A Survey of Women giving Birth regarding Respect for the Human Dignity of the Mother and the Newborn
Rasoul Raesi1, Sam Saghari2, Seyed Saeed Tabatabaee3, Sepideh Mirzaei4, Kiavash Hushmandi5, *
Identifiers and Pagination:Year: 2023
E-location ID: e187494452305170
Publisher ID: e187494452305170
Article History:Received Date: 04/01/2023
Revision Received Date: 05/04/2023
Acceptance Date: 03/05/2023
Electronic publication date: 23/06/2023
Collection year: 2023
open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This study aimed to determine the current status of respect for the human dignity of mothers and newborn from the perspective of women who have given birth.
Providing health services with respect for the human dignity of the mother and the newborn can boost the mother's self-esteem, encourage her to become pregnant in the future, and may also strengthen her confidence in the medical system.
A cross-sectional study was carried out through a census of 384 women who gave birth in Khaf's 22nd Bahman Hospital, eastern Iran, in 2022. A researcher-developed questionnaire was used to collect data, which were then analyzed in SPSS-22 using one-sample t and multiple linear regression. The significance level was established at p <0.05.
Communication with respect (2.98 ± 0.53) and respect for individual autonomy (2.94 ± 0.54) ranked highest and lowest, respectively, among the components of respect for the mother and newborn's human dignity. From the perspective of women who had given birth, respect for the human dignity of the mother and newborn in general, as well as the components of respect for personal privacy and communication with respect, were at a moderate level, whereas respect for individual autonomy was below average.
The below-average score of the component of respect for individual autonomy and, finally the average level of respect for the human dignity of the mother and newborn necessitates that managers prioritize promoting these concepts in the provision of health services through practical programs.
Ethical concerns have always accompanied healthcare provision. Health, as the ultimate goal of organizations providing health services, can be achieved through scientific care and the application of ethical principles and practices [1, 2]. In order for the client to receive health care with greater confidence and trust, the science of ethics demands health service providers adhere to specific ethical principles regardless of their social standing. In this context, any breach in the observance of ethical principles can undermine the client's dignity and respect [3, 4]. People's dignity is one of the fundamental concepts and the cornerstone of medical care [5, 6]. It is possible to define dignity in absolute or relative terms. Absolute dignity is defined as respect for people, regardless of their positions and responsibilities, such that it is never compromised or destroyed. Relative dignity depends on a person's level of education, social class, religion, and culture, and these circumstances may pose a significant threat to this type of dignity .
Respect for one's dignity is a basic human need. However, health disorders and diseases may threaten and jeopardize people's dignity, so patients feel at risk of losing their dignity from the moment they are admitted to the hospital until they are discharged [8, 9].
In the health systems of most countries, recipients of healthcare services enjoy legal rights that health service providers must uphold. Thus, the observance of patients' rights is not only independent of the preferences and whims of the medical staff but is also continually monitored, evaluated, and handled by legal systems .
The Charter of Patient Rights in Iran was drafted for the first time in 2002, and it was announced by the Health Vice-chancellery of the Ministry of Health and Medical Education in the same year to defend human rights and preserve patients' sanctity and dignity. It is stated that in cases of illness, particularly medical emergencies, patients must be adequately cared for without regard to their age or gender, even if their financial circumstances are insufficient, and that this care should be provided in a climate of respect and acceptable quality . People's dignity is maintained when they are able to control their behavior and surroundings, acquire information, make decisions, and are at ease with their mental and physical condition. A person whose dignity is respected exhibits courteous, agreeable, and undispleased behavior. Maintaining a patient's dignity reduces stress, increases trust and satisfaction, shortens hospital stays, and improves treatment outcomes .
The members of the medical team, particularly those providing care for mothers and newborns, should pay particular attention to this issue and provide service to mothers and newborns with respect for their humanity, regardless of their social standing .
Women's satisfaction with labor and birth care is a critical issue that healthcare providers, administrators, and policymakers must consider . The results of Valizadeh et al.'s study (2009) indicate that the support of service providers helps mothers enjoy a positive childbirth experience. This support includes informing the mother, honoring the mother and newborn, offering emotional and physical support, providing protection, and delivering care follow-up .
In their study titled “The effect of education of Pregnant Women's Bill of Rights to Midwives on the satisfaction of the women referred to labor unit,” Masoumi et al. (2016) noticed that staff training is a solution to increasing compliance with increasing respect for client rights satisfaction. Nevertheless, achieving these objectives requires numerous mechanisms, such as providing suitable training and enhancing the working conditions of the personnel .
