensure the provision of certain facilities and services to patients, birth companions, and visitors. Cash payments, particularly after childbirth, are widely accepted and viewed as a gift or a stipend.68–70 Having rigorous monitoring, accountability, and patient feedback mechanisms are important strategies to improve RMC.71 The health facilities in this study had no formal mechanisms for patients to provide feedback about their care experiences, but patient feedback plays a pivotal role in improving the quality of health care.72

Strengths and Limitations

A major strength of our study was the use of a behavioral framework to holistically understand the drivers of mistreatment during childbirth in a health system context and to inform the development of interventions to address this issue. The inclusion of nonclinical staff was another strength of the research that enabled us to understand mistreatment during childbirth across various cadres of the maternity team.

Our study had a few limitations. First, we did not consider patients’ perspectives and experiences. Patients’ and community members’ voices need to be heard to fully recognize and address mistreatment during childbirth. A triangulation of our findings with women’s perspectives would have helped validate some claims that staff made about pregnant women and their companions. We have previously conducted studies on women’s experiences of childbirth in health facilities and reported our findings.20,36,73 Second, the sensitive nature of the topic may have introduced a bias of social desirability whereby providers might have felt reluctant to speak, resulting in the under-reporting of disrespectful and abusive behaviors prevalent at the health facility. Third, study participants were selected from secondary-level health facilities in 2 districts of Sindh. This may limit reflections on our findings to just secondary-level facilities because service delivery processes in primary- or tertiary-care settings differ.

CONCLUSIONS

We identified factors across 3 components of behavioral drivers. Limited training opportunities resulted in providers’ lack of knowledge regarding patients’ rights and limited skills to recognize their differential needs, which were major determinants of mistreatment during childbirth. Our findings point to the need for capacity building of maternity staff on respectful and rights-based maternity care to address mistreatment during childbirth. By clarifying essential values, these behavioral trainings should also focus on changing the mindset of providers on matters of prejudice and on the assumption that respect is a reciprocal phenomenon.

Inadequate infrastructure, unavailability of RMC guidelines compounded by social norms for birth, and lack of coordination among the maternity team were causes of mistreatment during childbirth. A further aggravating factor was the prohibition of a male birth companion because of health facility culture and local norms. To improve coordination between clinical and nonclinical staff, the organizational culture needs to be sufficiently generous and sensitive to mitigate the power dynamics of the maternity staff hierarchy.

Finally, the providers’ personality traits, mindsets that patients are difficult and uncooperative, normalization of mistreatment, and lack of accountability and governance mechanisms were identified as motivational drivers of mistreatment during childbirth. Therefore, at the health facility level, governance and accountability mechanisms need to be improved and include routine supervision and monitoring of staff and integration of patients’ feedback for ongoing improvement in making care more responsive to patients’ needs.

Acknowledgments

We would like to thank all the study participants for their time. We are grateful to our project staff: Faiza Ahmed and Safdar Ali for conducting the interviews. Thanks to Zahid Soomro and Ghani Muhammad for facilitating data collection and management.

Funding

This work was funded by the Medical Research Council, United Kingdom [Project Reference: MR/T003375/1].

Author contributions

BIA was the principal investigator and was involved with funding acquisition and supervision. BK, WH and BIA developed the methodology. WH was co-principal investigator. WH, BK, and BIA were involved with the conceptualization and investigation. WH and BK were involved with the data curation and project administration. MA and WH did the formal analysis. MA did the validation and wrote the original draft of the article. MA, WH, BK, SS, and BIA reviewed and edited the article.

Competing interests

None declared.

Notes

Peer Reviewed

First published online: January 23, 2023.

Cite this article as: Asim M, Hameed W, Khan B, Saleem S, Avan BI. Applying the COM-B model to understand the drivers of mistreatment during childbirth: a qualitative enquiry among maternity care staff. Glob Health Sci Pract. 2023;11(1):e2200267. https://doi.org/10.9745/GHSP-D-22-00267

  • Received: June 7, 2022.
  • Accepted: November 28, 2022.
  • Published: February 28, 2023.
  • © Asim et al.

