Rejina Gurung: Co-creating Respectful Maternity Care Intervention to Improve Perinatal Mental Health in Nepal

Abstract

Background: Mistreatment during institutional childbirth is a global health concern, with 80% of births taking place in hospitals. Postpartum depression remains inadequately addressed in many maternal health settings. There is an urgent need for research to investigate mistreatment during childbirth as exposure and its linkage with postpartum depression. 

Aims: The overarching aim was to investigate mistreatment during institutional childbirth in Nepal and to co-design intervention prototypes for respectful maternity care. The specific objectives were: to assess mistreatment during childbirth in tertiary care facilities (Paper I), to measure its association with postpartum depressive symptoms (Paper II), to explore mistreatment from women’s perspectives (Paper III), and to co-design early-stage respectful maternity care interventions (Paper IV).

Methods: Prospective cohort design was employed in paper I to measure the prevalence of mistreatment during childbirth in 11 hospitals and in Paper II to assess its association with postpartum depressive symptoms in one hospital. Paper III involved 16 in-depth interviews to explore women’s lived experiences of mistreatment during childbirth. Paper IV adopted a human-centered co-design process involving 28 midwives to develop prototypes of respectful care. 

Results: Altogether, 84.3% (n = 53,047) of women had no opportunity to discuss their concerns; 80.4% (n = 50,593) were not adequately informed; 42.1% (n = 26,492) did not receive breastfeeding counselling; 1.5% (n = 944) were refused postpartum care for inability to pay. Women aged 30–34 years old (β,− 0.38013; p-value, 0.000) were less likely to expereince mistreatment compared to women aged 18 years or younger. Furthermore, women from relatively disadvantaged (Dalit) ethnic groups were more likely to experience mistreatment (β, 0.29596; p-value, 0.000) than women from more advantaged (Chettri) ethnic groups. Paper II found that a third of women (n = 360, 29.5%) experienced mistreatment during childbirth and these women were almost 50% more likely (cRR 1.47; 95% CI 1.14, 1.89; p = 0.003) to experience postpartum depressive symptoms compared to those who did not report mistreatment. Paper III identified adverse hospital culture, systemic constraints and territorial behavior as perceived drivers of mistreatment during childbirth. Paper IV codesigned respectful care prototypes: bottom-up communication system, communication skills for midwives, and community-based health education for clients.

Conclusion: Thesis demonstrates high burden of mistreatment during childbirth and its potential linkage to postpartum depression, and highlight the capacity of co-designed interventions to address the root causes of mistreatment. Personalized care with effective communication in a supportive hospital environment, is essential for positive health outcomes.