Status of institutional‐level respectful maternity care: Results from the national Ethiopia EmONC assessment

Abstract Objective To assess the availability of an institutional‐level respectful maternity care (RMC) index, its components, and associated factors. Methods A cross‐sectional study design was applied to a 2016 census of 3804 health facilities in Ethiopia. The availability of an institutional‐level RMC index was computed as the availability of all nine items identified as important aspects of institutional‐level RMC during childbirth. Logistic regression analysis was used to identify factors associated with availability of the index. Results Three components of the institutional‐level RMC index were identified: “RMC policy,” “RMC experience,” and “facility for provision of RMC.” Overall, 28% of facilities (hospitals, 29.9%; health centers, 27.8%) reported availability of the institutional‐level RMC index. Facility location urbanization (urban region), percentage of maternal and newborn health workers trained in basic emergency obstetric and newborn care, and availability of maternity waiting homes in health facilities were positively associated with availability of the institutional‐level RMC index. Conclusion Only one in three facilities reported availability of the institutional‐level RMC index. The Ethiopian government should consider strengthening support mechanisms in different administrative regions (urban, pastoralist, and agrarian), implementing the provision training for health workers that incorporates RMC components, and increasing the availability of maternity waiting homes.


| INTRODUC TI ON
Mistreatment of women in health facilities during labor and childbirth has been recognized as a global problem. 1,2 The causes of mistreatment during childbirth are complex, embedded within a sociocultural context and shaped by characteristics of health facilities and care providers. 3,4 The WHO categorizes mistreatment of women into seven domains: (a) physical abuse, (b) sexual abuse, (c) verbal abuse, (d) stigma and discrimination, (e) failure to meet professional standards of care, (f) poor rapport between women and providers, and (g) health system conditions and constraints. 1 Several research groups, using various measurement criteria, found that 21%-79% of women experience mistreatment during childbirth in Ethiopia. 5 None of the studies conducted in Ethiopia focused on health system conditions as a component of mistreatment; however, the role of institutional characteristics deserves special attention because it affects a healthcare provider's behavior and attitude to providing respectful care. 6 For example, an unfavorable health facility environment is likely to increase stress levels among healthcare providers, resulting in mistreatment of women during childbirth. 7 In 2016, the Ethiopian government launched its Health Sector Transformation Plan, which aims to improve maternal and newborn health outcomes by promoting compassionate and respectful care. 8 A key strategy to achieve this goal comprises health resource facilitation, such as the rollout of maternity waiting homes (MWHs), which provide accommodation for pregnant women in close proximity to the health facility. [8][9][10] MWHs are usually constructed with community participation and managed by the health facility. Another important approach encompasses the provision of countrywide emergency obstetric and newborn care (EmONC), which includes life-saving interventions for the main causes of maternal and neonatal morbidity and mortality. 11 Understanding contributors to institutional-level respectful maternity care (RMC) during childbirth will help to maximize the effectiveness of RMC interventions. It may also positively influence the utilization of maternity services. To our knowledge, potential components of institutional-level RMC have not been systematically assessed before. Therefore, the primary aim of the present study was to describe an institutional-level RMC index. Secondary aims were to (a) identify components of the institutional-level RMC index during childbirth, (b) assess levels of the institutional-level RMC index and components in hospitals and health centers in Ethiopia; and (c) determine institutional-level factors associated with the reported institutional-level RMC prerequisites.

| Study design
The present study used a subset of the 2016 EmONC assessment data that focus on health facility level policies, norms, and practices that affect provision of RMC. The EmONC assessment utilized a cross-sectional census of all health facilities in Ethiopia that provided childbirth services prior to the assessment. 12,13 The study protocol was reviewed and approved by the Scientific and Ethical Review board of the Ethiopian Public Health Institute. Each study participant gave informed oral consent prior to participation.

| Study setting
The study included all private and public health facilities (hospitals, health centers, maternal and child health [MCH] specialty centers, MCH specialty clinics, and higher clinics) across all nine regions and two city administrations in Ethiopia. All health facilities that had a mandate to provide childbirth services according to national accreditation agency criteria confirmed that births had taken place in the 12 months preceding the assessment and were functional during the data collection period.

| Data collection
The data collection tools were adapted to the Ethiopian context from the 2008 EmONC assessment tool and the 2014 Averting Maternal Death and Disability tools. The analyzed data were extracted from modules one and two ("facility identification" and "infrastructure and human resources"). 14

| Data quality
To ensure accurate data quality, pre-and post-tests were administered to data collectors to assess their learning and understanding of assessment guidelines and standards for data collection. Team leaders reviewed all completed questionnaires to ensure completeness.
Regional and national coordinators visited and communicated with data collection teams to provide support and help when difficulties arose at individual facilities. Data were analyzed using Stata version 14 (Stata Corp., College Station, TX, USA).