This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-22-00267

REFERENCES

  1. 1.↵
    1. Bulto GA,
    2. Demissie DB,
    3. Tulu AS
    . Respectful maternity care during labor and childbirth and associated factors among women who gave birth at health institutions in the West Shewa zone, Oromia region, Central Ethiopia. BMC Pregnancy Childbirth. 2020;20(1):443. doi:10.1186/s12884-020-03135-z. pmid:32746788
    OpenUrlCrossRefPubMed
  2. 2.↵
    White Ribbon Alliance. Respectful Maternity Care: The Universal Rights of Childbearing Women. White Ribbon Alliance; 2011. Accessed December 5, 2022. https://cdn1.sph.harvard.edu/wp-content/uploads/sites/2413/2014/05/Final_RMC_Charter.pdf
  3. 3.↵
    World Health Organization (WHO). WHO Recommendations: Intrapartum Care for a Positive Childbirth Experience. WHO; 2018. Accessed December 5, 2022. https://www.who.int/publications/i/item/9789241550215
  4. 4.↵
    1. Bohren MA,
    2. Vogel JP,
    3. Hunter EC,
    4. et al
    . The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med. 2015;12(6):e1001847. doi:10.1371/journal.pmed.1001847. pmid:26126110
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. Bohren MA,
    2. Vogel JP,
    3. Tunçalp Ö,
    4. et al
    . “By slapping their laps, the patient will know that you truly care for her”: a qualitative study on social norms and acceptability of the mistreatment of women during childbirth in Abuja, Nigeria. SSM Popul Health. 2016;2:640–655. doi:10.1016/j.ssmph.2016.07.003. pmid:28345016
    OpenUrlCrossRefPubMed
  6. 6.
    1. Rosen HE,
    2. Lynam PF,
    3. Carr C,
    4. et al
    ; Quality of Maternal and Newborn Care Study Group of the Maternal and Child Health Integrated Program. Direct observation of respectful maternity care in five countries: a cross-sectional study of health facilities in East and Southern Africa. BMC Pregnancy Childbirth. 2015;15(1):306. doi:10.1186/s12884-015-0728-4. pmid:26596353
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. Bohren MA,
    2. Vogel JP,
    3. Tunçalp Ö,
    4. et al
    . Mistreatment of women during childbirth in Abuja, Nigeria: a qualitative study on perceptions and experiences of women and healthcare providers. Reprod Health. 2017;14(1):9. doi:10.1186/s12978-016-0265-2. pmid:28095911
    OpenUrlCrossRefPubMed
  8. 8.↵
    1. Hameed W,
    2. Avan BI
    . Women’s experiences of mistreatment during childbirth: a comparative view of home- and facility-based births in Pakistan. PLoS One. 2018;13(3):e0194601. doi:10.1371/journal.pone.0194601. pmid:29547632
    OpenUrlCrossRefPubMed
  9. 9.↵
    1. Mannava P,
    2. Durrant K,
    3. Fisher J,
    4. Chersich M,
    5. Luchters S
    . Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review. Global Health. 2015;11(1):36. doi:10.1186/s12992-015-0117-9. pmid:26276053
    OpenUrlCrossRefPubMed
  10. 10.↵
    1. Solnes Miltenburg A,
    2. Roggeveen Y,
    3. Shields L,
    4. et al
    . Impact of birth preparedness and complication readiness interventions on birth with a skilled attendant: a systematic review. PLoS One. 2015;10(11):e0143382. doi:10.1371/journal.pone.0143382. pmid:26599677
    OpenUrlCrossRefPubMed
  11. 11.↵
    1. Freedman LP,
    2. Kujawski SA,
    3. Mbuyita S,
    4. et al
    . Eye of the beholder? Observation versus self-report in the measurement of disrespect and abuse during facility-based childbirth. Reprod Health Matters. 2018;26(53):107–122. doi:10.1080/09688080.2018.1502024. pmid:30199353
    OpenUrlCrossRefPubMed
  12. 12.↵
    1. Stone R
    . Pregnant women and substance use: fear, stigma, and barriers to care. Health Justice. 2015;3(1):2. doi:10.1186/s40352-015-0015-5