In their study titled “Respect to the Bill of Mother's Rights in Labor and Delivery by Midwife Responsible for Delivery through 360° Evaluation,” Safaee et al. (2016) noted that midwives in charge of delivery respect the rights of mothers during labor and delivery to an optimal degree. However, the perspective of the midwives in charge of childbirth differed from that of the head of the maternity hospital and the women who had given birth, who felt that these rights were respected less .
Midwifery care plays a critical role in ensuring and improving the mother and newborn's health. Therefore, it is necessary to evaluate the quality of this care, which can be accomplished by measuring the mothers' satisfaction levels . Respecting the mother and newborn's dignity is the foundation of midwifery care, which is a step toward increasing mothers' satisfaction with the medical staff's services . Midwives play a crucial role in healthcare systems and maintain a close and constant relationship with mothers and their families . According to midwifery-focused research in Iran, midwives do not fully respect the rights of mothers and newborns for various reasons that need to be investigated. For instance, midwives tend to have insufficient knowledge of the mother and newborn's rights .
This communication increases comfort and self confidence, and reduces the risk of permanent psychological harm and Attention to dignity will also enhance the reputation of the hospital. Women's memories of pregnancy experiences remain with them for the rest of their lives. These memories are often shared with other women, resulting in a climate of self-assurance or doubts regarding pregnancy and childbirth care. This study sought to determine the status of respect for the human dignity of the mother and the newborn from the perspective of birthing women in Khaf's 22nd-Bahman Hospital. The study was conducted in light of the importance of respect for the human dignity of the mother and the neonate in promoting pregnancy and the lack of studies on respect for the human dignity of the mother and the neonate from the perspective of women who have newly given birth.
2. MATERIALS AND METHODS
In the second half of 2022, a cross-sectional study was conducted using the census method. The purpose was to determine the status of respect for the human dignity of the mother and the neonate from the perspective of birthing women at 22nd-Bahman Hospital (A public hospital) in Khaf (Khaf a city in eastern Iran). All women who had recently given birth and were admitted to the obstetrics and gynecology inpatient department constituted the study's statistical population.
Using Cochran's formula and accounting for an error margin of 5%, the sample size was calculated to be 384 people based on the size of the unknown population. Due to the possibility of dropping 4 percent of the sample, 400 questionnaires were distributed, of which 387 were returned with responses. Three questionnaires were eliminated because they were incomplete, leaving 384 questionnaires for statistical analysis. Inclusion criteria comprised consent to participate in the study, women whose delivery resulted in the birth of a live baby, and literacy in reading and writing; exclusion criteria included failure to answer questionnaire items in full.
After the project was approved by the research ethics committee affiliated with Mashhad University of Medical Sciences, the researcher received a letter of introduction from the university and presented it to hospital officials. The current study's ethical considerations were as follows: first, all participants participated in the research voluntarily and willingly; second, regarding the principles of secrecy and confidentiality of the participants' identities, they were assured that all information would remain confidential and the results would be reported in a general manner.
Respect for the human dignity of the mother and newborn was measured using a questionnaire developed by the researchers. A research colleague visited the obstetrics and gynecology department daily in order to collect data. After explaining the purpose of the study and obtaining informed consent from the women who had recently given birth, the colleague distributed questionnaires among the women and collected the completed questionnaires. The questionnaire consisted of two sections. The first section focused on demographic characteristics (age, level of education, occupation, and monthly income), while the second section focused on respect for the human dignity of the mother and newborn. This questionnaire was developed based on previous research and a literature search. The questionnaire consists of 20 items and three components, including respect for privacy, respect for individual autonomy, and establishing respectful communication. The items are graded on a 5-point Likert scale ranging from strongly disagree (score 1) to strongly agree (score 5). The score for each component is calculated by summing the items associated with that component and dividing by the total number of items. In addition, the sum total scores of the items are divided by 20 to determine the questionnaire’s mean score. The minimum score for the complete questionnaire is 1 x 20 (= 20) and the minimum average score for each component is one, the maximum score is five, and the average score is three.
The content validity method was utilized to determine the validity of the researcher-made questionnaire. To this end, the questionnaire was distributed to six faculty members relevant to the study's topic, and the data collection instrument was validated using their suggestions and feedback. The CVI and CVR indices had values greater than 0.79 and 0.58, respectively. The questionnaire's reliability was determined using the internal consistency (Cronbach's alpha coefficient) and the test-retest methods. The questionnaire was piloted on a small sample of women who had recently given birth (n=20). After ten days, the questionnaire was administered to the same 20 patients in order to calculate the internal correlation coefficient. Cronbach's alpha coefficient for the questionnaire was α=0.87, which is statistically acceptable and valid.
