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Summary
Background Women across the world are mistreated during childbirth. We aimed to develop and implement evidence- Published Online
informed, validated tools to measure mistreatment during childbirth, and report results from a cross-sectional study October 8, 2019
https://doi.org/10.1016/
in four low-income and middle-income countries. S0140-6736(19)31992-0
See Online/Comment
Methods We prospectively recruited women aged at least 15 years in twelve health facilities (three per country) in https://doi.org/10.1016/
Ghana, Guinea, Myanmar, and Nigeria between Sept 19, 2016, and Jan 18, 2018. Continuous observations of labour S0140-6736(19)32258-5
and childbirth were done from admission up to 2 h post partum. Surveys were administered by interviewers in the Gender and Women’s Health
community to women up to 8 weeks post partum. Labour observations were not done in Myanmar. Data were Unit, Centre for Health Equity,
Melbourne School of
collected on sociodemographics, obstetric history, and experiences of mistreatment.
Population and Global Health,
University of Melbourne,
Findings 2016 labour observations and 2672 surveys were done. 838 (41·6%) of 2016 observed women and Carlton, VIC, Australia
945 (35·4%) of 2672 surveyed women experienced physical or verbal abuse, or stigma or discrimination. Physical (M A Bohren PhD); UNDP/
UNFPA/UNICEF/WHO/World
and verbal abuse peaked 30 min before birth until 15 min after birth (observation). Many women did not consent
Bank Special Programme of
for episiotomy (observation: 190 [75·1%] of 253; survey: 295 [56·1%] of 526) or caesarean section (observation: Research, Development and
35 [13·4%] of 261; survey: 52 [10·8%] of 483), despite receiving these procedures. 133 (5·0%) of 2672 women or Research Training in Human
their babies were detained in the facility because they were unable to pay the bill (survey). Younger age (15–19 years) Reproduction, Department of
Reproductive Health and
and lack of education were the primary determinants of mistreatment (survey). For example, younger women with
Research, World Health
no education (odds ratio [OR] 3·6, 95% CI 1·6–8·0) and younger women with some education (OR 1·6, 1·1–2·3) Organization,
were more likely to experience verbal abuse, compared with older women (≥30 years), adjusting for marital status Geneva, Switzerland
and parity. (M A Bohren, H Mehrtash MPH,
S S Thwin PhD, S Landoulsi MSc,
A M Gülmezoglu PhD,
Interpretation More than a third of women experienced mistreatment and were particularly vulnerable around the Ö Tunçalp PhD); Department of
time of birth. Women who were younger and less educated were most at risk, suggesting inequalities in how women Obstetrics and Gynaecology,
are treated during childbirth. Understanding drivers and structural dimensions of mistreatment, including gender National Institute of Maternal
and Child Health, College of
and social inequalities, is essential to ensure that interventions adequately account for the broader context. Medicine, University of Ibadan,
Ibadan, Nigeria
Funding United States Agency for International Development and the UNDP/UNFPA/UNICEF/WHO/World Bank (Prof B Fawole MBBS);
Special Programme of Research, Development and Research Training in Human Reproduction, Department of Department of Medical
Research, Yangon, Myanmar
Reproductive Health and Research, WHO. (T M Maung MBBS,
N O Mon MBBS); Cellule de
Copyright This is an Open Access article published under the CC BY 3.0 IGO license which permits unrestricted use, Recherche en Sante de la
distribution, and reproduction in any medium, provided the original work is properly cited. In any use of this article, Reproduction en Guinee
(CERREGUI), Conakry, Guinea
there should be no suggestion that WHO endorses any specific organisation, products or services. The use of the (Prof M D Balde MBBS,
WHO logo is not permitted. This notice should be preserved along with the article’s original URL. B A Diallo MBBS,
A-M Soumah MBBS,
Introduction health indicators have historically focused on process and A O Sall MA); Department of
Population, Family and
High rates of avoidable maternal and newborn mortality coverage outcomes related to life-saving interventions Reproductive Health, School of
and morbidity in low-income and middle-income (eg, proportion of births with skilled attendance) and Public Health, University of
countries could be mitigated by improving quality of health outcomes (eg, maternal mortality). These indi Ghana, Legon, Ghana
care.1 A Lancet Global Health Commission1 highlighted cators do not fully reflect or correlate well with quality, (E Maya FWACS); Department