    OpenUrlCrossRef
  13. 13.↵
    1. Gebremichael MW,
    2. Worku A,
    3. Medhanyie AA,
    4. Edin K,
    5. Berhane Y
    . Women suffer more from disrespectful and abusive care than from the labour pain itself: a qualitative study from women’s perspective. BMC Pregnancy Childbirth. 2018;18(1):392. doi:10.1186/s12884-018-2026-4. pmid:30286734
    OpenUrlCrossRefPubMed
  14. 14.
    1. Afshin A,
    2. Peñalvo JL,
    3. Del Gobbo L,
    4. et al
    . The prospective impact of food pricing on improving dietary consumption: a systematic review and meta-analysis. PLoS One. 2017;12(3):e0172277. doi:10.1371/journal.pone.0172277. pmid:28249003
    OpenUrlCrossRefPubMed
  15. 15.↵
    1. Mohammadi S,
    2. Carlbom A,
    3. Taheripanah R,
    4. Essén B
    . Experiences of inequitable care among Afghan mothers surviving near-miss morbidity in Tehran, Iran: a qualitative interview study. Int J Equity Health. 2017;16(1):121. doi:10.1186/s12939-017-0617-8. pmid:28687082
    OpenUrlCrossRefPubMed
  16. 16.↵
    1. Orpin J,
    2. Puthussery S,
    3. Davidson R,
    4. Burden B
    . Women’s experiences of disrespect and abuse in maternity care facilities in Benue State, Nigeria. BMC Pregnancy Childbirth. 2018;18(1):213. doi:10.1186/s12884-018-1847-5. pmid:29879944
    OpenUrlCrossRefPubMed
  17. 17.
    1. Orpin J,
    2. Puthussery S,
    3. Burden B
    . Healthcare providers’ perspectives of disrespect and abuse in maternity care facilities in Nigeria: a qualitative study. Int J Public Health. 2019;64(9):1291–1299. doi:10.1007/s00038-019-01306-0. pmid:31673736
    OpenUrlCrossRefPubMed
  18. 18.↵
    1. Afulani PA,
    2. Kelly AM,
    3. Buback L,
    4. Asunka J,
    5. Kirumbi L,
    6. Lyndon A
    . Providers’ perceptions of disrespect and abuse during childbirth: a mixed-methods study in Kenya. Health Policy Plan. 2020;35(5):577–586. doi:10.1093/heapol/czaa009. pmid:32154878
    OpenUrlCrossRefPubMed
  19. 19.↵
    1. Asefa A,
    2. Morgan A,
    3. Bohren MA,
    4. Kermode M
    . Lessons learned through respectful maternity care training and its implementation in Ethiopia: an interventional mixed methods study. Reprod Health. 2020;17(1):103. doi:10.1186/s12978-020-00953-4. pmid:32615999
    OpenUrlCrossRefPubMed
  20. 20.↵
    1. Hameed W,
    2. Avan BI
    . Women’s experiences of mistreatment during childbirth: a comparative view of home- and facility-based births in Pakistan. PLoS One. 2018;13(3):e0194601. doi:10.1371/journal.pone.0194601. pmid:29547632
    OpenUrlCrossRefPubMed
  21. 21.↵
    1. Azhar Z,
    2. Oyebode O,
    3. Masud H
    . Disrespect and abuse during childbirth in district Gujrat, Pakistan: a quest for respectful maternity care. PLoS One. 2018;13(7):e0200318. doi:10.1371/journal.pone.0200318. pmid:29995939
    OpenUrlCrossRefPubMed
  22. 22.↵
    1. Sharma G,
    2. Mathai M,
    3. Dickson KE,
    4. et al
    . Quality care during labour and birth: a multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy Childbirth. 2015;15(Suppl 2):S2. doi:10.1186/1471-2393-15-S2-S2. pmid:26390886
    OpenUrlCrossRefPubMed
  23. 23.
    1. Dickson KE,
    2. Kinney MV,
    3. Moxon SG,
    4. et al
    . Scaling up quality care for mothers and newborns around the time of birth: an overview of methods and analyses of intervention-specific bottlenecks and solutions. BMC Pregnancy Childbirth. 2015;15(Suppl 2):S1. doi:10.1186/1471-2393-15-S2-S1. pmid:26390820
    OpenUrlCrossRefPubMed
  24. 24.↵
    1. Hameed W,
    2. Khan B,
    3. Siddiqi S,
    4. Asim M,
    5. Avan BI
