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      By slapping their laps, the patient will know that you truly care for her”: A qualitative study on social norms and acceptability of the mistreatment of women during childbirth in Abuja, Nigeria

      a , b , * , b , b , c , d , e , d , d , d , d , f , g , b , b , a , b
      Ssm - Population Health
      Elsevier Ltd
      ACASI, audio computer assisted self-interview, COREQ, consolidated criteria for reporting qualitative research, DHS, Demographic and Health Survey, FGD, focus group discussion, HRP, World Health Organization Human Reproduction Programme, IDI, in-depth interview, IPV, intimate partner violence, LMIC, low- and middle-income country, RP2, Review Panel on Research Projects, SDG, Sustainable Development Goals, USAID, United States Agency for International Development, Maternal health, Childbirth, Mistreatment, Quality of care, Qualitative research, Nigeria

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          Many women experience mistreatment during childbirth in health facilities across the world. However, limited evidence exists on how social norms and attitudes of both women and providers influence mistreatment during childbirth. Contextually-specific evidence is needed to understand how normative factors affect how women are treated. This paper explores the acceptability of four scenarios of mistreatment during childbirth.


          Two facilities were identified in Abuja, Nigeria. Qualitative methods (in-depth interviews (IDIs) and focus group discussions (FGDs)) were used with a purposive sample of women, midwives, doctors and administrators. Participants were presented with four scenarios of mistreatment during childbirth: slapping, verbal abuse, refusing to help the woman and physical restraint. Thematic analysis was used to synthesize findings, which were interpreted within the study context and an existing typology of mistreatment during childbirth.


          Eighty-four IDIs and 4 FGDs are included in this analysis. Participants reported witnessing and experiencing mistreatment during childbirth, including slapping, physical restraint to a delivery bed, shouting, intimidation, and threats of physical abuse or poor health outcomes. Some women and providers considered each of the four scenarios as mistreatment. Others viewed these scenarios as appropriate and acceptable measures to gain compliance from the woman and ensure a good outcome for the baby. Women and providers blamed a woman's “disobedience” and “uncooperativeness” during labor for her experience of mistreatment.


          Blaming women for mistreatment parallels the intimate partner violence literature, demonstrating how traditional practices and low status of women potentiate gender inequality. These findings can be used to facilitate dialogue in Nigeria by engaging stakeholders to discuss how to challenge these norms and hold providers accountable for their actions. Until women and their families are able to freely condemn poor quality care in facilities and providers are held accountable for their actions, there will be little incentive to foster change.


          • Women and providers in Nigeria reported that women experience mistreatment during childbirth.

          • Mistreatment is normalized and accepted for punishing “disobedient” women.

          • Maternity ward power relations between providers and women propagate mistreatment.

          • Mistreatment was acceptable when used by providers to gain compliance and improve health outcomes.

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          Disrespect and abuse during facility-based childbirth in a low-income country.

          To determine the prevalence and pattern of disrespectful and abusive care during facility-based childbirth in Enugu, southeastern Nigeria. A questionnaire-based, cross-sectional study was undertaken at Enugu State University Teaching Hospital between May 1 and August 31, 2012. Women accessing immunization services for their newborns were eligible when they had delivered in the previous 6weeks and had received prenatal care and delivery services at the hospital. The main outcome was the proportion of women who had experienced disrespectful and abusive care during their last childbirth. In total, 437 (98.0%) of 446 respondents reported at least one form of disrespectful and abusive care during their last childbirth. Non-consented services and physical abuse were the most common types of disrespectful and abusive care during facility-based childbirth, affecting 243 (54.5%) and 159 (35.7%) respondents, respectively. Non-dignified care was reported by 132 (29.6%) women, abandonment/neglect during childbirth by 130 (29.1%), non-confidential care by 116 (26.0%), detention in the health facility by 98 (22.0%), and discrimination by 89 (20.0%). Disrespect and abuse during childbirth are highly prevalent in Enugu. The findings indicate the size of the issue of disrespectful and abusive care during childbirth in low-income countries. Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
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            Experiences of and responses to disrespectful maternity care and abuse during childbirth; a qualitative study with women and men in Morogoro Region, Tanzania