of Obstetrics and Gynaecology,
the need for high-quality health systems that improve nor account for women’s perceptions or experiences of Mother and Child Hospital,
health, and are valued, trusted, and responsive to dynamic care, particularly respect, communication, and emotional Oke-Aro, Akure,
population needs. Kruk and colleagues1 have called for support.2,3 Poor experiences of maternity care can nega Ondo State, Nigeria
(A K Aderoba FWACS);
health systems to “measure and report what matters most tively affect both the woman herself and future health-
Maternal and Child Health
to people”, including user experiences, health outcomes, seeking behaviours,4,5 but are typically not routinely Program, Burnet Institute,
competent care, and confidence in the system. Maternal assessed. For example, in a Cochrane review of continuous Melbourne, VIC, Australia
support for women during childbirth, only 11 (41%) of childbirth”.10 Manifestations and structural drivers of
27 trials reported women’s experiences, a primary review mistreatment are now well documented,5,11–13 but debate
outcome.6,7 remains about measurement approaches, including
Evidence suggests that women across the world experi the type (observation, woman-reported) and timing (exit
ence mistreatment during childbirth, including physical interviews, community-based interviews) of measure
abuse, verbal abuse, discrimination, non-consented pro ment.14–17 For example, across 15 studies in seven low-
cedures, and non-supportive care.5 Bowser and Hill’s income and middle-income countries,18–32 location, timing,
landscape analysis8 brought this issue to global attention and populations varied substantially: facility-based exit
and our mixed-methods systematic review developed a interviews,18,19,21,24,26,28 facility-based interviews during post
typology of what constitutes mistreatment.9 The WHO natal immunisation,23,27 and community-based inter
intrapartum care guideline recommends respect ful views20,22,25,26,29–32 with women from 3 h to 5 years post
maternity care for all women, which is care that maintains partum. The use of different populations, sampling, tools,
“dignity, privacy, and confidentiality, ensures freedom and data collection methods might influence the risk of
from harm and mistreatment, and enables informed bias (selection, social desirability, information, recall)
choice and continuous support during labour and and render cross-study and cross-context comparisons
challenging.14,15 Accurate measurement is essential to they were admitted for reasons other than childbirth,
improve accountability, design interventions, and measure were a first-degree relation to a facility employee, were
impact over time. distressed or otherwise unable to reasonably provide
In 2013, a technical consultation recommended that consent, resided outside the catchment area, or were
WHO initiate research to develop and validate tools to unable to provide sufficient contact information.
measure the mistreatment of women during childbirth.17 All women provided written consent. Institutional
The aim of the present study was to use a systematic, permission for recruitment and observation was obtained
evidence-informed approach to develop tools to provide from each site; consent was not sought from providers.
comparable data on the burden of mistreatment across This study was approved by the WHO Ethical Review
contexts. The formative phase consisted of systematic Committee, WHO Review Panel on Research Projects,
reviews9,33 and primary qualitative research34–39 in Nigeria, and in-country ethics committees. The country-specific
Ghana, Guinea, and Myanmar. Formative research and a ethical review committees that reviewed and approved
review of existing tools informed the measurement this project were Le Comité National d’Ethique pour la
phase, which used continuous observations of women Recherche en Santé (Guinea); Federal Capital Territory
during labour and childbirth, and community-based Health Research Ethics Committee (Nigeria); Research
surveys with post-partum women to measure the Ethical Review Committee, Oyo State (Nigeria); State
prevalence of mistreatment in Nigeria, Ghana, Guinea, Health Research Ethics Committee of Ondo State
and Myanmar. We report the prevalence of mistreatment (Nigeria); Ethical Review Committee of the Ghana Health
during childbirth based on continuous labour obser Service (Ghana); Ethical and Protocol Review Committee
vations and a community-based survey with women. of the College of Health Sciences, University of Ghana
(Ghana); and Ethics Review Committee, Department of
Methods Medical Research (Myanmar).
