Plain English summary
Background
Methods
Terminology and Definitions of mistreatment
Terminology and definitions of mistreatment in Latin America and the Caribbean
Challenges to the definition of mistreatment
Measurement of mistreatment
Quantitative methodologies for the measurement of mistreatment
Author/Year/Location | Study Purpose | Study Population | Methodology | Detailed Methodology |
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Reis et al., 2005, Nigeria [53] | To conduct a population-based assessment of health workers’ attitudes and practices of discrimination against people with HIV in clinical settings. | 1021 Nigerian health-care professionals (including 324 physicians, 541 nurses, and 133 midwives identified by profession) in 111 health-care facilities in four Nigerian states. | Cross-sectional study with two surveys | The first included 104 items with questions on respondent demographics; practices regarding informed consent, testing, and disclosure; treatment and care of patients with HIV/AIDS; and attitudes and beliefs about treatment and care of patients with HIV/AIDS including informed consent, testing, and disclosure. Treatment and care practices were assessed using Likert-type scales. Attitudes were assessed by a response of “agree” or “disagree” with statements regarding testing, treatment, and care of patients with HIV/AIDS. The second instrument had 103 items that asked about each facility’s capacity, resources, and policies from facility directors. |
De Marco et al., 2008, Oregon, USA [74] | To assess women’s perceptions of being discriminated against during prenatal care, labor, and delivery; to assess the relationship between perceived experiences of discrimination and maternal/infant characteristics and frequency of infant checkup appointments. | 5672 women living in Oregon who participated in 3 cohorts from the Pregnancy Risk Assessment Monitoring System (PRAMS) study. | Analysis of survey data from cohort study | The study analyzed data from the 1998–1999, 2000, and 2001 Oregon PRAMS study, which collected information about the attitudes and experiences of women through the continuum of maternal health care. To assess perceived discrimination in health care, the PRAMS asked women if they felt they had ever been treated differently by health care providers during prenatal care, labor, or delivery because of their race, culture, ability to speak or understand English, age, insurance status, neighborhood in which they lived, religious beliefs, sexual orientation or lifestyle, marital status, or desire to have an out-of-hospital birth. Response categories included “yes” and “no.” |
Faneite et al., 2012, Venezuela [41] | To understand the extent to which health care providers understand national laws on obstetric violence and the mechanisms for reporting it. | 500 health workers in three maternity hospitals in different parts of the country recruited through purposive sampling. | Cross-sectional study with survey | The study was conducted shortly after Venezuela passed legislation defining and outlawing obstetric violence. Participants completed the self-administered questionnaires in the hospitals where they worked. Questions consisted of yes/no questions about different types of obstetric violence and then open questions about the identification of who is responsible for violence and how to report it. Researchers were present while participants completed the survey. The study found little knowledge about details of the law or obstetric violence. |
Terán et al., 2013, Venezuela [40] | To evaluate the perceptions of women using maternal health care services regarding experiences of obstetric violence. | 425 postpartum women still admitted at one national hospital. | Cross-sectional study with survey | The survey included questions about women’s experiences of acts that would constitute obstetric violence according to the Venezuela Organic Law about the Rights of Women to a Life Free of Violence. Researchers analyzed the absolute frequency, percentages, and standard deviations of different experiences of obstetric violence. |
Kruk et al., 2014, Tanzania [43] | To assess the frequency of reported disrespect and abuse during childbirth in rural areas of Tanzania. | 1779 who had recent given birth at any of two district hospitals, five government health centers, and one government health dispensary and were recruited upon exiting the hospital. | Cross-sectional study with exit survey and follow-up survey | Questionnaires were administered to 1779 women upon exiting the health facilities, and follow-up surveys were administered to a random subset (593 women) of those initial participants between 5 and 10 weeks after giving birth. Surveys included 14 questions about potential experiences of abuses that were modeled on the categories of disrespect and abuse during childbirth developed by Bowser and Hill [5]. Responses were categorized as “experienced” or “not experienced.” Researchers determined frequencies and logistic regression to analyze associations between abusive treatment and individual and birth experience characteristics. |