Therefore, the questionnaire's reliability enjoyed acceptable adequacy. Data were analyzed with SPSS-22 statistical software using one-sample t and multiple linear regression. The significance level was set to p<0.05.
This study evaluated 384 women who gave birth at Khaf's 22nd-Bahman Hospital. The minimum age was 24, the maximum was 37, and the mean was 31.13±3.94 years. The majority of the women were homemakers (59.9%), had primary/secondary education (55.5%), and earned between 5-10 million tomans per month (40.4%) (Table 1).
The questionnaire responses had a normal distribution as the skewness and kurtosis coefficients for the variables fell within the interval [-2, 2]. Among the components of respect for the human dignity of mother and newborn, respect for individual autonomy in caring for mother and newborn was found to have the lowest average (2.94±0.54), while establishing respectful communication in the care of mother and newborn had the highest average (2.98±0.53). The results of the one-sample t-test indicated that, from the perspective of the women, the mean score of respect for the human dignity of the mother and newborn in general, as well as the components of respect for personal privacy and communication with respect, were not significantly different from the midpoint of the scale: neither satisfied nor dissatisfied (p <0.05). The mean respect for individual autonomy score was significantly lower than the average theoretical score (i.e., 3) (p=0.04). In other words, from the perspective of the women who had given birth, the status of respect for the human dignity of the mother and newborn in general, and the components of respect for personal privacy and communication with respect in 22nd Bahman Hospital of Khaf were moderate, whereas the status of respect for individual autonomy in the care of the mother and newborn was below average (Table 2).
|Variable||Mean||Standard Deviation||Skewness||Kurtosis||One-sample t-test Result|
|Respect for personal privacy||2.96||0.56||0.89||0.09||1.41||0.16|
|Respect for individual autonomy||2.94||0.54||1.06||0.53||2.04||0.04|
|Communication with respect||2.98||0.53||1.30||1.11||0.67||0.50|
|Respect for the human dignity of the mother and newborn||2.96||0.46||1.03||1.20||1.49||0.14|
|Variable||Non-standard Coefficient||Standard Coefficient||T value||Significance Level||Correlation Coefficient||Coefficient of Determination|
|B value||Standard Error||β value|
|Monthly income (million tomans)||5-10||-0.11||0.06||-0.12||1.90||0.06|
Multiple linear regression was employed to examine the impact of demographic variables on attitudes toward respect for the human dignity of the mother and infant. Age was incorporated quantitatively, while occupation, monthly income, and education were included qualitatively. Qualitative variables were added to the model using the duming coding. The results of this study revealed that viewpoints regarding respect for the human dignity of mother and infant were negatively and significantly correlated with employed and self-employed occupations, a monthly income of more than 10 million tomans, and the tertiary level of education. Indeed, opinion scores on respect for the human dignity of mother and infant were significantly higher in working women than in homemakers, in women with a monthly income of more than 10 million tomans than in women with less than 5 million tomans, and in women with a university education than in women with non-university education (p <0.05). However, no significant associations were found between age and people's opinions regarding respect for the human dignity of the mother and infant (p=0.39) (Table 3).
The current study was designed and conducted to determine the status of respect for the human dignity of the mother and neonate from the perspective of women who have given birth at 22nd-Bahman Hospital of Khaf.
The present study revealed that, from the perspective of women who have given birth, respect for the human dignity of the mother and the newborn is at an average level.
This finding of the present study can be explained by the fact that, most likely, most mothers who have recently given birth tend not to judge the level of respect for their human dignity and that of their newborn when receiving health services from the maternity ward and that they do not explicitly state the extent of respect for their human dignity and that of their baby when answering the survey. Therefore, the culture of the people in this region, women's lack of knowledge about their rights in the hospital, and their special respect for the position of health service providers may all contribute to the moderate level of respect for the human dignity of the mother and the newborn from the perspective of women who have given birth. Since the charter of patient's rights and the mission of the hospital considers respecting the dignity of patients as an important principle, it is expected that the human dignity of the mother and baby will always be maintained at the highest level by the health service providers. Therefore, it can be said that the average level of respect and dignity in this hospital is a challenge that needs more investigation by the managers. These investigations should lead to the institutionalization of respect for the dignity of the mother and the baby in the health service providers so that subsequently the level of respect for the dignity of the mother and the baby will be improved and reach its highest level.
