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      How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys


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          Women across the world are mistreated during childbirth. We aimed to develop and implement evidence-informed, validated tools to measure mistreatment during childbirth, and report results from a cross-sectional study in four low-income and middle-income countries.


          We 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.


          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.


          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.


          United States Agency for International Development and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO.

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          Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis

          Background What constitutes respectful maternity care (RMC) operationally in research and programme implementation is often variable. Objectives To develop a conceptualisation of RMC. Search strategy Key databases, including PubMed, CINAHL, EMBASE, Global Health Library, grey literature, and reference lists of relevant studies. Selection criteria Primary qualitative studies focusing on care occurring during labour, childbirth, and/or immediately postpartum in health facilities, without any restrictions on locations or publication date. Data collection and analysis A combined inductive and deductive approach was used to synthesise the data; the GRADE CERQual approach was used to assess the level of confidence in review findings. Main results Sixty‐seven studies from 32 countries met our inclusion criteria. Twelve domains of RMC were synthesised: being free from harm and mistreatment; maintaining privacy and confidentiality; preserving women's dignity; prospective provision of information and seeking of informed consent; ensuring continuous access to family and community support; enhancing quality of physical environment and resources; providing equitable maternity care; engaging with effective communication; respecting women's choices that strengthen their capabilities to give birth; availability of competent and motivated human resources; provision of efficient and effective care; and continuity of care. Globally, women's perspectives of what constitutes RMC are quite consistent. Conclusions This review presents an evidence‐based typology of RMC in health facilities globally, and demonstrates that the concept is broader than a reduction of disrespectful care or mistreatment of women during childbirth. Innovative approaches should be developed and tested to integrate RMC as a routine component of quality maternal and newborn care programmes. Tweetable abstract Understanding respectful maternity care – synthesis of evidence from 67 qualitative studies.
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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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              Status of respectful and non-abusive care during facility-based childbirth in a hospital and health centers in Addis Ababa, Ethiopia

              Background According to the 2011 Ethiopian Demographic and Health Survey, 90.1% of mothers do not deliver in health facilities, with 29.5% citing non-customary service as causative. A low level of skilled attendance at birth is among the leading causes of maternal mortality in low - and middle-income countries. Methods A cross-sectional study was undertaken in four health facilities (one specialized teaching hospital and its three catchment health centers) in Addis Ababa, Ethiopia, to quantitatively determine the level and types of disrespect and abuse faced by women during facility-based childbirth, along with their subjective experiences of disrespect and abuse. A questionnaire was administered to 173 mothers immediately prior to discharge from their respective health facility. Reported disrespect and abuse during childbirth was measured under seven categories using 23 performance indicators. Results Among multigravida mothers (n = 103), 71.8% had a history of a previous institutional birth and 78% (75.3% in health centers and 81.8% in hospital; p = 0.295) of respondents experienced one or more categories of disrespect and abuse. The violation of the right to information, informed consent, and choice/preference of position during childbirth was reported by all women who gave birth in the hospital and 89.4% of respondents in health centers. Mothers were left without attention during labor in 39.3% of cases (14.1% in health centers and 63.6% in hospital; p < 0.001). Although 78.6% (n = 136) of respondents objectively faced disrespect and abuse, only 22 (16.2%) subjectively experienced disrespect and abuse. Conclusions This quantitative study reveals a high level of disrespect and abuse during childbirth that was not perceived as such by the majority of respondents. It is every woman’s right to give birth in woman-centered environment free from disrespect and abuse. Understanding how women define abuse is crucial if Ethiopia is to succeed in increasing the uptake of facility-based births.

                Author and article information

                Lancet (London, England)
                09 November 2019
                09 November 2019
                : 394
                : 10210
                : 1750-1763
                [a ]Gender and Women's Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Carlton, VIC, Australia
                [b ]UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
                [c ]Department of Obstetrics and Gynaecology, National Institute of Maternal and Child Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
                [d ]Department of Medical Research, Yangon, Myanmar
                [e ]Cellule de Recherche en Sante de la Reproduction en Guinee (CERREGUI), Conakry, Guinea
                [f ]Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Legon, Ghana
                [g ]Department of Obstetrics and Gynaecology, Mother and Child Hospital, Oke-Aro, Akure, Ondo State, Nigeria
                [h ]Maternal and Child Health Program, Burnet Institute, Melbourne, VIC, Australia
                [i ]Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, University of Medical Sciences, Ondo, Ondo State, Nigeria
                [j ]University of Medical Sciences Teaching Hospital, Akure, Ondo State, Nigeria
                [k ]Adeoyo Maternity Teaching Hospital, Yemetu, Ibadan, Oyo State, Nigeria
                [l ]Department of Obstetrics and Gynaecology, School of Medicine and Dentistry, Unive rsity of Ghana, Accra, Ghana
                [m ]Department of Biostatistics, School of Public Health, University of Ghana, Legon-Accra, Ghana
                [n ]School of Public Health, University of Ghana, Legon-Accra, Ghana
                Author notes
                [* ]Correspondence to: Dr Meghan A Bohren, Gender and Women's Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Carlton, VIC, 3053 Australia meghan.bohren@ 123456unimelb.edu.au

                Prof Fawole died in January, 2019

                © 2019 World Health Organization

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




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