To assess levels of disrespect and abuse during childbirth as part of a pre and post intervention. | Women ages 15–45 who had delivered with 24–48 h at one of the 13 hospitals included in the intervention, regardless of their pregnancy outcome. | Cross-sectional study with exit survey, and structured observation checklists | Women were administered a questionnaire concerning mistreatment in general as well as typologies based on the categories developed by Bowser and Hill. General questions about mistreatment were constructed using a Likert scale, and questions about specific types of mistreatment were asked in a “yes” or “no” format. Midwife or nurse researchers also conducted structured observations of patient-provider interactions during labor using a checklist of seven categories of mistreatment. Observations measured both process (how patients are treated) and content (what they were told, revealing technical competency, accuracy of information and provision of essential information) of services. | |
Asefa and Bekele, 2015, Ethiopia [61] | To quantitatively determine the level and types of disrespect and abuse faced by women during childbirth at four health centers in Ethiopia. | 173 who had recently had a vaginal delivery at one of the study sites were recruited via purposive sampling before being discharged from the health centers. | Cross-sectional study with exit survey | This cross-sectional study administered exit surveys that asked participants about experiences of 23 different types of mistreatment, which were grouped into seven categories. The types of mistreatment were determined through the seven categories of mistreatment defined by Bowser and Hill, and the verification criteria were developed as part of the Maternal and Child Health Integrated Program (MCHIP). Participants’ objective and subjective experiences of mistreatment were taken into consideration. |
Kujawski et al., 2015, Tanzania [44] | To assess the association between perceived experiences of mistreatment and delivery satisfaction, perceived quality of care, and intention to deliver at the same facility in the future. | 1388 postpartum women upon discharge from two hospitals in Tanzania. A subset of women received another survey 5–10 after the initial survey. | Cross-sectional study with survey | This study drew from a subset of participants in the Kruk et al. study in Tanzania [43]. Multivariable logistic regression models were used to assess the association between mistreatment and (1) satisfaction with delivery, (2) perceived quality of care for delivery, and (3) intent to use the same facility for a future delivery, controlling for confounders. Participants were asked to rate their satisfaction with delivery from four response choices: very satisfied, somewhat satisfied, somewhat dissatisfied and very dissatisfied. Women rated the quality of care they received for their delivery as excellent, very good, good, fair, or poor. Responses were dichotomized into excellent and very good compared to good, fair, and poor – categories based on past research, which indicated potential for courtesy bias among the population. The instrument drew from Bowser and Hill [5] and had “yes” and “no” questions about experiences of various forms of mistreatment. |
Lukasse et al., 2015, Belgium, Iceland, Denmark, Estonia, Norway & Sweden [72] | To assess the impact of reported experiences of Abuse in Health Care (AHC) on women’s fear of childbirth and desire for a cesarean delivery. | 6923 pregnant women attending routine prenatal care who participated in the Belgium, Iceland, Denmark, Estonia, Norway, and Sweden (BIDENS) cohort study. | Analysis of survey data from multi-country cohort study | The BIDENS study questionnaire included general questions on participants’ demographic and socioeconomic characteristics, mental health, and obstetric history. The questions on abuse were taken from the Norvold Abuse Questionnaire (NorAQ) and included three descriptive questions about experiences of AHC and one scaled-question about frequency of past experiences of AHC. Fear of childbirth (FOC) was assessed by the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) version A. Women were also asked how they would prefer to give birth. Current and past experiences of AHC were associated with the other variables of interested. |
Okafor et al., 2015, Nigeria [52] | To determine the prevalence of disrespect and abuse of women during childbirth at a large teaching hospital in Nigeria. | Convenience sample of 437 women who were accessing immunizations for their newborns within six weeks after delivery. | Cross-sectional study with survey | This cross-sectional study included a structured questionnaire with questions concerning disrespect and abuse. Mistreatment was grouped into seven categories based on the work of Bowser and Hill [5]. Participants were given yes/no as possible responses. |
