How Women Are Treated During Facility-Based Childbirth in Four Countries: A Cross-sectional Study With Labour Observations and Community-Based Surveys

Abstract

Background Women across the world are mistreated during childbirth. We aimed to develop and implement evidenceinformed, validated tools to measure mistreatment during childbirth, and report results from a cross-sectional study in four low-income and middle-income countries. MethodsWe prospectively recruited women aged at least 15 years in twelve health facilities (three per country) in Ghana, Guinea, Myanmar, and Nigeria between Sept 19, 2016, and Jan 18, 2018. Continuous observations of labour and childbirth were done from admission up to 2 h post partum. Surveys were administered by interviewers in the community to women up to 8 weeks post partum. Labour observations were not done in Myanmar. Data were collected on sociodemographics, obstetric history, and experiences of mistreatment. Findings 2016 labour observations and 2672 surveys were done. 838 (41•6%) of 2016 observed women and 945 (35•4%) of 2672 surveyed women experienced physical or verbal abuse, or stigma or discrimination. Physical and verbal abuse peaked 30 min before birth until 15 min after birth (observation). Many women did not consent for episiotomy (observation: 190 [75•1%] of 253; survey: 295 [56•1%] of 526) or caesarean section (observation: 35 [13•4%] of 261; survey: 52 [10•8%] of 483), despite receiving these procedures. 133 (5•0%) of 2672 women or their babies were detained in the facility because they were unable to pay the bill (survey). Younger age (15-19 years)and lack of education were the primary determinants of mistreatment (survey). For example, younger women with 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) were more likely to experience verbal abuse, compared with older women (≥30 years), adjusting for marital status and parity.Interpretation More than a third of women experienced mistreatment and were particularly vulnerable around the time of birth. Women who were younger and less educated were most at risk, suggesting inequalities in how women are treated during childbirth. Understanding drivers and structural dimensions of mistreatment, including gender and social inequalities, is essential to ensure that interventions adequately account for the broader context.

Respectful maternal and newborn care: measurement in one EN-BIRTH study hospital in Nepal

“…In Pokhara Hospital, women having caesareans are less likely to share a bed and are monitored more closely in the immediate postnatal period, which may also contribute to an increased feeling of satisfaction with standards of care. In many settings, higher socio-economic status is associated with both a higher prevalence of caesarean section and more respectful care [17]. Measurement tools for RMNC clearly require validation at a local level.…”

“…Many studies in the last decade have highlighted mistreatment of women during labour in LMICs [12][13][14], including physical and verbal abuse, discrimination based on maternal age (young or elderly), and ethnicity or social class [15,16]. Other manifestations of mistreatment included the provision of care without consent, obstructing the presence of a birth companion, and withholding food during labour without the woman's consent or a clinical indication [15,17]. In contrast, respectful care is synonymous with a positive user experience and should include women and families as active-participants throughout pregnancy and childbirth [18].…”

“…Improving RMNC requires a health systems approach to support frontline health workers' capacity to facilitate a positive experience of care [27]. A recent study highlighted that many health systems struggle to support family/woman-centred care [17]. This gap in service provision could risk a decline in facility births, and reverse the hard-won momentum for improving outcomes for maternal and newborn survival and reducing stillbirths.…”

Challenges and Coping Strategies Adopted by Midwives in Nursing Patients With Eclampsia in a Low Resource Setting: A Qualitative Descriptive Study

“…Also, another study in rural northern Ghana revealed that midwives lack beds to provide maternity services for women admitted to the health facilities [22]. Due to lack of suitable beds (do not have the necessary bed accessories such as side rails), some women in the current study were managed on the oor and this act is observed in resource constraint settings, where women would have to share beds with other women during and after childbirth or even nursed on the oor [23]. In this study, the midwives indicated that in instances where the beds had no side rails, family relatives were invited to sit by the side of the patient to prevent falls due to eclamptic seizures.…”

Facility-level determinants of quality routine intrapartum care in Afghanistan

“…Another possible mechanism is that RMC training helps reduce discrimination and stigma that may otherwise lead to inequitable quality of care. Studies have noted that women of younger age and lower education experience higher levels of disrespect and abuse during labor and delivery [36]. In Afghanistan, qualitative research has demonstrated that respectful maternity care is a gap that must be addressed [13,17].…”