Study design and participants
Twelve health facilities (maternity hospitals and mater Procedures
nity units within general hospitals [eg, district or regional Each study site had two or three data collectors per shift
hospitals]; three per country, all in urban areas) were to manage recruitment and data collection. All data
purposively selected (appendix p 2). Health facilities were collectors were experienced women (aged ≥18 years) See Online for appendix
included in the study if they were not included in the trained in research methods, and not providers or
formative phase, were a secondary-level facility or higher, clinical trainees or students.14 All women admitted to
had at least 200 births per month, had a well defined the facility during the study period were assessed for
community catchment area, and allowed non-clinicians eligibility. Data collectors approached women face to
to perform observations. Data collection took place in face and invited them to participate. Women meeting
Nigeria from Sept 19, 2016, to Feb 26, 2017, in Ghana the eligibility criteria were provided with information
from Aug 1, 2017, to Jan 18, 2018, in Guinea from July 1 to about the study and those who agreed to participate
Oct 30, 2017, and in Myanmar from Jun 26 to Sept 5, 2017. consented and were enrolled. Women eligible to par
The labour observations were continuous, one-to-one ticipate in both the labour observation and survey were
observations of women by study researchers from asked to participate in both, and data were linked by the
admission, throughout labour and childbirth, until 2 h medical record number (results of linked data will be
post partum. Labour observations were not done in reported elsewhere).
Myanmar. The community-based survey was done with For the labour observations, every eligible woman could
women up to 8 weeks post partum. not be observed because of practical limitations around
Women were eligible for the labour observation if they the number of data collectors required. To minimise
were admitted for childbirth in early established or selection bias, when a data collector completed an obser
active labour (<6 cm cervical dilation), were aged at vation, she returned to the admissions area to enrol the
least 15 years, were willing and able to participate, and next eligible woman. Each participant was assigned a
provided informed consent. Women were not eligible number, used in all other data collection forms. Further
if they were admitted for reasons other than childbirth, communication between the data collector and the par
immediately transferred or taken directly to theatre, ticipant was dis couraged. The timeframe of interest
a first-degree relation to a facility employee (mother, was from admission until 2 h post partum, facility
sister, cousin), or distressed or otherwise unable to discharge, or maternal death (whichever happened first).
reasonably consent. Pregnant women who were not The data collector observed the participant continuously
admitted were eligible to participate if they returned throughout labour, childbirth, and up to 2 h post partum,
and were admitted for childbirth. meaning that there was one data collector per woman,
Women were eligible for the survey if they were observing only one woman at a time throughout the
admitted for childbirth, were aged at least 15 years, were period of interest. Data collection took place 24 h per day,
willing and able to participate, resided in the catchment 7 days per week to ensure no coverage gaps and mini
area, and provided consent. Women were not eligible if mise truncation bias (terminating the observation early
because the woman had not given birth). A structured For the survey, women received a telephone call at
observation guide was used to record interactions 2–3 weeks post partum to schedule the survey at a time
between the woman and provider and her birth and place of their convenience. Contact was attempted
environment. Recruitment con tinued until the facility up to three times over 2 weeks. Women who could not
sample size was reached. There was no contact with be contacted were recorded as lost to follow-up. Data
participants after the observation, unless they were also collectors travelled to the interview location, reaffirmed
enrolled in the survey. consent, and administered the survey in a private place
with no other people present. Recruitment continued Data were submitted using a 3G cellular connection.
until the facility sample size was reached; there was no Consistency checks of screening logs, recruitment,
contact after survey administration. and data were done weekly by WHO and country
research teams; inconsistencies were resolved during
Measurements data collection. Data analysis was done with SAS
An iterative mixed-methods approach was used for version 9.4.
tool development, described in detail elsewhere.14 The For observation and survey data, sociodemographics,
typology of mistreatment provided the structure, health outcomes, and interventions (categorical variables)
domains, and items.5 Both tools are available in open were aggregated and presented as proportion of the total
access.14 Data were collected using digital, tablet-based
tools (BLU Studio XL2, Android, BLU Products, Miami,
A
FL, USA).