Rosen et al., 2015, Ethiopia, Kenya, Madagascar, Rwanda, Tanzania [46] | To gather the prevalence of mistreatment during childbirth at a diverse array of health centers in five countries in Africa. | Direct observations of 2164 labor and delivery processes. | Structured clinical observation checklists | Observations were part of a larger cross-sectional study called the Maternal and Child Health Integrated Program (MCHIP), conducted between 2009 to 2012. The observation checklist included 10 actions the providers should perform to guarantee that the client received respectful care. Elements of respectful care derived from the rights discussed in the Respectful Maternity Care Charter. For each country, percentage of women receiving these practices and delivery room privacy conditions were calculated. Observers’ open-ended comments were also analyzed to identify examples of mistreatment. Researchers tried to minimize the Hawthorne effect by letting health care providers know that the observations were anonymous and would not be reported if they did anything wrong. Obstetric professionals were trained as observers, used paper checklists or smartphones. |
Valdez-Santiago, 2015, Mexico [39] | To characterize the types of abuse that occur in obstetric facilities in three hospitals of Morelos, Mexico. | 512 women recruited immediately after giving birth in the postpartum areas of the study sites. | Cross-sectional study with survey | The study consisted of a structured questionnaire about experiences of abuse during labor, delivery, or postpartum care from the perspective of women. Questionnaire asked mostly yes/no questions. |
Moyer et al., 2016, Ghana [54] | To examine what midwifery students learn and witness concerning respectful labor and delivery care. | 853 students in the final year of their studies at 15 midwifery schools. | Cross-sectional study with computer-based survey | The cross-sectional study consisted of a computer-based self-administered survey. In addition to questions about demographics, the survey included questions about working in underserved areas, observations of respectful and disrespectful care during training, and perceptions of working conditions in the clinical settings where students train. For questions about witness events, participants had three choices of responses: “rarely or never,” “sometimes,” or “most of the time.” Surveys took between 30 and 45 min to complete, and participants received small monetary incentives. |
Qualitative methodologies for the measurement of mistreatment
Author/Year/Location | Study Purpose | Study Population | Methodology | Detailed Methodology |
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Castro & Erviti, 2003, Mexico [15] | To shed light on various sociological factors that contribute to abuse during facility-based childbirth. | 200 women who reported abuses in medical facilities in Mexico, and another 64 observations of patient-provider interactions during labor and delivery. | Unstructured birth testimonies and qualitative direct observation | The study consisted of three phases. First, researchers compiled approximately 200 testimonies from women who reported having experienced various types of mistreatment over a five-year period. Many testimonies were collected from other studies that did not directly intend to measure mistreatment. Second, testimonies were assessed using qualitative methodology, looking for patterns that emerge from the testimonies. Third, researched conducted direct observation in labor and delivery rooms in the two largest public hospitals in Cuernavaca. |
Beck, 2004, New Zealand, USA, Australia, and United Kingdom [71] | To gain insight on the factors that contribute to reported traumatic experiences during childbirth. | 38 women who had given birth within the previous 5 weeks to 14 years and reported emotional trauma from their birth experiences. | Written birth narratives | Participants were recruited online through Trauma and Birth Stress (TABS), a charitable trust based in New Zealand that helps women who have experienced PTSD during their childbirth experiences. Over an 18-month period, participants were asked to write and submit descriptions of their traumatic birth experiences, which were analyzed using Colaizzi’s method of thematic data analysis. Overall study methodology included descriptive phenomenology. |
Steele & Chiarotti, 2004, Argentina [42] | To understand experiences of mistreatment for women who access post-abortion care. | 300 women who received post-abortion care at public hospitals in Rosario, recruited through women’s community organizations, health workers, and community contacts. 31 women also gave testimonies. | Focus group discussions as part of full day workshops, role play of care scenarios, unstructured testimonies | Researchers organized 13 workshops, in which women participated in discussions about mistreatment and discrimination while seeking post-abortion care and engaged in role-play scenarios of receiving care. Investigators reported that role-play was effective in helping women discuss personal, sensitive, and taboo topics. 31 women gave in-depth testimonies of their experiences. Those interviews were unstructured. |