    . Health system bottlenecks hindering provision of supportive and dignified maternity care in public health facilities. PLOS Global Public Health. 2022;2(7):e0000550. doi:10.1371/journal.pgph.0000550
    OpenUrlCrossRef
  25. 25.↵
    1. Agyenim-Boateng A,
    2. Cameron H,
    3. Bemah Boamah Mensah A
    . Health professionals’ perception of disrespectful and abusive intrapartum care during facility-based childbirth in LMIC: a qualitative systematic review and thematic synthesis. Int J Africa Nurs Sci. 2021;15:100326. doi:10.1016/j.ijans.2021.100326
    OpenUrlCrossRef
  26. 26.↵
    1. Albina JK
    . Patient abuse in the health care setting: the nurse as patient advocate. AORN J. 2016;103(1):74–80. doi:10.1016/j.aorn.2015.10.021. pmid:26746029
    OpenUrlCrossRefPubMed
  27. 27.↵
    1. Baillie L
    . Patient dignity in an acute hospital setting: a case study. Int J Nurs Stud. 2009;46(1):23–37. doi:10.1016/j.ijnurstu.2008.08.003. pmid:18790477
    OpenUrlCrossRefPubMed
  28. 28.↵
    1. Krapfl JE
    . Behaviorism and society. Behav Anal. 2016;39(1):123–129. doi:10.1007/s40614-016-0063-8. pmid:27606191
    OpenUrlCrossRefPubMed
  29. 29.↵
    1. Layne DM,
    2. Nemeth LS,
    3. Mueller M,
    4. Martin M
    . Negative behaviors among healthcare professionals: relationship with patient safety culture. Healthcare (Basel). 2019;7(1):23. doi:10.3390/healthcare7010023. pmid:30717313
    OpenUrlCrossRefPubMed
  30. 30.
    1. Razu SR,
    2. Yasmin T,
    3. Arif TB,
    4. et al
    . Challenges faced by healthcare professionals during the COVID-19 pandemic: a qualitative inquiry from Bangladesh. Front Public Health. 2021;9:647315. doi:10.3389/fpubh.2021.647315. pmid:34447734
    OpenUrlCrossRefPubMed
  31. 31.↵
    1. Mosadeghrad AM
    . Factors influencing healthcare service quality. Int J Health Policy Manag. 2014;3(2):77–89. pmid:25114946
    OpenUrlPubMed
  32. 32.↵
    1. Smith J,
    2. Banay R,
    3. Zimmerman E,
    4. Caetano V,
    5. Musheke M,
    6. Kamanga A
    . Barriers to provision of respectful maternity care in Zambia: results from a qualitative study through the lens of behavioral science. BMC Pregnancy Childbirth. 2020;20(1):26. doi:10.1186/s12884-019-2579-x. pmid:31918682
    OpenUrlCrossRefPubMed
  33. 33.↵
    1. Pandor A,
    2. Gomersall T,
    3. Stevens JW,
    4. et al
    . Remote monitoring after recent hospital discharge in patients with heart failure: a systematic review and network meta-analysis. Heart. 2013;99(23):1717–1726. doi:10.1136/heartjnl-2013-303811. pmid:23680885
    OpenUrlAbstract/FREE Full Text
  34. 34.↵
    1. Magidson JF,
    2. Roberts BW,
    3. Collado-Rodriguez A,
    4. Lejuez CW
    . Theory-driven intervention for changing personality: expectancy value theory, behavioral activation, and conscientiousness. Dev Psychol. 2014;50(5):1442–1450. doi:10.1037/a0030583. pmid:23106844
    OpenUrlCrossRefPubMed
  35. 35.↵
    1. Walshe K
    . Understanding what works—and why—in quality improvement: the need for theory-driven evaluation. Int J Qual Health Care. 2007;19(2):57–59. doi:10.1093/intqhc/mzm004. pmid:17337518
    OpenUrlCrossRefPubMed
  36. 36.↵
    1. Hameed W,
    2. Uddin M,
    3. Avan BI
    . Are underprivileged and less empowered women deprived of respectful maternity care: inequities in childbirth experiences in public health facilities in Pakistan. PLoS One. 2021;16(4):e0249874. doi:10.1371/journal.pone.0249874. pmid:33858009
    OpenUrlCrossRefPubMed
  37. 37.↵
    1. Bhutta ZA,
    2. Hafeez A,
    3. Rizvi A,
    4. et al