| Variables and data analysis
The "institutional-level RMC index" was defined as the health facility's availability of physical infrastructure, equipment, policies, and norms that together enable women to experience RMC during childbirth services. It includes a physical infrastructure that encourages privacy and confidentiality, availability of waiting area for companions, availability of bathrooms, and facility-related policies and norms to ensure a positive experience during labor and childbirth.
In the first step, 11 items (questions) measured in a binary (yes/ no) format were identified that highlight important aspects of institutional-level RMC during childbirth: "women can choose a companion of their choice," "women can choose birthing position," "women can walk around during labor," "availability of curtains for privacy," "availability of waiting areas for women and companions," "availability of functioning toilets for companions," "availability of food for women," "women have never shared beds before or after birth," "women have never slept on the floor," and "women have never given birth on the floor." Two items ("woman can walk around during labor" and "availability of food for women") were excluded from the principal component analysis due to low factor loadings (<0.35), although one item was retained owing to technical relevance even though it did not fulfill statistical criteria. The nine remaining items that measured specific aspects of institutional RMC during childbirth were grouped into components (Table 1). Three components were extracted by using scree plot criteria, 15 which are used to identify the number of factors to retain in a principal component analysis (see File S1 for communalities, total variance explained, and rotated component matrix). These components were labeled "policy," "facility," and "experience" (Figure 1).
The component "policy" was calculated from three items ("women can choose a companion of their choice," women can choose a birthing position," and "women can walk around during labor") and labeled as available when all three items were reported as yes. The component "facility" was calculated from three items ("availability of curtains for privacy," "availability of waiting areas for women and companions," and "availability of functioning toilets for visitors and family use") and considered as available when all three conditions were observed or reported as yes. The component "experience" was calculated from three items ("women have never shared beds before or after birth," "women have never slept on the floor," and "women have never given birth on the floor") and considered to be available when all three items were reported as yes by the maternity unit lead. The variable institutional-level RMC index was calculated as a composite score of all nine items. The institutional-level RMC index was considered to be available only if all nine items were available.
In the second step, multivariate logistic regression was used to identify factors associated with the availability of the institutional-level RMC index during childbirth, which was the outcome variable. Covariates identified from other studies included managing authority, administrative region type, ratio of births to maternity beds, ratio of childbirth to maternity healthcare workers, proportion of MCH providers trained in BEmONC, and availability of MWHs in health facilities. 3,7 The variable "ratio of births per year to maternity beds" indicated the level of crowding at the facility, whereas"the ratio of childbirth to maternity healthcare workers" was applied as a measure of the workload of providers. Continuous explanatory variables (number of childbirths to maternity beds, number of childbirths to maternity unit assigned health workers and proportion of MCH providers trained in BEmONC) were categorized into

| RE SULTS
Among 4385 private and public health facilities in Ethiopia, 11 were excluded from the assessment due to civil unrest in their catchment areas, 568 were excluded due to absence of service during the

| DISCUSS ION
In the present study, facilities in urban regions, facilities with a higher The finding that facilities with a higher proportion of MNH providers trained in BEmONC (quartiles 2-4) had higher availability of the institutional-level RMC index might be attributed to both the fact that RMC is included in the national BEmONC training package, 18  In conclusion, the present study found that the institutional-level RMC index in health facilities comprised three components: policy, facilities, and experience. Urban administrative region, proportion of healthcare providers trained in EmONC, and availability of MWHs were associated with availability of the institutional-level RMC index.
Two in three health facilities did not have the institutional-level RMC index in place. In line with its effort to provide a compassionate, respectful, and caring service, the study suggests that the Ethiopian government needs to consider strengthening support mechanisms in different administrative regions (i.e., urban, pastoralist, and agrarian), implement the provision of healthcare training that incorporates components of RMC, and increase the availability of MWHs.
We recommend that the government should develop and implement RMC policies at the health facility level. The government also needs to support health facilities with the necessary resources to ensure availability of the necessary infrastructure and supplies for the provision of RMC.

ACK N OWLED G M ENTS
The authors thank the Ethiopian Public Health Institute for allowing the use of secondary data for the study. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

CO N FLI C T S O F I NTE R E S T
The authors have no conflicts of interest.

AUTH O R CO NTR I B UTI O N S
EDS contributed to study conceptualization, data analysis, original draft preparation, and manuscript editing. RB contributed to study conceptualization, original draft preparation, and manuscript editing. YMK, TVA, and JS contributed to the conceptualization, writing, review and editing of the manuscript. TT contributed to study design, and manuscript review and editing. AG contributed to manuscript review and editing. All authors read and approved the final manuscript.