Women Health Right and Empowerment during Childbirth

Dr. Norah A. Alshehri MD and Dr. Yasser Sabr, MD, MHSc, the first two authors contributed equally to this work. Abstract Background: Women health right and empowerment during childbirth is an emerging important topic worldwide. Violation of women dignity, privacy, and confidentiality impact birth outcomes as consequence influencing both morbidity and mortality rate. This occurs as result to complex reasons that attributable to health services which include inadequate coverage of health care, lack of trained assistance, insufficient essential obstetric care and poor health referral system. Objective: To explore women experience during childbirth in terms of health rights and the quality of care provided and to further study women attuited and experience with midwives and their future role in obstetric care. Method: Based on informant report, a random snowballing sampling technique was carried out through using an anonymous online based questionnaire. Participants in this study were (n=360) women. Ethical approval was obtained by the institutional review board at King Saud University (IRB No. E-18-32836). Results: The majority of women reported their childbirth experience as unfavourable. According to our findings, women encounter various kinds of obstetric violence including denial of access to a health care, restriction of analgesia, violation of privacy and failure of obtaining an informed consent which found to be high as (91.0%), (53.0%) respectively. Conclusion: Optimal maternity care can be assured through appropriate access to medical resources and health care expertise with a higher priority committed to supporting midwife led care during childbirth.


Introduction:
Childbirth signifies an exceptional experience in a woman's life impacting her both postpartum physical and psychological state. 1 Studies reporting that 10-34% of childbirth end with traumatic birth experiences to women. 2,3 Desirable childbirth outcomes depend on acceptable, affordable and accessible health care system. 4 However, the medicalization of childbirth experience, and neglect in others context result to abuse. 5 The literature suggests that mistreatment during childbirth is a worldwide phenomenon, composed of non-supportive care incorporating both physical and verbal abuse, violation of privacy, lack of autonomy to the patient and non-consented procedures. 6,7,8 A respectful maternity care as envisioned by the World Health Organization (WHO) in 2018 is the care that maintain "dignity, privacy, and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth". 9 In parallel, a positive childbirth experience can be encouraged through midwife-led care as has been reported by Cochrane reviews. 10,11 Such an effective strategy, should promote continuous support for women during childbirth and improve behavior of the caregivers. 12,13 Women health right and empowerment during childbirth is an emerging important topic. 14,15 Our study aims to improve maternal health within this context and address this issue to further improve the current health care system and to prevent avoidable adverse events.

Research Design and Setting
This cross-sectional study explored women right during childbirth using an anonymous online based questioner posted on Social Media between December 2019 to February 2020.

Subject and Sampling
A random snowballing sampling technique using an online based questionnaire was carried out.
Participants in this research (n=360) were all primiparous women. Participants were invited to complete an assessment measure based on informant report about their experience during childbirth. Women who were multiparous or had their pregnancy before the year 2016 were excluded from the study.

Research Instrument
The questionnaire was developed by the authors based on the study objectives. To ensure that it was suitable, precise and relevant, the questionnaire was submitted for evaluation by two obstetricians and a family doctor who provided clinical care for pregnant women. These individuals were acquainted with the survey development.
The questionnaire consisted of 19 items in total.

Statistical analysis
Categorical variables were presented as frequencies and percentage, while continuous variable was presented as mean and a standard deviations (SD).

Ethical considerations
The study was approved by the institutional review board at King Saud University (IRB No. E-18-32836). Table 1 demonstrate the sociodemographic and clinical characteristics of women whom gave birth. A 360 women, with a mean age of 34.08 ± 7.35 years were included. Of these, 94.0% were Saudi, 62.0% held a bachelor's degree, and 34.0% reported an overall monthly household income of more than 10,000 SR.