    . Reproductive, maternal, newborn, and child health in Pakistan: challenges and opportunities. Lancet. 2013;381(9884):2207–2218. doi:10.1016/S0140-6736(12)61999-0. pmid:23684261
    OpenUrlCrossRefPubMed
  38. 38.↵
    1. Downe S,
    2. Lawrie TA,
    3. Finlayson K,
    4. Oladapo OT
    . Effectiveness of respectful care policies for women using routine intrapartum services: a systematic review. Reprod Health. 2018;15(1):23. doi:10.1186/s12978-018-0466-y. pmid:29409519
    OpenUrlCrossRefPubMed
  39. 39.↵
    1. Nilsen P
    . Making Sense of Implementation Theories, Models, and Frameworks: Implementation Science. Springer; 2015.
  40. 40.↵
    Social Change UK. A Guide on the COM-B Model of Behaviour. Social Change UK; 2019. Accessed December 5, 2022. https://social-change.co.uk/files/02.09.19_COM-B_and_changing_behaviour_.pdf
  41. 41.↵
    1. Jatau AI,
    2. Peterson GM,
    3. Bereznicki L,
    4. et al
    . Applying the capability, opportunity, and motivation behaviour model (COM-B) to guide the development of interventions to improve early detection of atrial fibrillation. Clin Med Insights Cardiol. 2019;13. doi:10.1177/1179546819885134. pmid:31700252
    OpenUrlCrossRefPubMed
  42. 42.↵
    1. McDonagh LK,
    2. Saunders JM,
    3. Cassell J,
    4. et al
    . Application of the COM-B model to barriers and facilitators to chlamydia testing in general practice for young people and primary care practitioners: a systematic review. Implement Sci. 2018;13(1):130. doi:10.1186/s13012-018-0821-y. pmid:30348165
    OpenUrlCrossRefPubMed
  43. 43.↵
    1. Michie S,
    2. van Stralen MM,
    3. West R
    . The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(1):42. doi:10.1186/1748-5908-6-42. pmid:21513547
    OpenUrlCrossRefPubMed
  44. 44.↵
    1. Alexander KE,
    2. Brijnath B,
    3. Mazza D
    . Barriers and enablers to delivery of the Healthy Kids Check: an analysis informed by the Theoretical Domains Framework and COM-B model. Implement Sci. 2014;9(1):60. doi:10.1186/1748-5908-9-60. pmid:24886520
    OpenUrlCrossRefPubMed
  45. 45.↵
    1. McDonagh LK,
    2. Saunders JM,
    3. Cassell J,
    4. et al
    . Application of the COM-B model to barriers and facilitators to chlamydia testing in general practice for young people and primary care practitioners: a systematic review. Implement Sci. 2018;13(1):130. doi:10.1186/s13012-018-0821-y. pmid:30348165
    OpenUrlCrossRefPubMed
  46. 46.↵
    1. Avan BI,
    2. Hameed W,
    3. Khan B,
    4. Asim M,
    5. Saleem S,
    6. Siddiqi S
    . Supportive and Dignified Maternity Care (SDMC) - development and feasibility assessment of an intervention package for public health systems. UK Research and Innovation; 2021.
  47. 47.↵
    1. Najam A,
    2. Bari F
    . Pakistan National Human Development Report: Unleashing the Potential of a Young Pakistan. United Nations Development Programme, Pakistan; 2017. Accessed December 5, 2022. https://hdr.undp.org/system/files/documents//pk-nhdrpdf.pdf
  48. 48.↵
    Sindh Bureau of Statistics, UNICEF. Sindh Multiple Indicator Cluster Survey 2014, Final Report. Sindh Bureau of Statistics/UNICEF; 2015. Accessed December 5, 2022. https://mics-surveys-prod.s3.amazonaws.com/MICS5/South%20Asia/Pakistan%20%28Sindh%29/2014/Final/Pakistan%20%28Sindh%29%202014%20MICS_English.pdf
  49. 49.↵
    World Health Organization (WHO). Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and Their Measurement Strategies. WHO; 2010. Accessed December 5, 2022. https://apps.who.int/iris/handle/10665/258734
  50. 50.↵
    1. Abuya T,
    2. Ndwiga C,
    3. Ritter J,
    4. et al