            Background Interventions to reduce maternal mortality have focused on delivery in facilities, yet in many low-resource settings rates of facility-based birth have remained persistently low. In Tanzania, rates of facility delivery have remained static for more than 20 years. With an aim to advance research and inform policy changes, this paper builds on a growing body of work that explores dimensions of and responses to disrespectful maternity care and abuse during childbirth in facilities across Morogoro Region, Tanzania. Methods This research drew on in-depth interviews with 112 respondents including women who delivered in the preceding 14 months, their male partners, public opinion leaders and community health workers to understand experiences with and responses to abuse during childbirth. All interviews were recorded, transcribed, translated and coded using Atlas.ti. Analysis drew on the principles of Grounded Theory. Results When initially describing birth experiences, women portrayed encounters with providers in a neutral or satisfactory light. Upon probing, women recounted events or circumstances that are described as abusive in maternal health literature: feeling ignored or neglected; monetary demands or discriminatory treatment; verbal abuse; and in rare instances physical abuse. Findings were consistent across respondent groups and districts. As a response to abuse, women described acquiescence or non-confrontational strategies: resigning oneself to abuse, returning home, or bypassing certain facilities or providers. Male respondents described more assertive approaches: requesting better care, paying a bribe, lodging a complaint and in one case assaulting a provider. Conclusions Many Tanzanian women included in this study experienced unfavorable conditions when delivering in facilities. Providers, women and their families must be made aware of women’s rights to respectful care. Recommendations for further research include investigations of the prevalence and dimensions of disrespectful care and abuse, on mechanisms for women and their families to effectively report and redress such events and on interventions that could mitigate neglect or isolation among delivering women. Respectful care is a critical component to improve maternal health.
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              Please understand when I cry out in pain: women's accounts of maternity services during labour and delivery in Ghana

              Background This study was undertaken to investigate women's accounts of interactions with health care providers during labour and delivery and to assess the implications for acceptability and utilisation of maternity services in Ghana. Methods Twenty-one individual in-depth interviews and two focus group discussions were conducted with women of reproductive age who had delivered in the past five years in the Greater Accra Region. The study investigated women's perceptions and experiences of care in terms of factors that influenced place of delivery, satisfaction with services, expectations of care and whether they would recommend services. Results One component of care which appeared to be of great importance to women was staff attitudes. This factor had considerable influence on acceptability and utilisation of services. Otherwise, a successful labour outcome and non-medical factors such as cost, perceived quality of care and proximity of services were important. Our findings indicate that women expect humane, professional and courteous treatment from health professionals and a reasonable standard of physical environment. Women will consciously change their place of delivery and recommendations to others if they experience degrading and unacceptable behaviour. Conclusion The findings suggest that inter-personal aspects of care are key to women's expectations, which in turn govern satisfaction. Service improvements which address this aspect of care are likely to have an impact on health seeking behaviour and utilisation. Our findings suggest that user-views are important and warrant further investigation. The views of providers should also be investigated to identify channels by which service improvements, taking into account women's views, could be operationalised. We also recommend that interventions to improve delivery care should not only be directed to the health professional, but also to general health system improvements.

                Author and article information

                SSM Popul Health
                SSM Popul Health
                Ssm - Population Health
                Elsevier Ltd
                1 December 2016
                December 2016
                : 2
                : 640-655
                [a ]Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615N. Wolfe St, Baltimore, MD, USA
                [b ]UNDP/UNFPA/UNICEF/WHO/WorldBank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
                [c ]Departmentof Obstetrics & Gynaecology, National Institute of Maternal & Child Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
                [d ]Departmentof Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
                [e ]Departmentof Sociology, Faculty of the Social Sciences, University of Ibadan, Ibadan, Nigeria
                [f ]Nyanya General Hospital, Abuja, Federal Capital Territory, Nigeria
                [g ]Maitama District Hospital, Abuja, Federal Capital Territory, Nigeria
                Author notes
                [* ]Corresponding author at: Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615N. Wolfe St, Baltimore, MD, USA.Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public HealthWolfe StBaltimoreMD615NUSA mbohren1@ 123456jhu.edu
                © 2016 The Authors

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

                : 18 April 2016
                : 7 July 2016
                : 18 July 2016

                acasi, audio computer assisted self-interview,coreq, consolidated criteria for reporting qualitative research,dhs, demographic and health survey,fgd, focus group discussion,hrp, world health organization human reproduction programme,idi, in-depth interview,ipv, intimate partner violence,lmic, low- and middle-income country,rp2, review panel on research projects,sdg, sustainable development goals,usaid, united states agency for international development,maternal health,childbirth,mistreatment,quality of care,qualitative research,nigeria


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