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Experiences and Perceptions of Disrespectful and Abusive Facility-based Childbirth Care in the Western Highlands of Guatemala: A Mixed Methods Analysis Open Access

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Background. The present research takes place among a largely indigenous Mayan population living in rural to remote villages in the Western Highlands of Guatemala. This population has a disproportionately higher maternal mortality ratio compared to their non-indigenous counterparts and is less likely to utilize skilled childbirth care in health institutions. In addition to geographic and economic access barriers, negative perceptions of health services, specifically discrimination, poor client-provider interactions and language barriers reinforce the tradition to give birth at home. Methods. The first manuscript is a qualitative case study that explores the contributors, manifestations, and consequences of poor maternity care quality, from the community’s perspective. The analysis employs the disrespectful and abusive maternity care typology to guide a thematic analysis of thirty in-depth interviews and fifteen focus group discussions. The second manuscript uses a quantitative nested modeling approach to consider the factors associated with reporting experiences or perceptions of disrespect and abuse among a ‘facility birth cohort’ and separately among a ‘home birth cohort.’ Variables hypothesized to increase reports of disrespect and abuse and protect against disrespect and abuse are tested. The third manuscript aims to identify factors associated with future intention to give birth in a health facility, separately among members of the home and the facility cohorts. The independent variables of interest represent care-seeking determinants: access to care (geographic and financial), perceived need for maternity care, and two measures of perceived quality: satisfaction with last birth and disrespect and abuse (perceived or experienced). Results. In manuscript one, respondents from across the study villages described (to some degree) all seven categories of disrespect and abuse. Societal, facility-level and individual-level factors were cited as contributors to disrespect and abuse. In manuscript two, eighteen percent of women who gave birth to their last child in a health facility reported experiencing at least one of three measures of disrespect and abuse. The most marginalized (indigenous, uneducated, relatively poorer with high parity) have an increased probability of reporting disrespect and abuse, but are less likely to perceive it. In manuscript three, perceived need for facility-based childbirth services and satisfaction with either last childbirth experience, at home or in a facility, are key factors associated with intention to give birth in a health institution in the future. Reporting disrespect and abuse (facility cohort) is a deterrent to seeking facility-based care in the future. Select perceptions of disrespect and abuse (home cohort) did not have an association with future intention.Conclusion. Poor perceptions of care quality and negative client experiences are an important barrier that erode trust in a health system, contribute to delays or decisions to seek facility-based care. By extension, the former can lead to preventable cases of maternal and neonatal death and disability. This work has important implications for improving quality of care, upholding human rights and addressing disparities critical to the achievement of universal health coverage and other Sustainable Development Goals.

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