    . The effect of a multi-component intervention on disrespect and abuse during childbirth in Kenya. BMC Pregnancy Childbirth. 2015;15(1):224. doi:10.1186/s12884-015-0645-6. pmid:26394616
    OpenUrlCrossRefPubMed
  51. 51.↵
    1. Solnes Miltenburg A,
    2. van Pelt S,
    3. Meguid T,
    4. Sundby J
    . Disrespect and abuse in maternity care: individual consequences of structural violence. Reprod Health Matters. 2018;26(53):88–106. doi:10.1080/09688080.2018.1502023. pmid:30132403
    OpenUrlCrossRefPubMed
  52. 52.↵
    1. Pant L,
    2. Khalid N,
    3. Sharma K,
    4. Srivastav N
    . Disrespectful maternity care: labor room violence in government health facilities in India. SocArXiv. Preprint. Posted online March 26, 2021. doi:10.31235/osf.io/8mbxz
    OpenUrlCrossRef
  53. 53.↵
    1. McMahon SA,
    2. George AS,
    3. Chebet JJ,
    4. Mosha IH,
    5. Mpembeni RNM,
    6. Winch PJ
    . Experiences of and responses to disrespectful maternity care and abuse during childbirth; a qualitative study with women and men in Morogoro Region, Tanzania. BMC Pregnancy Childbirth. 2014;14(1):268. doi:10.1186/1471-2393-14-268. pmid:25112432
    OpenUrlCrossRefPubMed
  54. 54.↵
    1. Narayanasamy N
    . Participatory Rural Appraisal: Principles, Methods and Application. SAGE Publications India; 2009.
  55. 55.↵
    1. Pandey J
    . Deductive approach to content analysis. In: Qualitative Techniques for Workplace Data Analysis. IGI Global; 2019:145–69.
  56. 56.↵
    1. Hodnett ED,
    2. Gates S,
    3. Hofmeyr GJ,
    4. Sakala C
    . Continuous support for women during childbirth. Cochrane Database Syst Rev. 2013;7:CD003766. doi:10.1002/14651858.CD003766.pub5. pmid:23857334
    OpenUrlCrossRefPubMed
  57. 57.↵
    World Health Organization (WHO). Prevention and Elimination of Disrespect and Abuse During Childbirth. WHO; 2014. Accessed December 5, 2022. https://apps.who.int/iris/bitstream/handle/10665/134588/WHO_RHR_14.23_eng.pdf
  58. 58.↵
    1. Firouzan V,
    2. Noroozi M,
    3. Farajzadegan Z,
    4. Mirghafourvand M
    . Barriers to men’s participation in perinatal care: a qualitative study in Iran. BMC Pregnancy Childbirth. 2019;19(1):45. doi:10.1186/s12884-019-2201-2. pmid:30691402
    OpenUrlCrossRefPubMed
  59. 59.
    1. Maluka SO,
    2. Peneza AK
    . Perceptions on male involvement in pregnancy and childbirth in Masasi District, Tanzania: a qualitative study. Reprod Health. 2018;15(1):68. doi:10.1186/s12978-018-0512-9. pmid:29678184
    OpenUrlCrossRefPubMed
  60. 60.
    1. Aborigo RA,
    2. Reidpath DD,
    3. Oduro AR,
    4. Allotey P
    . Male involvement in maternal health: perspectives of opinion leaders. BMC Pregnancy Childbirth. 2018;18(1):3. doi:10.1186/s12884-017-1641-9. pmid:29291711
    OpenUrlCrossRefPubMed
  61. 61.↵
    1. Lowe M
    . Social and cultural barriers to husbands’ involvement in maternal health in rural Gambia. Pan Afr Med J. 2017;27:255. doi:10.11604/pamj.2017.27.255.11378. pmid:29187924
    OpenUrlCrossRefPubMed
  62. 62.↵
    1. Khalil DD
    . Nurses’ attitude towards ‘difficult’ and ‘good’ patients in eight public hospitals. Int J Nurs Pract. 2009;15(5):437–443. doi:10.1111/j.1440-172X.2009.01771.x
    OpenUrlCrossRef
  63. 63.↵
    1. Mselle LT,
    2. Moland KM,
    3. Mvungi A,
    4. Evjen-Olsen B,
    5. Kohi TW
    . Why give birth in health facility? Users’ and providers’ accounts of poor quality of birth care in Tanzania. BMC Health Serv Res. 2013;13(1):174. doi:10.1186/1472-6963-13-174. pmid:23663299
    OpenUrlCrossRefPubMed
  64. 64.
    1. Housseine N,
    2. Punt MC,
    3. Mohamed AG,
    4. et al