d’Ambruoso et al., 2005, Ghana [57] | To gather women’s perspectives of their interactions with maternal health care providers and assess the acceptability of maternal health services. | Opportunistic sample of 21 women who were participating in another study in Ghana and had accessed maternal health services in the prior five years. | Focus group discussions, in-depth interviews | This study was part of the SAFE initiative, which aimed to increase the knowledge base on skilled birth attendance in various developing countries. The topics of semi-structured interviews and focus group discussions drew from the SAFE study framework and included: (1) Place of delivery, (2) Satisfaction with services, (3) Recommendations of care, (4) Recommendations of services to other women. Investigators first started using focus groups discussions, but abandoned that research strategy in favor of in-depth interviews when it became clear that women were not comfortable sharing personal, emotional experiences in front of a group. Interviews were conducted at a location of the participant’s choosing. The methodology was based on the constructivist paradigm toward enquiry. |
Marque et al., 2006, Brazil [35] | To understand nurses’ perspectives of the humanization of childbirth. | 12 nurses in obstetric wards recruited from study hospitals with convenience sampling. | Semi-structured interviews | Semi-structured interviews were categorized into (1) the meaning of “humanization” of childbirth, (2) examples of “humanizing” practices, (3) examples of “dehumanizing” practices, (4) role of nurses in humanizing care. Participant interviews were transcribed and analyzed using thematic analysis. |
Muñoz, 2008, Spain [69] | To understand the forms of abuse that occurs during facility-based childbirth. | 10 women who had just given birth at a hospital. | In-depth interviews and qualitative direct observations | The study consisted of in-depth interviews and participant observations with 10 women who had recently given birth in hospitals. Themes that emerged from the interviews included hierarchal and asymmetric power structures with doctors in hospitals, in which patients are passive, obedient, and submissive to the physicians’ demands. The author used patients’ descriptions of mistreatment as a framework to discuss gender inequalities within society. |
Santos & Shimo, 2008, Brazil [36] | To understand women’s knowledge and consent to episiotomies during childbirth. | 16 women who received episiotomies during their births at a teaching hospital. | Semi-structured interviews and unstructured observations | Semi-structured interviews asked women about their knowledge of episiotomies, whether someone asked their permission to perform an episiotomy, and information given to them by medical personnel about episiotomies. Interviews took place three days after the woman’s delivery and were audio-recorded and transcribed. Observations were conducted throughout participants’ labor, delivery, and postpartum period at the hospital. |
Kruger et al., 2010, South Africa [67] | To understand the psychological experiences of giving birth and working as a nurse in South African maternity wards. | 93 low-income, Afrikaans-speaking women who gave birth in maternity wards and 8 of the 12 of the maternity ward nurses. | Semi-structured interviews | Researchers conducted semi-structured interviews with maternity ward nurses to ask about the psychological experiences of their work. They were never directly questioned about violence or abuse of patients, though that was the topic of interest. Women who had recently delivered with interviewed and asked about experiences in which they did not like nurses’ behaviors. Participants participated in four interviews (during pregnancy, a few days after giving birth, three months after giving birth and six months after giving birth) by the same interviewer. Interviews were analyzed using social constructionist grounded theory and coded. The study helped to shed light on some of the structural drivers of mistreatment as it demonstrated that nurses’ aggressive behaviors might stem from hierarchal power structures within hospitals. |
de Aguiar & d’Oliveira, 2011, Brazil [32] | To understand the dynamic between power structures and institutional violence in maternity care from the perspective of women using public services. | 21 women who had given birth within three months before the interview. | Semi-structured interviews | Semi-structured interviews were conducted at participants’ homes to allow for participants’ comfort. The number of interviews was determined by when investigators thought saturation was reached. The interview guide contained open-ended questions that asked about access, quality of care, and previous experiences with public maternity hospitals, and women’s perceptions and experiences of mistreatment. Results shed light on how obstetric violence occurs against patients and how patients learn to adapt strategies of acceptance or resistance against mistreatment. Results also indicate that many patients come to trivialize and expect mistreatment as part of the care process. |