Respecting the human dignity of mothers and newborns is a significant challenge that is not governed by a specific law, which can severely harm this vulnerable group. This legal void can potentially hinder the efforts of ethical activists in the medical field. It is true that the preparation and implementation of an ethical guide based on the provisions of the patient's bill of rights can be somewhat effective in resolving this issue; however, it is necessary to implement and predict measures that address violations. The formulation of a set of regulations by the health policymaker may provide a temporary solution to the problem. Nevertheless, such guidelines require specific legal support to garner the commitment and compliance of all health service providers. Consequently, alongside the development of ethical guidelines to explain the media's relationship with the health system, efforts should be made to enact laws mandating adherence to these guidelines.
Midwifery and nursing care often require intrusions into patients' private spaces because of the intimate nature of the services they provide . Despite the treatment staff agreeing to respect patients' privacy and human dignity , the evidence indicates that the patient's privacy and dignity are not adequately protected. Insufficient personnel, time constraints, and inadequate facilities have been cited in research reports conducted in Iran as reasons for disregarding patients' human dignity . The inadequate patient-nurse ratio, the lack of a sense of psychological security, and the long working hours of nurses are all mentioned, along with the economic and social pressures and heavy workload for care providers, especially nurses, and the specific limitations of the work environment, such as the work structure and communication environment, limited equipment and facilities, lack of time, and inappropriate structure of the department and hospital [24, 25].
Consistent with the present study's findings, Amorós et al. demonstrated that one of the ethical challenges in health service provision environments is the inadequate consideration of patients' right to autonomy and dignity . Patients who participated in a study concurred with this finding, stating that the most stressful aspects of hospitalization are a change of habits, lack of control, and lack of respect for dignity, autonomy, and privacy . The negative effects of hospitalization on the physical and mental health of elderly patients have been demonstrated in a number of studies to result in a decline in performance at the time of discharge compared to admission. This issue is not the result of illness but rather a result of feeling powerless and being ignored in the decision-making process, which is associated with decreased performance and mental damage . Patients in a study conducted in Iran felt their human dignity was not respected . According to the findings of another study, none of the patients reported that the nurse gave them an opportunity to make a choice .
Respect for the human dignity of the mother and newborn was most strongly associated with establishing respectful communication in the care of the mother and newborn, according to the findings of the present study. As an explanation, it can be noted that the client's understanding of how to communicate varies by culture. Contradictions as such indicate the need for additional research into communicating with patients and respecting dignity. Since health service providers typically serve clients of various ages and each age group has a unique perspective on health, illness, and bodily functions, health service providers should be cognizant of these differences to communicate with them more effectively . In line with this finding of the present study, numerous studies indicate that, from the client's perspective, respectful communication is one of the most important factors affecting dignity [30, 31].
Contradicting this finding are the findings of the studies by Raee et al.  and Henderson et al. . They demonstrated that healthcare providers are inept at establishing respectful relationships. Different sociocultural conditions and study environments, investigated groups, and working conditions of health service providers in different health and treatment departments and wards should be considered when interpreting this discrepancy in the research findings.
According to the findings of this study, among the components of respect for the human dignity of the mother and newborn, respect for privacy was on an average level. Indeed, protecting patients' privacy is one of the widely accepted principles among patients and health service providers. In light of this, patients would reveal to doctors and health service providers matters that they typically conceal even from their closest friends. It is increasingly important to protect patients' privacy as a result of developments in medical technology; ignoring this concern could have serious consequences for both the patient and the healthcare system.
This finding is consistent with those of Baillie's study , which showed that the vast majority of patients report experiencing issues with confidentiality and privacy, including the disclosure of secrets and the intrusion of health service providers into their personal space. In accordance with this finding, the results of the study by Manookian et al.  demonstrated that one of the most important aspects of patient dignity is confidentiality and personal privacy, which should be accorded a greater degree of consideration by health service providers.
Consistent with the current study's finding, another study found that 25% of British hospitalized patients felt their privacy and human dignity were not respected during their stay . Similarly, an Australian study revealed that 25% of hospitalized patients believed others could hear their conversations with medical staff, and 11% reported that their body parts had been exposed . In line with this finding, the results of a study conducted in Kerman revealed that some aspects of the patients' privacy and dignity were less respected by nurses when they were hospitalized in internal diseases and surgical departments .
The results of the studies conducted by Parsapoor et al.  and Sabzevari et al.  contradict this research finding. According to these reports, the confidentiality and privacy of the patients were respected to an acceptable degree. The context of the studies, the populations (patients) analyzed, and the sociocultural context of the participants can all play a role in interpreting the discrepancy in research findings.
The findings of this study indicated that, from the perspective of women who gave birth, respect for individual autonomy in caring for the mother and newborn was below average.