Result:
Moreover, 35.0% of participants reported having their birth in a teaching hospital followed by a privet hospital by 34.0%. In comparison, the husband was reported to be the companion in childbirth by 40.0%, while 39.0% of respondents reported no companion during childbirth.   Among variables examined, violation of privacy and failure of obtaining an informed consent were found to be the most common unethical practice (91.0%), (53.0%) respectively. Around (64.0%) of women rated their childbirth experience as unfavorable.  Figure 1 shows the most common unconsented obstetric interventions during childbirth that experienced by women. Around (39.0%) of women had their birth through a cesarean section. In contrast, women who had vaginal delivery, their birth were complicated by an episiotomy (36%), while one-fourth needed an induction of labor. Table 3 shows women experience and attitude towards midwives. Out of 360 women, 174 had in interaction with midwifes. Out of those women, more than half reported their experience as favorable. However, disapproval regarding their future role was noted by (53.0%) of all women. Quality of care is an important element of the right to health. 16 Building on this concept, our study investigated six health care characteristics that would insure both equity and dignity for women during childbirth as describes by the World Health Organization (WHO). 17, 18 An alarming rate was observed in this study among women whom denied an access to a reproductive care service during childbirth. It is found that a range of barriers limit women's access to care, including distance, cost or health facilities reglations. 19 Ensuring women needs during delivery is a key characteristic in patient centered care that aims to a better quality of maternity care. Most women reported a lack of support with around one third had to endure this experience alone with no companion. A study explained that women experience of mistreatment during childbirth is strongly associated to lack of support; 20 this could be related to the vulnerability of women in these circumstances.
Women experience painful events during childbirth, to ease her pain, labor analgesia are usually introduced. 21 However, the majority of women in our sample reported no pain management which is considered as a violation to a fundamental health right. 22 An explanation to this and by the exclusion of the medical rezoning could be relied to the cost of the procedure.
Compromising women privacy and failure in obtaining an informed consent were noted as well.
Such an intimate issue is both ethical and legal. 23 The law mandate expressing consent as an essential component of care providing accurate, clear and evidence-based information. 24 In Saudi Arabia, women are legally having the rights to consent for their health care. 25 In contrast to this study findings, around half the women who were included did not consented; this could be attributed to lack of awareness about their legal right.
Unconsented obstetric interventions during childbirth were common practices in our study sample. It is critical to note that most procedures are done as routine by health professionals. 26 Evidence Cesarean section 39% Induction of labor 25% Episiotomy 36% based approaches should be adapted to address this concern especially in the absence of clinical need.
Supportive care during childbirth is an important factor contributing to women's experiences of delivery. 27 Similarly, midwifes led care during childbirth among our surveys had a favorable experience. Nevertheless, some showed distrust in their future role in improving maternity care. It could be due less interaction and lack of knowledge about their role in maternity care.

Conclusion and recommendations:
Women's health and right issues are gaining a global trend. Nationally, according to the Ministry of Health, morbidity and mortality rate among women and children are high. 28 Reasons that attributable to health services includes inadequate coverage of health care, lack of trained assistance, insufficient essential obstetric care and poor health referral system.
Provision of optimal maternity care will necessitate access to appropriate medical institutions and expert care. This includes ensuring full and unrestricted access to prenatal care, resources and expertise, as well as access to safe, pain-free childbirth and comprehensive medical care before, during and after birth.
Furthermore, a higher priority should be committed to support midwifes led care during childbirth. Having skilled midwives in antenatal, natal, or postnatal is one of key potential interventions for reducing maternal and prenatal mortality. Consequently, it goes in alliance with the united nation sustainable development goals in decreasing the neglect of the rights, health and equality of women in the country.

Conflict of interest:
Authors have no interest to disclose. This manuscript has not been published and is not under consideration for publication elsewhere.

Declaration of Funding
This research was fully financially independent and funded by the researchers.

Declaration of Financial
This research was fully financially independent and funded by the researchers.

Author Contributions
The single authors was contributed equally in Conceptualization, Methodology, Software, Data curation, Writing-Original draft preparation, Visualization, Investigation, Supervision, Validation, Writing-Reviewing and Editing. based, respectful maternity care worldwide.
The Lancet.