    . Quality of intrapartum care: direct observations in a low-resource tertiary hospital. Reprod Health. 2020;17(1):36. doi:10.1186/s12978-020-0849-8. pmid:32171296
    OpenUrlCrossRefPubMed
  65. 65.↵
    1. Saxena M,
    2. Srivastava A,
    3. Dwivedi P,
    4. Bhattacharyya S
    . Is quality of care during childbirth consistent from admission to discharge? A qualitative study of delivery care in Uttar Pradesh, India. PLoS One. 2018;13(9):e0204607. doi:10.1371/journal.pone.0204607. pmid:30261044
    OpenUrlCrossRefPubMed
  66. 66.↵
    1. Freedman LP,
    2. Ramsey K,
    3. Abuya T,
    4. et al
    . Defining disrespect and abuse of women in childbirth: a research, policy and rights agenda. Bull World Health Organ. 2014;92(12):915–917. doi:10.2471/BLT.14.137869. pmid:25552776
    OpenUrlCrossRefPubMed
  67. 67.↵
    1. Hall WJ,
    2. Chapman MV,
    3. Lee KM,
    4. Merino YM,
    5. Thomas TW,
    6. Payne BK,
    7. et al
    . Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105(12):e60–e76. doi:10.2105/AJPH.2015.302903. pmid:26469668
    OpenUrlCrossRefPubMed
  68. 68.↵
    1. Tripathi N,
    2. John D,
    3. Chatterjee PK,
    4. Murthy S,
    5. Parganiha N,
    6. Brokar A
    . Informal payments for maternal and neonatal health services in public hospitals in central India. J Health Manag. 2020;22(3):490–505. doi:10.1177/0972063420908158
    OpenUrlCrossRef
  69. 69.
    1. Balabanova D,
    2. McKee M
    . Understanding informal payments for health care: the example of Bulgaria. Health Policy. 2002;62(3):243–273. doi:10.1016/S0168-8510(02)00035-0. pmid:12385850
    OpenUrlCrossRefPubMed
  70. 70.↵
    1. Asim M,
    2. Ahmed ZH,
    3. Hayward MD,
    4. Widen EM
    . Prelacteal feeding practices in Pakistan: a mixed-methods study. Int Breastfeed J. 2020;15(1):53. doi:10.1186/s13006-020-00295-8. pmid:32513203
    OpenUrlCrossRefPubMed
  71. 71.↵
    World Health Organization (WHO). Standards for Improving Quality of Maternal and Newborn Care in Health Facilities. WHO; 2016. Accessed December 5, 2022. https://www.who.int/publications/i/item/9789241511216
  72. 72.↵
    1. Weingart SN,
    2. Pagovich O,
    3. Sands DZ,
    4. et al
    . Patient-reported service quality on a medicine unit. Int J Qual Health Care. 2006;18(2):95–101. doi:10.1093/intqhc/mzi087. pmid:16282334
    OpenUrlCrossRefPubMed
  73. 73.↵
    1. Asim M,
    2. Karim S,
    3. Khwaja H,
    4. Hameed W,
    5. Saleem S
    . The unspoken grief of multiple stillbirths in rural Pakistan: an interpretative phenomenological study. BMC Womens Health. 2022;22(1):45. doi:10.1186/s12905-022-01622-3. pmid:35193576
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Global Health: Science and Practice: 11 (1)
Global Health: Science and Practice
Vol. 11, No. 1
February 28, 2023
  • Table of Contents
  • About the Cover
  • Index by Author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word about Global Health: Science and Practice.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Applying the COM-B Model to Understand the Drivers of Mistreatment During Childbirth: A Qualitative Enquiry Among Maternity Care Staff
(Your Name) has forwarded a page to you from Global Health: Science and Practice
(Your Name) thought you would like to see this page from the Global Health: Science and Practice web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Applying the COM-B Model to Understand the Drivers of Mistreatment During Childbirth: A Qualitative Enquiry Among Maternity Care Staff
Muhammad Asim, Waqas Hameed, Bushra Khan, Sarah Saleem, Bilal Iqbal Avan
Global Health: Science and Practice Feb 2023, 11 (1) e2200267; DOI: 10.9745/GHSP-D-22-00267