Janevic et al., 2011, Serbia and Macedonia [70] | To develop a conceptual framework showing how different levels of racism occur in maternal health settings and affect access to maternal health care among Romani women. | 71 Romani women who had given birth within the past year recruited through purposive sampling, 8 gynecologists, 11 key informant interviews from NGOs & state institutions recruited through snowball sampling. | Community-based participatory research study with focus groups and semi-structured interviews | Based on community-based participatory research principles, the study included focus group discussions with Romani women with questions on health knowledge and beliefs during pregnancy, what women did after they found out they were pregnant, and experiences during prenatal care and delivery. The study also included semi-structured interviews with gynecologists and key informants. For gynecologists, interview questions focused on the provider practices, their daily challenges, and experiences with Romani patients. For key informants from NGOs, interviews focused on barriers to maternal care for Romani women. Experiences of racism in maternal health care were organized into a framework of three categories: institutional racism, personally-mediated racism, and internalized racism. |
de Souza et al., 2011, Brazil [38] | To explore how health care providers perceive the humanization of childbirth. | 17 professionals who work in four hospitals, two public, one affiliated with SUS, and one not affiliated with SUS. | Semi-structured interviews | The study used semi-structured interviews to examine perceptions of the humanization of childbirth care process as defined by national legislation. Thematic analysis revealed three principle categories: (1) the meaning of humanization; (2) practice of humanized care, and (3) difficulties in practicing humanized childbirth care. The study showed deficiencies in healthcare infrastructure and medical training that leave personnel not fully equipped to provide humanized care. |
Aguiar et al., 2013, São Paolo, Brazil [33] | To understand the dynamic between institutional violence, gender, and power structures in public maternity hospitals. | 21 women who had given birth at public hospitals within three months, 18 health care workers recruited through snowball sampling. | Semi-structured interviews | Interview questions focused on participants’ experiences and definition of violence. Interviews were conducted a location of participants’ choosing outside of the hospitals. Transcripts were analyzed using thematic coding and considered the social position of the participants (gender, age, income, race, etc.). The study found that health providers acknowledged violent practices but didn’t see them as violence but as necessary in a ‘difficult’ context and for the patients ‘own good. |
Moyer et al., 2013, Ghana [55] | To examine community and health providers attitudes towards mistreatment during delivery incorporating a human rights perspective. | 128 community members, including women with their newborn infants, and 13 health care providers recruited purposively at hospitals and health facilities. | Semi-structured interviews and focus group discussions | Community member participants were identified through community key informants in two randomly selected zones of study areas. Topics for interviews and focus group discussions were constructed using the Respectful Maternity Care Charter with an additional category concerning traditional birth practices. Both interviews and FGDs were analyzed using NVIVO thematic analysis. |
Mselle et al., 2013, Tanzania [45] | To identify potential weaknesses in acceptable and quality care for women who suffer obstetric fistula. | 16 women who suffered obstetric fistula, 5 nurse-midwives, six husbands of affected women, and six community members. | Semi-structured interviews and focus group discussions | Data collection was carried out over two years at a Comprehensive Community Based Rehabilitation Center. Semi-structured interviews were conducted with women about their experiences of care and with nurse-midwives from different levels about their experiences in delivering care. Sample size was determined by when saturation was reached. Focus groups were conducted with community members and described hypothetical situations about women facing challenges in obtaining quality birth care. Focus groups were also conducted with women’s husband about the challenges their wives faced. The study documented poor quality of care and gained insights into why health care personnel do not care well for their patients. |
Andrade & de Melo Aggio, 2014, Brazil [34] | To gain exploratory data about obstetric violence from the perspectives of women who receive institutional care. | Four women who had given birth in health facilities. | Semi-structured interviews | Semi-structured interviews were conducted at women’s houses until saturation level was reached. The interview guide was developed using principles established in the National Law for the Humanization of Childbirth. |