The labour observation tool has three forms completed 2806 women screened for labour observation
and submitted at different times: (1) admission form;
(2) incident report form; and (3) childbirth, inter 787 excluded
ventions, and discharge form.14 The admission form was 30 not admitted for childbirth
82 transferred to other facility
completed once (immediately after enrolment) for all 175 cervical dilation >6 cm
women, and included screening questions and socio 2 age <15 years
demographics. The incident report form was completed 27 first-degree relative of staff
471 other reason
for the following events: physical or verbal abuse,
stigma or discrimination, or vaginal examination, and
could be submitted multiple times (repeating form 2019 eligible
for multiple events). For physical or verbal abuse and
stigma or discrimination, the incident report included
3 did not give consent
the timing and type of provider involved. For vaginal
examinations, information was collected about consent,
privacy, and confidentiality. The childbirth, interven 2016 included in analysis (eligible, identity
tions, and discharge form was completed once at the end confirmed, gave consent)
926 Ghana
of the observation for all women, and included pain 682 Guinea
relief, mobilisation, fluids, companionship, fees, neglect, 408 Nigeria
privacy, health outcomes, and interventions.
The survey tool had two forms completed and submitted B
at different times. The screening form assessed eligi
3806 women screened for community survey
bility.14 The survey form was completed during survey
administration,14 and included sociodemographics, birth
experiences (including mistreatment, vaginal examina 389 excluded
386 not eligible
tions, companionship, and pain relief), health outcomes, 3 eligibility not established
interventions, post-partum depression, and satisfaction
with care.
3417 eligible
Statistical analysis
Few data exist estimating the prevalence of mistreatment 745 excluded
of women during childbirth, complicating sample size 404 not able to reach by telephone
calculation. For the labour observation, we prespecified 135 moved, address not found, or incorrect
address
sample size for the development sample (Nigeria) of 100 did not give consent
130 women per facility and 390 women in total.14 For 94 sample size reached and not contacted
9 referred from hospital
the survey, we used the same calculation and assumed 3 screened before data collection
30% loss to follow-up between recruitment and survey start date
administration; the target sample size for Nigeria was
169 women per facility and 507 women in total. The
2672 included in analysis (eligible, identity
prevalence of any type of physical abuse, verbal abuse, or confirmed, gave consent, completed
stigma or discrimination in Nigeria was used as a proxy survey)
836 Ghana
for a prevalence estimate for the other countries. For 644 Guinea
the validation sample, the required sample size was 631 Myanmar
209 women per facility, and 627 women per country, 561 Nigeria
based on ±5% precision, 80% sensitivity, 5% type 1 error
(two-tailed), and 30% prevalence. Figure 1: Flow diagram for labour observation (A) and community survey (B)
study population and by country (see appendix p 3 for population, stratified by country. We assessed temporal
description of variables). patterns of physical or verbal abuse among women with
In the labour observation, specific acts of physical or complete observations for at least 1 h before and after
verbal abuse, and stigma or discrimination were childbirth using two methods: (1) aggregating the total
collected as recurring events. Observed events were number of incidents in 15-min intervals and deriving a
aggregated and presented as proportion of participants density measure of number of mistreatment events per
with at least one occurrence for the total study 1000 women for each 15-min interval, and (2) generalised
Ghana (n=836) Guinea (n=644) Myanmar (n=631) Nigeria (n=561) Total (n=2672)
