WOMEN’S AUTONOMY AND RESPECTFUL CARE IN THE MATERNITY CARE DURING COVID-19 PANDEMIC

Background: Women's autonomy and respect are crucial for ensuring high-quality maternity care. However, during the COVID-19 pandemic, healthcare workers have had to adapt to new protocols and follow social distancing regulations, which can impact their ability to provide autonomous and respectful care to their patients. Therefore, the objective of this study was to describe how mothers perceive autonomy and respect during their antenatal and childbirth care. Method: This study used a cross-sectional approach to collect data via an online survey from March 2020 to July 2021. The questionnaire was distributed through social media. The population of this study was pregnant women in Indonesia during March 2020-January 2021 and the sample of this study was 160 pregnant women. Descriptive statistics were used to analyze the data. Results: The majority of the women in this study reported experiencing a moderate level of autonomy (Mean ±SD=31.4±10.08) but low levels of respect during their maternity care (Mean ±SD= 44.99±7.13). Conclusion: The results of this study suggest that, during the COVID-19 pandemic, women are receiving moderate levels of autonomy in decision-making but low levels of respectful care from maternity staff during pregnancy and childbirth. Despite the challenges posed by the pandemic, healthcare workers such as midwives, nurses, and obstetricians should remain mindful of their patients' rights to make decisions about their own health and provide respectful care.


INTRODUCTION
Autonomy and respectful care in decision-making refers to women's autonomy in decision-making during midwifery care which is characterized by midwifery care that respects women's decisions and recognizes that women's and gender equality is the foundation of an effective health program. Quill and Brody (1996) assert that the core component of autonomy in health care is respect for the patient as a person, which requires presenting her with all medically valid choices.
Decision-making autonomy is an important factor in women's ability to look after their health. To acquire knowledge, a woman must be empowered and have the ability to collect information sources received from the environment. Furthermore, the prominent role of health care providers is to share evidence-based information related to mother's health and empower them to aware of their rights to make informed choice. Giving women's clear information can improve the quality of care by helping avoid unnecessary interventions and preventing maternal morbidity and mortality (Miller et al., 2016).
Women's empowerment and autonomy of decision making is related to successful family planning programs, longer birth intervals, and lower rates of unwanted pregnancies.
Women who are aware of their own autonomy rights tend to be more able to make decisions together with health workers. Shared decision-making is considered the cornerstone of patientcentered care (women's centered care) and is related to improving health (Vedam et al., 2017).
Women's independence in decision-making is associated with maternal health behaviors that protect their children and produce better outcomes for both mother and child (Hendrick and Marteleto, 2017). Maternal autonomy in the household can improve child health and well-being outcomes. For example, in Indonesian families, pregnant women who are involved in decisionmaking are more likely to use antenatal care than those who are not involved in making their own health decisions (Rammohan and Johar, 2009). Respect for women's autonomy is one indicator in internationally-accepted guidelines for mother-and baby-friendly facilities (International Federation of Gynecol, 2015).
The delivery of high quality midwifery care depends on more than comprehensive services and effective processes; childbirth also occurs within socio-cultural norms and also challenges they were facing. For example, during pandemic comprehensive services may not be obtained due to additional taskforce of maternity staff related to COVID-19 prevention and treatment. The existence of new regulations regarding the use of personal protective equipment, midwifery care, and delivery methods during the COVID-19 pandemic caused some mothers to feel uncomfortable during childbirth. Some hospitals and community health center do not even allow families to accompany them during labour. Considering that there is still a few study that investigate how women perceived autonomy and respect in maternity care during pandemic, therefore, therefore the aim of this study was to describe mothers' experiences in making decisions and respecting mothers during the COVID-19.

Study Design
This study used a cross-sectional design where the research data was taken at one time with an online survey from January to March 2021. The data were collected anonymously using purposive sampling which was distributed via Instagram, WhatsApp, Facebook, and Twitter.

1) Demographic Characteristics
The demographic characteristics which investigated in this study was age, religion, education status, working status, household income, living situation (with partners only or with extended family members), parity, and care providers during antenatal care. This characteristic was described using frequency and percentage.