Da Silva et al., 2014, Brazil [37] | To understand obstetric nurses’ perspectives, attitudes, and experiences of obstetric violence. | Obstetric nurses working in public and private health facilities. | “Brainstorming” sessions as part of full day meeting | Investigators conducted a full-day meeting with obstetric nurses. The purpose of the meeting was to “brainstorm” different ways in which obstetric violence occurs in hospitals based on the experiences and perceptions of nurse participants. Participant conversations were audio-recorded, transcribed, and analyzed using thematic analysis. The results were categorized into (1) violent utterances of health professionals to patients, (2) unnecessary and/or iatrogenic experiences procedures performed by health professionals and (3) the institutional unpreparedness with unstructured environment. |
McMahon et al., 2014, Tanzania [28] | To gather data on the perspectives of mistreatment during childbirth among women and their male partners in order to inform policy and advance research . | Women who had delivered within the past 14 months at a health facility, their male partners, community leaders and health workers from 16 villages across 4 districts. | In-depth interviews | Community leaders and community health workers were identified purposively from areas that were identified as lacking access to health care. Participant recruitment emphasized women who had normal deliveries. All participants participated in interviews in a location of their choice. Interviews included open questions about perceptions of care and care seeking, and later asked probing questions about experiences of disrespect and abuse. Grounded Theory was used in developing codes from interviews a literature review was conducted based on code results. Results were also compared to categories of mistreatment described by Bowser and Hill [5]. |
To understand the extent to which mistreatment becomes normalized among health care providers and women accessing health care. | 41 women who had given birth within the past year, women who had given birth within the past five years, 17 nurse/midwives, 17 doctors, and 9 heath care administrators. | In-depth interviews and focus group discussions | The study included focus group discussions with women who had given birth within the past five years and in-depth-interviews with women who had given birth within the past year and healthcare providers. Topics included questions about experiences and perceptions of, and perceived factors influencing mistreatment during childbirth. IDI and FGDs were also presented with four scenarios of mistreatment: physical restraint, slapping, verbal abuse, and refusing to help a woman. Thematic analysis of results was conducted based on categories identified in systematic review by Bohren et al. [3]. Combined approach of asking general questions with very specific examples of mistreatment allowed for comparison with other studies and locations. | |
Rominski et al., 2016, Ghana [56] | To examine perspectives of mistreatment during childbirth among midwifery students in Ghana. | Midwifery students in the final year of training at 15 midwifery schools in all of the country’s regions. | Focus group discussions | Investigators constructed the discussion guide using Bowser and Hill’s categories of mistreatment and participants general perceptions of respectful maternity care [5] and the author’s previous study [55]. Recruitment involved contacting students who had previously participated in a related computer survey. Discussions began with definitions of respectful care. FGDs were transcribed verbatim, coded, and analyzed. The study found that students often tried to justify disrespectful care. |
Amroussia et al., 2017, Tunisia [63] | To examine single mothers’ experiences and perceptions of giving birth in medical facilities. | 11 single mothers who had given birth a public healthcare facility. | Semi-structured interviews | The study used a semi-structured interview guide. Questions drew from authors’ personal experience and knowledge and focused on four main topics: single women’s experiences of mistreatment, perceptions of the attitudes of health care personnel, barriers to accessing care, and self-perceptions as single mothers. Data was analyzed using feminist intersectional approach. |
To examine women’s and health care providers’ perceptions and experiences of mistreatment. | Women of reproductive age who had given birth within the past year and within the past five years, health care providers, and health facility administrators in an urban area and a semi-urban area of the country. | Focus groups and in-depth interviews | Participants were given four scenarios of mistreatment during childbirth including: (1) providers slapping a woman, (2) verbal abuse, (3) providers refusing to help patients, and (4) providers forcing women to give birth on the floor. Participants were also asked questions about the story of childbirth, perceptions and experiences of childbirth, elements of mistreatment, and factors that might influence how women are treated. Researchers used thematic analysis to understand the acceptability of and attitudes towards those instances of mistreatment, as well as the different types of mistreatment that may occur. Typologies of mistreatment drew from the Bohren et al. review [3]. Results found various forms of mistreatment and that both providers and women may accept mistreatment in certain scenarios. |