Any physical abuse, verbal abuse, or stigma or 308 (36·8%) 235 (36·5%) 131 (20·8%) 271 (48·3%) 945 (35·4%)*
discrimination
Any physical abuse 52 (6·2%) 124 (19·3%) 21 (3·3%) 90 (16·0%) 287 (10·7%)*
Any verbal abuse 284 (34·0%) 173 (26·9%) 116 (18·4%) 248 (44·2%) 821 (30·7%)*
Any stigma or discrimination 31 (3·7%) 9 (1·4%) 11 (1·7%) 28 (5·0%) 79 (3·0%)*
Failure to meet professional standards†
Caesarean section 118 (14·1%) 76 (11·8%) 267 (42·3%) 22 (3·9%) 483 (18·1%)
Non-consented 24 (20·3%) 6 (7·9%) 21 (7·9%) 1 (4·5%) 52 (10·8%)*
Episiotomy (2187 women with vaginal birth)‡ 92 (12·8%) 52 (9·2%) 250 (68·7%) 132 (24·5%) 526 (24·1%)
Non-consented 38 (41·3%) 38 (73·1%) 166 (66·4%) 53 (40·2%) 295 (56·1%)*
Induction of labour 125 (15·0%) 3 (0·5%) 173 (27·4%) 48 (8·6%) 349 (13·1%)
Non-consented 24 (19·2%) 1 (33·3%) 60 (34·7%) 9 (18·8%) 94 (26·9%)
Vaginal examinations
Woman had any vaginal examination 808 (96·7%) 589 (91·5%) 505 (80·0%) 543 (96·8%) 2445 (91·5%)
No consent before vaginal examination 379 (46·9%) 294 (49·9%) 232 (45·9%) 309 (56·9%) 1214 (49·7%)*
Staff member discussed private health information 55 (6·8%) 67 (11·4%) 71 (14·1%) 210 (38·7%) 403 (16·5%)
from vaginal examination so that others could hear
Vaginal examination not done privately 236 (29·2%) 292 (49·5%) 131 (25·9%) 365 (67·2%) 1024 (41·9%)*
General description of experience of vaginal examinations
Comfortable 71 (8·8%) 153 (26·0%) 375 (74·3%) 46 (8·5%) 645 (26·4%)*
A little uncomfortable 142 (17·6%) 193 (32·8%) 93 (18·4%) 141 (26·0%) 569 (23·3%)*
Quite uncomfortable 217 (26·9%) 125 (21·2%) 21 (4·2%) 144 (26·5%) 507 (20·7%)*
Very uncomfortable 371 (45·9%) 115 (19·5%) 11 (2·2%) 203 (37·4%) 700 (28·6%)*
Pain relief
Woman not offered pain relief during time in hospital 511 (61·1%) 456 (70·8%) 90 (14·3%) 471 (83·9%) 1528 (57·2%)*
Woman requested pain relief 85 (10·2%) 212 (32·9%) 181 (28·7%) 51 (9·1%) 529 (19·8%)
Woman requested pain relief but did not receive it 40 (47·1%) 67 (31·6%) 15 (8·3%) 29 (56·9%) 151 (28·5%)*
Woman denied pain relief during time in hospital 46 (5·5%) 19 (3·0%) 34 (5·4%) 50 (8·9%) 149 (5·6%)*
Neglect and abandonment
Staff member not present when the baby came out 24 (3·4%) 2 (0·4%) 2 (0·6%) 16 (3·0%) 44 (2·0%)
(2187 women with vaginal birth)‡
Woman waited for long periods of time before 281 (33·6%) 75 (11·7%) 139 (22·0%) 92 (16·4%) 587 (22·0%)*
attended by health workers
Woman felt ignored, neglected, or that presence was 137 (16·4%) 72 (11·2%) 121 (19·2%) 104 (18·5%) 434 (16·2%)*
a nuisance for health workers or staff
Communication
Language interpretation needed 10 (1·2%) 15 (2·3%) 0 2 (0·4%) 27 (100·0%)
Interpreter not available 2 (20·0%) 3 (20·0%) 0 2 (100·0%) 7 (25·9%)*
Woman felt that health workers or staff did not listen 105 (12·6%) 113 (17·6%) 200 (31·7%) 59 (10·5%) 477 (17·9%)
and respond to her concerns
Supportive care
Not allowed to have a labour companion during 486 (58·1%) 336 (52·2%) 5 (0·8%) 373 (66·5%) 1200 (44·9%)*
labour and birth
Did not have a labour companion present at any point 437 (52·3%) 560 (87·0%) 1 (0·2%) 320 (57·0%) 1318 (49·3%)*
Autonomy
Did not have easy access to water or oral fluids 89 (12·4%) 74 (13·1%) 50 (13·7%) 214 (39·7%) 427 (19·5%)*
(2187 women with vaginal birth)‡
Not allowed to eat (2187 women with vaginal birth)‡ 298 (41·6%) 82 (14·5%) 1 (0·3%) 327 (60·7%) 708 (32·4%)*
Woman not told to or did not mobilise during labour 707 (84·6%) 60 (9·3%) 317 (50·2%) 523 (93·2%) 1607 (60·1%)
Woman did not have a preferred birthing position 810 (96·9%) 517 (80·3%) 512 (81·1%) 526 (93·8%) 2365 (88·5%)
Woman or baby detained in hospital because of 40 (4·8%) 56 (8·7%) 7 (1·1%) 30 (5·4%) 133 (5·0%)
inability to pay hospital bills
(Table 5 continues on next page)
Ghana (n=836) Guinea (n=644) Myanmar (n=631) Nigeria (n=561) Total (n=2672)
(Continued from previous page)
Health systems
Curtains, partitions, or other privacy measures not 65 (7·8%) 339 (52·6%) 330 (52·3%) 468 (83·4%) 1202 (45·0%)
used