This research finding can be explained by noting that the unique conditions of health and treatment environments are sometimes associated with factors that limit the independence of individual clients. Routine care measures, lack of attention to the individual ability of clients, time limitations, mental and physical conditions of clients, workload and fatigue of health service providers, lack of awareness of patients about the treatment process, absence of correct assessment of health service providers of the physical condition of clients, the level of participation of clients, and access to facilities and equipment that facilitate the autonomy of patients in health and treatment environments are among the factors influencing the individual autonomy of patients [40, 41].
The findings of this study are consistent with those of other studies, which have found that patients are not given sufficient autonomy during treatment and that their input into their care is rarely considered [34, 42, 43].
On the contrary, Raee et al.  and Arab et al.  found that respect for the patient's individual autonomy received the highest score in their studies, which is inconsistent with this study's findings. In interpreting this discrepancy, it is possible to make reference to different sociocultural conditions, study environments, and investigated groups.
CONCLUSION AND RECOMMENDATIONS
Respect for the human dignity of the mother and the newborn in general, as well as the components of respect for personal privacy and communication with respect, were found to be average among women laboring in the 22 nd Bahman Hospital of Khaf, whereas respect for autonomy in maternal and newborn care was found to be below average. In general, the recipients of health services (Due to culture of the people, women's lack of knowledge about their rights in the hospital, and their special respect for the position of health service providers
), the treatment team (Due to the lack of awareness of the concept of dignity and its dimensions in mother and newborn, heavy workload, fatigue and job burnout), managers (Due to insufficient awareness of the human dignity of mother and newborn in the hospital, Poor attitude and vision of the importance of the dignity of mother and newborn, Not having a scientific and practical plan to evaluate the service providers' respect for the dignity of mothers and newborns in hospital departments and Inadequate awareness of the concept of dignity as a principle of care in providing health services to mothers and newborns) and health policymakers (Inadequate attention to the dignity component of mother and newborn as a criterion in periodic evaluations of hospitals) may all pose obstacles to respecting the human dignity of the mother and newborn. Poor attitudes of mothers regarding their right to respect the human dignity of the mother and newborn may result from low self-esteem and inadequate knowledge of their rights in the hospital. Patients' attitudes are improved, and mothers are motivated to receive health care with respect for human dignity when they are informed of their hospital rights. In addition, the care team must be aware of the patient's rights in order to take them into account during their interactions with mothers. Therefore, it is suggested that health policymakers provide training to maternal health service providers on the importance of respecting the human dignity of mother and child, as well as how to take this into account when communicating with mothers. Healthcare administrators and elected officials must prioritize the implementation of these concepts when providing health services to mothers and newborns.
LIMITATIONS OF THE STUDY
This study has limitations, including:
1. Given a dearth of relevant works and studies, the findings could not be easily compared with those of related research reports.
2. A questionnaire was used to collect data for this study; as a result, some participants may have refused to provide reliable information.
3. This study was conducted cross-sectionally, which makes it difficult to draw conclusions regarding causality.
4. The present study's findings are applicable to all women who have given birth at the 22nd Bahman Hospital in Khaf city. Therefore, there are limitations to the generalizability of the current study's findings.
5. Since this study was conducted with literate, childbearing women, it cannot be generalized to the entire population.
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
This article reports the results of a research project approved by Mashhad University of Medical Sciences with the code of ethics (IR.MUMS.REC.1401.070).
HUMAN AND ANIMAL RIGHTS
No animals were used for studies that are the basis of this research. All human procedures followed were per the guidelines of the Helsinki Declaration of 1975.
CONSENT FOR PUBLICATION
In order to comply with ethical considerations in this research, the information of the participants was kept confidential and other people were not able to access this information. The names and surnames of the participants were not used for data collection, and data collection was done after obtaining the code of ethics from the Tehran Islamic Azad University of Medical Sciences.
This study was funded by Mashhad University of Medical Sciences, Funder ID 4001687, Awards/Grant No. 4001687.
AVAILABILITY OF DATA AND MATERIALS
The data supporting the findings of the article is available in the Zenodo Repository, at https://openpublichealthjournal.com/availability-of-data-materials.php.
STANDARDS OF REPORTING
STROBE guideline has been followed.
CONFLICT OF INTERESTS
The authors declare no conflict of interest, financial or otherwise.
We would like to express our sincere gratitude to the honorable Vice-chancellery for Research of Mashhad University of Medical Sciences, the honorable officials of 22nd-Bahman Hospital in Khaf, the participants, and all the people who helped us conduct this research.