Mixed methodologies for the measurement of mistreatment
Author/Year/Location | Study Purpose | Study Population | Methodology | Detailed Methodology |
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Moore et al., 2002, Kenya and Bangladesh [68] | To discuss the adaptation process and pretest results for Maternity Care Provider Caring Behavior (MCPCB) assessment tools to improve “caring behaviors” of maternal health care providers during labor and delivery. | 24 observations of labor and delivery processes, 22 midwives, 13 women who had recently given birth, and another 17 staff midwives and their instructors. | Direct observation tools, self-assessment survey for providers, focus group discussions, patient exit survey | The complete set of tools included four instruments: (1) the Maternity Care Provider Caring Behaviors Observational Assessment Tools; (2) maternity health care providers self-assessment tool; (3) provider focus group discussion guide; and (4) patient exit interview guide. The observational tool was developed to address the gaps between perceived issues and observed behaviors of medical providers. The eight original categories of provider ‘caring’ behaviors are: (1) Attending to human needs, (2) Being accessible to patient (3) Attending to emotional needs, (4) Respecting human rights and dignity, (5) Informing, explaining, and instructing, (6) Involving family members, (6) Incorporating cultural context, and (8) Minimizing negative behaviors. These categories were developed from the results of a literature review. Two hospitals in Kenya (one rural, one urban) and four facilities in Bangladesh (one rural, one urban, one public, one private) were selected to be nationally representative. |
Hulton et al., 2007, India [73] | To assess the quality of care in maternity facilities in urban slum areas with a focus on patient experiences of respectful care and clinical practices of care | 650 women living near study site health facilities who had given birth between 6 weeks to 8 months previously, hospitals records for all women at 6 hospitals who gave birth between 1996 and 1999, 70 women being discharged at 3 hospitals, 14 staff at 3 facilities. | Quality schedule, exit surveys, review of hospital records, mystery clients, community survey, direct observation, interviews | The study setting was an urban slum area with high poverty but high rates of institutionalized deliveries. Researchers developed a quality of care framework with emphasis on Experience and Provision of care. Subcategories of Experience of Care include: Human and physical resources; Cognition; Respect, dignity, and equity; and Emotional support. Subcategories of Provision of Care included: Human and physical resources; Referral system; maternity information systems; Use of appropriate technologies; and International recognized good practice. |
Warren et al., 2013, Kenya [60] | To detail the protocol for study assessing mistreatment against women in childbirth before and after interventions. | Six health facilities and a large maternity hospital, health providers and managers in those facilities, national level managers and policy makers, women in labor and postpartum women and community members in the areas of the six facilities. | Focus group discussions, in-depth interviews, observations, service statistics, exit surveys, reviewing patient records, facility inventory | The evaluations includes 3–5 focus group discussions with women who gave birth at health facilities and at home, their family members, and local health workers that focus on perceptions, attitudes, and experiences of care. Also, researchers will hold in-depth interviews with 25 senior health managers and assess health facility practices through interviews with medical personnel, patient records, structured facility inventory, service statistics, observations of delivery and labor, and exit interviews with women patients ages 15–45. For interviews with medical personnel, Likert scales are used and providers are given the option to self-administer part of the interview. Researchers follow up with some women for case narratives on mistreatment. Using Bowser and Hill’s categories of mistreatment [5], researchers create a Construct Map with measurable elements of mistreatment to assess in study components and interventions. |
Sando et al., 2014, Tanzania [49] | To examine if women with HIV experienced increased levels of mistreatment during childbirth at an urban hospital in Tanzania. | 2000 postpartum women with and without HIV, 68 health care providers, and 200 observations of labor and delivery. | Direct observations, in-depth interviews, exit surveys, provider surveys | Researchers conducted interviews with women 3–6 h after delivery to capture their experiences of disrespect and abuse and assess their overall perceptions of care. Categories of mistreatment mentioned included in interviews parallels categories documented by Bowser and Hill [49]. Researchers also conducted direct observations of client-provider interactions around the time of childbirth. To understand provider attitudes and opinions, researches administered a structured questionnaire and conducted in-depth interviews. Topics of the surveys and interviews included definitions and perceptions mistreatment, training and practices for managing patients with HIV, and comfort level with women with HIV. |