Staff suggested or asked for a bribe, informal 104 (12·4%) 306 (47·5%) 255 (40·4%) 60 (10·7%) 725 (27·1%)
payment, or gift
Woman instructed to clean up own blood, urine, 8 (1·0%) 6 (0·9%) 99 (15·7%) 5 (0·9%) 118 (4·4%)
faeces, or amniotic fluid after birth
See appendix (pp 11–14) for extended version. *Results with significant p values (p<0·05). χ² test used to compare proportions of mistreatment items across countries.
†Procedure explained and woman agreed to the procedure (informed consent). ‡Number of women with vaginal birth per country: Ghana, n=717; Guinea, n=567; Myanmar,
n=364; Nigeria, n=539.
women with no education (OR 3·6, 95% CI 1·6–8·0) stigma or discrimination during labour, with younger,
and younger women with some education (OR 1·6, less educated women at highest risk, suggesting
1·1–2·3) were more likely to experience verbal abuse, inequalities in how women are treated during child
compared with older women (≥30 years), adjusting birth. This finding is supported by qualitative research
for marital status and parity. Younger, unmarried in the study countries showing that adolescents experi
women were more likely to have non-consented vaginal enced mistreatment because of judgments made by
examinations (OR 4·6, 95% CI 1·7–12·3), adjusting health-care providers about their age and engagement in
for country. Women who reported no use of privacy sexual activity.38 Furthermore, observation and survey
measures, such as curtains, were more likely to report data show that many women have vaginal examinations
lack of privacy (OR 3·4, 95% CI 2·3–5·0), compared and procedures (caesarean section, episiotomy, induc
with women who had privacy measures used, adjusting tion) done without their consent. 4·5% of observed and
for age, education, marital status, and parity. Women 2·0% of surveyed women gave birth without the
giving birth for the first time were less likely to report presence of a skilled attendant, and 5·0% of women
long wait times or delays (OR 0·8, 95% CI 0·6–0·9), reported detainment because they were unable to pay
compared with women with previous births. Unadjusted the hospital bill.
and adjusted predictors were not significant for neglect Other studies exploring mistreatment during childbirth
and autonomy outcomes. using observations have different periods of interest,
clinical observers, measurement tools, and outcomes,
Discussion thus complicating comparison (appendix pp 15–16).18,21,30,40–43
We report observed experiences of mistreatment from In brief, studies in Ethiopia, Malawi, and Kenya reported
2016 labour observations, and woman-reported experi lower frequencies of physical abuse (0·2% to 9·0%) and
ences of mistreatment from a community-based survey verbal abuse (1·9% to 18·1%),40,41,43 and similar proportions
of 2672 post-partum women. We found that during of non-consented proce dures (17·1% to 77·0%)41,43 and
labour observations, 41·6% of women had experiences non-consented vaginal examinations (20·5% to 81·0%).41,42
of physical abuse, verbal abuse, or stigma or dis Four studies measured mistreatment using community-
crimination, most commonly occurring from 30 min based surveys within a similar time period (2–12 weeks
before birth until 15 min after birth. The increased risk post partum).20,24,25,30 Studies in India, Brazil, and Tanzania
during this period might be because providers are more showed lower frequencies of physical abuse (<1·0% to
likely to be present around the time of birth, or because 5·1%) and verbal abuse (2·6% to 10·0%). Afulani and
of stressors influencing provider behaviour (such as colleagues44 measured person-centred care in Ghana,
availability of resources, and clinical skills to manage India, and Kenya, and reported that providers did not
childbirth and complications). According to qualitative explain the purpose of examinations or procedures for
research, midwives and doctors described women as two-thirds of women, slightly higher than the propor
“uncooperative” during this period and some justified tion seen in our study.