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Applying the COM-B Model to Understand the Drivers of Mistreatment During Childbirth: A Qualitative Enquiry Among Maternity Care Staff
Muhammad Asim, Waqas Hameed, Bushra Khan, Sarah Saleem, Bilal Iqbal Avan
Global Health: Science and Practice Feb 2023, 11 (1) e2200267; DOI: 10.9745/GHSP-D-22-00267
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Statistics from Altmetric.com

Jump to section

  • Article
    • ABSTRACT
    • INTRODUCTION
    • METHODS
    • RESULTS
    • DISCUSSION
    • CONCLUSIONS
    • Acknowledgments
    • Funding
    • Author contributions
    • Competing interests
    • Notes
    • REFERENCES
  • Figures & Tables
  • Supplements
  • Info & Metrics
  • Comments
  • PDF

Related Articles

  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • The First Differentiated TB Care Model From India: Delays and Predictors of Losses in the Care Cascade
  • Stakeholders’ Perspectives on the Financial Sustainability of the HIV Response in Nigeria: A Qualitative Study
  • Evaluation of a Depression Intervention in People With HIV and/or TB in Eswatini Primary Care Facilities: Implications for Southern Africa
Show more ORIGINAL ARTICLE

Similar Articles

Subjects

  • Cross-Cutting Topics
    • Health Workers
  • Health Topics
    • Maternal, Newborn, and Child Health
US AIDJohns Hopkins Center for Communication ProgramsUniversity of Alberta

Follow Us On

  • Twitter
  • Facebook
  • LinkedIn
  • RSS

Articles

  • Current Issue
  • Advance Access Articles
  • Past Issues
  • Topic Collections
  • Most Read Articles
  • Supplements

More Information

  • Submit a Paper
  • Instructions for Authors
  • Instructions for Reviewers
  • GH Journals Database

About

  • About GHSP
  • Advisory Board
  • FAQs
  • Privacy Policy
  • Contact Us

© 2023 Creative Commons Attribution 4.0 International License. ISSN: 2169-575X

Powered by HighWire