2) The Mothers' Autonomy in Decision Making scale (MADM)
The questionnaire used was the Mothers' Autonomy in Decision Making Scale (MADM) which was developed to be able to describe their experience in care during pregnancy and childbirth. The MADM scale is a reliable and valid instrument that assesses the degree of autonomy an individual experiences when participating in decision-making with maternity care providers. The scale has seven items that measure autonomy and role in decision making. The test has been validated and proven reliable, with Cronbach alpha being 0.90 (Vedam et al., 2017) and 0.68 for the Indonesian version (Jannah, 2020). The statistical analysis used in this questionnaire was frequency, median, and mean.
The MADM scale has seven items and is scored on a six-point Likert scale (1 to 6) where each point indicates a woman's feelings about her experience with a score of 1 = "strongly disagree", 2 = "Disagree", 3 = "somewhat disagree" , 4 = "somewhat agree", 5 = "agree", 6 = "strongly agree". The total score represents respect for decision-making as a degree of autonomy (by quartiles) from a women's perspective. Scores on this scale range from 7 to 42. Scores from 7 to 15 indicate very low patient autonomy, scores from 16 to 24 indicate low patient autonomy, scores from 25 to 33 indicate moderate patient autonomy, and scores between 34 and 42 indicate high patient autonomy.

3) Mothers on Respect Index
The second scale is the Mothers on Respect Index (MOR) instrument with the aim of gathering information about interactions between patients and health workers for the purpose of understanding mothers' experiences of respect in maternity care. This questionnaire has been administered to respondents in Canada and the United States (2017).
The Cronbach's alpha for the US sample (n=1.613) was 0.94 and the Cronbach's alpha for the Indonesian MOR was 0.675 (Hair et al., 2006). The statistical analysis used in this questionnaire was frequency, median, and mean.
The MORi scale has 14 items and is scored on a six-point Likert scale (1 to 6) each point indicating a woman's feelings about her experience with a score of 1 = "strongly disagree", 2 = "Disagree", 3 = "somewhat disagree" , 4 = "somewhat agree", 5 = "agree", 6 = "strongly agree". The possible range of scores on the scale for measuring the level of respect experienced is from 14 to 84. Scores from 14 to 31 indicate very low respect, scores from 32 to 49 indicate low respect, scores from 50 to 66 indicate respect. moderate, and a score between 67 and 84 indicates high respect.

RESULT
This study obtained the characteristics of the respondents, data regarding the autonomy of the mother in making decisions, and the index of respect for the mother.   (Ikeako et al., 2014) and the accessible ultrasound facilities that used by obstetrician might influence women's choice of maternal care services and their views about autonomy. Prior knowledge, individual autonomy, social support, information access influence mother's decision making to seek for health care services (Syam, Suriah and Abdullah, 2019). That is because, educated and empowered women tended to be more aware to make decisions based on their health and capable to communicate their condition (Adhikari, 2016). Due to the limited time and access during pandemic, it might limit the process of shared decision making among midwives and obstetricians. Therefore, the autonomy scored moderate in this study.