using physical and verbal abuse as “punishment” for Key strengths of our study are the use of an evidence-
non-cooperation and to ensure “good outcomes” for the informed typology of mistreatment, and measurement
baby.34,35 Although concerns about the baby’s wellbeing tools based on an iterative development process
might provide a partial explanation during this time including primary qualitative research. For the observa
period in particular, such abusive behaviours will likely tions, we had 24 h per day, 7 days per week data collection,
only worsen women’s anxiety, distress, and disempower reducing the risk of selection and truncation bias.
ment. Similarly, in the community survey, more than a Non-clinical observers might reduce the risk of under-
third of women reported physical abuse, verbal abuse, or reporting because of the normalisation of mistreatment
Physical Verbal Verbal Any physical Non-consented Non-consented No privacy or Long wait Felt ignored, Mobilisation
abuse abuse abuse or verbal vaginal vaginal lack of privacy times or neglected,
(by no (by at least abuse, or examination examination during delays or their
education) some stigma or (by single (by marital status vaginal presence was a
education) discrimination marital status) other than single) examination nuisance
Age
15–19 years 1·8 3·6 1·6 1·9 4·6 1·2 1·1 1·3 1·0 1·0
(1·1–2·8)* (1·6–8·0)† (1·1–2·3)‡ (1·4–2·6)§ (1·7–12·3)¶ (0·8–1·6) (0·9–1·2) (0·9–1·9) (0·7–1·6) (0·9–1·1)
20–29 years 1·1 1·1 1·3 1·2 1·9 1·2 0·9 1·1 1·0 1·0
(0·8–1·5) (0·6–1·9) (1·0–1·6) (1·0–2·5) (0·8–4·9) (1·0–1·5) (0·9–1·1) (0·9–1·4) (0·8–1·3) (0·9–1·1)
≥30 years 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref)
Education
No education 0·83 NA NA 1·0 NA NA 1·1 1·2 1·2 NA
(0·6–1·2) (0·7–1·3) (0·9–1·2) (0·8–1·8) (0·8–1·8)
At least some education 1 (ref) NA NA 1 (ref) NA NA 1 (ref) 1 (ref) 1 (ref) NA
Marital status
Single 1·2 1·2 1·1 1·1 NA NA 1·1 0·8 0·9 1·1
(0·7–1·8) (0·4–3·3) (0·8–1·6) (0·8–1·5) (0·9–1·2) (0·6–1·2) (0·6–1·3) (1·0–1·2)
Other than single|| 1 (ref) 1 (ref) 1 (ref) 1 (ref) NA NA 1 (ref) 1 (ref) 1 (ref) 1 (ref)
Number of previous births
First birth 1·21 0·7 1·0 1·0 NA NA 1·0 0·8 0·9 1·0
(0·9–1·6) (0·4–1·2) (0·8–1·2) (0·8–1·2) (0·9–1·1) (0·6–0·9)** (0·7–1·1) (0·9–1·0)
≥2 births 1 (ref) 1 (ref) 1 (ref) 1 (ref) NA NA 1 (ref) 1 (ref) 1 (ref) 1 (ref)
Curtains used
No NA NA NA NA NA NA 3·4 NA NA NA
(2·3–5·0)††
Yes NA NA NA NA NA NA 1 (ref) NA NA NA
Data are odds ratio (95% CI). Verbal abuse was stratified by no education and some education because of an interaction between education and age. Non-consented vaginal examinations were stratified by
single and not single marital status because of an interaction between age and marital status. Results with significant p values (p<0·05) are indicated. NA=not applicable. *p=0·0077. †p=0·0004. ‡p=0·0460.
§p=0·0005. ¶p=0·0014. ||Includes currently married, separated, divorced, widowed, cohabitating, or other. **p=0·0109. ††p<0·0001.