Vogel et al., 2015, Ghana, Guinea, Myanmar, Nigeria [7] | To explain a study protocol for assessing mistreatment against women in childbirth in four countries. | Medical personnel in maternity centers, facility administrators, and women (15–49) using those facilities recruited through purposive sampling. | Two-phase WHO study with in-depth interviews, focus group discussions, systematic review, exit surveys, direct observation | In the first phase, researchers will conduct a mixed methods systematic review concerning mistreatment during childbirth, and they will conduct focus group discussions as well as in-depth interviews with medical personnel, health facility administrators, and women who have used maternal healthcare facilities. Focus groups will occur with women who have given birth within 5 years, and interviews with women who have given birth within 12 months. These activities will occur in two maternal health facilities in each country (1 rural/peri-urban, 1 urban). Data from the first phase will be used to construct instruments for the second phase, in which the investigators will conduct surveys with postpartum women and observations of delivery room procedures and interactions. Categories of mistreatment addressed in the study are based on typologies outlined by Bohren et al. [3]. |
Warren et al., 2015, Mali [66] | To explore auxiliary midwives’ perspectives of mistreatment during childbirth in rural Mali. | 67 rural auxiliary midwives recruited from a continuing education session at the regional reference hospital. | Survey, semi-structured interviews | The study consisted of a survey with 53 participants, and semi-structured interviews with 33 participants. Study components focused on descriptive norms of mistreatment (“what most people actually do”), as opposed to practices that participants reported doing themselves. Surveys incorporated open ended and Likert scale questions about respectful care practices and mistreatment, with a few questions specific to stage of labor. Semi-structured interviews focused more on participants’ own practices. Analysis considers categories of mistreatment defined by Bowser and Hill [5] and Freedman and Kruk [4]. |
To report the effects of a set of interventions to reduce abusive care during childbirth and measure levels of mistreatment before and after the interventions. | Women using the intervention hospital, medical providers and administrators at the hospitals. | Exit surveys, direct observations, follow up interviews, provider surveys, and provider in-depth interviews | The intervention consisted of an antenatal education program for women and workshops for medical providers. Baseline assessment strategies included: postpartum interviews, direct observations of labor and delivery, follow up interviews with women, provider questionnaires, and provider in-depth interviews. Intervention monitoring included: observations, pre-and-post tests for workshops and education, and post-workshop action plan. Post-intervention evaluation included: direct observation of labor and delivery, follow up interviews, and provider in-depth interviews. | |
Sheferaw et al., 2016, Ethiopia [62] | To validate a scale that measures women’s perceptions of respectful care. | 509 women seeking postnatal care for infants within seven weeks after childbirth at public hospitals in three towns. | Literature reviews, in-depth interviews, survey tool | Items were generated through in-depth interviews with women who give birth in health facilities and a literature review. Face validity and content validity were assessed through expert review. The draft scale included 37 items and two additional measures of global satisfaction items, measured on a five- point Likert scale. The final scale with 15 items was loaded on four components. “The extracted components were labeled as friendly care, abuse-free care, timely care, and discrimination-free care. The final scale correlated strongly with the global satisfaction measures, indicating criterion-related validity of the scale.” |
To gain a comprehensive understanding of women’s perspectives of mistreatment during childbirth in health facilities. | 418 women with a child under the age of 5, whose most recent birth had occurred at one of the local hospitals. | Focus group discussions, surveys | Focus groups were based on an interview guide with questions about migration, social connections with villages of origin and in the study site, experiences of mistreatment, health knowledge, access to health services, and gender norms and beliefs. Surveys asked questions about 11 types of mistreatment: discrimination, verbal abuse, threatening to withhold treatment, patient abandonment, neglect, refusing choice position, restricting birth companions, requesting bribes, and unnecessary separation from the baby. Questions draw from Cultural Health Capital framework. |