A. Respondent Characteristics
To achieve a good decision making in maternity care, it should involve informed and empowered decision-making based on individual needs, preferences, and values. The decision making process, especially from whom the decision is made, poses significant impact to mothers health. Based on survey included 3435 women, women who have more autonomy in the household were more likely to have adequate health care services and antenatal care (Rizkianti et al., 2020). In addition, the difference between every antenatal care and birthing model whether it was in hospital, midwives clinic, and with who women would deliver their babies, affect the process of discussion and shared decision making process (Vedam et al., 2017).
Women's ability to maintain their health and their knowledge of the health resources available to them depend on their decision-making autonomy (Osamor and Grady, 2016). Even during pandemic, women usually want better information about the procedures and actions they will experience during pregnancy and childbirth, and how the COVID-19 may affect their health and the babies. Therefore, it is very important to consider the expectations and experiences of women and providers, as they have a real impact on maternal health outcomes (Bhattacharyya et al., 2018). A study by Srivastava et al conducted in India found that users who felt the quality of care at a health center was good were more likely to revisit them, thereby increasing the demand for the service. Therefore, health service providers can improve the quality of childbirth and make it more acceptable to women, use of services, thereby improving the health of mothers and babies (Srivastava et al., 2015), even though pandemic is still occurring.
In contrast, women experience low level of respect during antenatal care. However, our study took place during COVID-19 pandemic in Indonesia where the access of healthcare is limited due to strict regulation of virus prevention. This might have been due to the adaptation 159 of COVID-19 protocol and policies in health care facilities and fear of infection from health care professionals (Anggraeni et al., 2023). Some rejection from and incomplete ANC services in healthcare facilities even occurred during pandemic in Indonesia (Ariani, 2022). Moreover, In hospital settings, the respectful maternity care might not be optimal because of the workload of healthcare staffs which limit their time to treat one patient to another. In addition to providing direct patient care, healthcare staff have had to deal with increased administrative tasks related to the pandemic. This can include tracking and reporting COVID-19 cases, managing personal protective equipment (PPE), and ensuring that healthcare facilities are following safety protocols. In many cases, healthcare staff have had to adapt to new roles and responsibilities during the pandemic. For example, the obstetric care standards had to be compromised by maternity staff, who faced significant difficulties and had to make structural changes, which had an impact on their well-being (Schmitt et al., 2021).
Previous study has the same findings, for example, women's in Zambia experienced disrespect during labour and delivery (Asefa et al., 2018). Women's in an Ethiopian study reported witnessing disrespectful practices during childbirth, and a study from Nigeria found that women's commonly experienced disrespect during labour and delivery (Orpin et al., 2018;Smith et al., 2020). However, a study in US reported women's perceived they had received high respect during childbirth. Higher scores in that study corresponded with women's feeling that they were treated with greater levels of dignity during their birth experience (Liddell and Johnson, 2018). The differences in results among these studies might be explained by differences in healthcare staff's behavior related to social and cultural attitudes, and they conducted the study was not during pandemic. Related studies during COVID-19 pandemic explain that there were limited participation by family members in the birth process, including a decrease in emotional and physical support for women, a decline in the quality of care provided, a greater likelihood of medically unnecessary caesarean sections, and overwhelmed staff due to the implementation of new infection prevention measures and changing guidelines (Asefa et al., 2022).
Therefore, health care workers should be transparent with patients about the risks and benefits of different treatment options, and work collaboratively with them to make informed decisions. Care providers have a responsibility to inform women's about clinical practices and to support them exercising their right to autonomy during pregnancy and birth (Kruske et al., 2013). This may involve discussing alternative care options, such as telemedicine, if appropriate.
In addition, health care workers should be mindful of the potential impact of COVID-19 on patients' mental and emotional well-being, and provide support and resources as needed.
This may include offering counselling services or connecting patients with community resources. Providers must understand autonomy and respect in order to identify gaps and challenges that might lead to quality improvement. Evidence about the quality of maternity care that is according on the perspectives of both users and providers can help to pinpoint which aspects of care need to be strengthened to increase the quality of care (Bhattacharyya et al., 2015).
Ultimately, good shared decision making and respect for patients during the COVID-19 pandemic requires health care workers to prioritize the needs and preferences of each individual patient, while also adhering to the latest public health guidelines and best practices for preventing the spread of COVID-19. Additional investigation is imperative to gather insights from midwives regarding respectful maternity care and collaborative decision-making with their patients. Such research would enhance the existing literature and overcome the constraints of the present study.

CONCLUSION, SUGGESTION,
In conclusion, this study found that mothers' decision-making during the COVID-19 pandemic was at a moderate level. However, many women reported low levels of respect, which may have been influenced by the health protocols and guidelines related to the pandemic in Indonesia. Therefore, healthcare workers in the maternity care field should prioritize the autonomy of mothers in decision-making and provide respectful care. It is also important to investigate the views of maternity staff on decision-making and respectful care in order to improve the way they treat mothers.

ACKNOWLEDGEMENT
This study had no conflicts of interest and did not receive any grants from agencies.
The researchers would like to express their gratitude to the respondents who participated in this study.