Table 6: Multivariable logistic regression models to assess factors potentially associated with mistreatment (community survey)
by clinical observers. Non-clinical observers might have Ghana, which might have affected recall. Finally, all
difficulty understanding clinical aspects of childbirth; study facilities were public and in urban areas, which
we addressed this issue by including obstetricians and might limit generalisability. Despite the risk of under-
midwives in training workshops. Our observations estimation inherent in the use of observational and
might be limited by the Hawthorne effect because the self-reported data collection methods, we found that
observers’ presence might alter provider behaviour, mistreatment during childbirth was a serious issue, and
resulting in underestimation of mistreatment. Explo use of two separate measurement methods is a key
ration of the Hawthorne effect by facility, country, and strength of this study.
month of recruitment in our study showed no evidence More work is needed to explore how woman-reported
of its presence (appendix pp 17–18). In the survey, we experiences of mistreatment during childbirth can be
prospectively identified all eligible women, and had feasibly integrated into quality improvement initiatives,
lower than expected loss to follow-up (548 [16·0%] of and further adaptation will be required to use these
3417 eligible women). Surveys were community-based to tools for facility-based assessments of women’s ex
reduce the risk of bias inherent with exit interviews periences within widely used mechanisms.46 Further
(courtesy or social desirability). We asked women about analyses are in progress to develop consolidated meas
experiences of specific items of mistreatment9 rather urement scales, which might be more practical for
than an overall question about experience of mistreat targeted monitoring and quality improvement. Within
ment to reduce information bias, which is in agreement country implementation, the Quality of Care Network is
with standards of measuring violence against women.45 standardising measurement of women’s maternity care
Some experiences of mistreatment are more subjective experiences, and nine low-income and middle-income
(eg, discrimination); future analyses are planned on a countries are currently testing these tracer indicators.1,47
linked subgroup who participated in both the observation Understanding drivers and structural dimensions of
and survey to explore subjectivity of experiences. The mistreatment during childbirth, such as gender and
median time from birth to survey administration varied social inequalities, and judgments about women’s
from 35 days (IQR 21–44) in Nigeria to 58 days (41–78) in sexuality, is essential to ensure that any interventions
adequately account for societal context. Sen and col Declaration of interest
leagues12 hypothesised that structural dimensions influ We declare no competing interests.
ence mistreatment during childbirth via historical biases, Acknowledgments
power inequalities, normalisation of poor treatment, and This paper is dedicated to the memory of our dear colleague and friend,
Bukola Fawole. We would like to express our sincere gratitude to the
communication barriers. Further research is needed to women who participated in this study for allowing us to observe and ask
understand how institutional structures and processes questions about such an intimate time of their lives. We thank the data
can be reorganised to provide better woman-centred collection team for their excellent work, particularly during the data
care. The depth of these challenges suggests that it is collection period. We appreciate the thoughtful contributions of
Mary Ellen Stanton, Neal Brandes, Jigyasa Sharma, Emma Sacks,
unlikely that interventions that do not address these and Blair Berger to the design and conduct of this analysis. Many thanks
factors, such as one-off training, will have a lasting to Charlotte Warren who provided additional information about her
effect on behaviour change. This situation is further research. Thank you to Kyaw Zin Thant, Hla Mya Thway Einda,
complicated by the fact that many providers, particularly and Khaing Nwe Tin for their support in Myanmar, and Adesina Akintan
for his support in Nigeria. This research was made possible by the
midwives, are women and experience mistreatment support of the American People through the United States Agency for
and gender discrimination themselves both within International Development (USAID) and the UNDP/UNFPA/UNICEF/
and outside of the health system.48 WHO/World Bank Special Programme of Research, Development and
Nevertheless, our study shows clear areas for targeted Research Training in Human Reproduction (HRP), Department of
Reproductive Health and Research, WHO. The contents of this Article
quality improvement that addresses country-specific or are the sole responsibility of the authors and do not necessarily reflect
facility-specific challenges, or both, particularly around the views of USAID, the United States Government, WHO, or their
communication and consent. Provider training to sup individual institutions.
port women to give birth in other positions might build References
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