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      The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review


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          Despite growing recognition of neglectful, abusive, and disrespectful treatment of women during childbirth in health facilities, there is no consensus at a global level on how these occurrences are defined and measured. This mixed-methods systematic review aims to synthesize qualitative and quantitative evidence on the mistreatment of women during childbirth in health facilities to inform the development of an evidence-based typology of the phenomenon.

          Methods and Findings

          We searched PubMed, CINAHL, and Embase databases and grey literature using a predetermined search strategy to identify qualitative, quantitative, and mixed-methods studies on the mistreatment of women during childbirth across all geographical and income-level settings. We used a thematic synthesis approach to synthesize the qualitative evidence and assessed the confidence in the qualitative review findings using the CERQual approach. In total, 65 studies were included from 34 countries. Qualitative findings were organized under seven domains: (1) physical abuse, (2) sexual abuse, (3) verbal abuse, (4) stigma and discrimination, (5) failure to meet professional standards of care, (6) poor rapport between women and providers, and (7) health system conditions and constraints. Due to high heterogeneity of the quantitative data, we were unable to conduct a meta-analysis; instead, we present descriptions of study characteristics, outcome measures, and results. Additional themes identified in the quantitative studies are integrated into the typology.


          This systematic review presents a comprehensive, evidence-based typology of the mistreatment of women during childbirth in health facilities, and demonstrates that mistreatment can occur at the level of interaction between the woman and provider, as well as through systemic failures at the health facility and health system levels. We propose this typology be adopted to describe the phenomenon and be used to develop measurement tools and inform future research, programs, and interventions.


          Meghan Bohren and colleagues review the extent and types of mistreatment against women during childbirth.

          Editors' Summary


          In 2000, as Millennium Development Goal (MDG) 5, world leaders set a target of reducing the global maternal mortality ratio—the number of deaths among women caused by pregnancy- or childbirth-related complications (maternal deaths) per 100,000 live births—to a quarter of its 1990 level by 2015. MDG 5, along with seven other MDGs, was designed to alleviate extreme poverty by 2015. Although progress towards MDG 5 (and towards the other MDGs) has been good, in 2013, the global maternal mortality ratio was still 210, well above the target of 95. In that year alone, nearly 300,000 women, 99% them living in low- and middle-income countries, died from pregnancy- or childbirth-related complications. Most of these maternal deaths were caused by hemorrhage (severe bleeding) after childbirth, post-delivery infections, obstructed (difficult) labor, or blood pressure disorders during pregnancy. These conditions are largely preventable if women have access to good-quality reproductive health services and if trained birth attendants are present during childbirth.

          Why Was This Study Done?

          The rates of skilled birth attendance and of facility-based childbirth have risen in resource-limited countries over the past two decades, but almost a third of women in these countries still deliver without a skilled birth attendant. Among the numerous obstacles likely to prevent further increases in the proportion of women delivering in a health facility is women’s fear of mistreatment during delivery. Women need to be sure that they will receive dignified and respectful care during childbirth. Unfortunately, recent studies have indicated that women are often exposed to neglectful, abusive, and disrespectful care (care that local consensus regards as humiliating or undignified) during childbirth in health facilities. There is currently no consensus about how to define and measure the mistreatment of women during childbirth, so here, the researchers develop an evidence-based typology of the mistreatment of women during childbirth in health facilities worldwide by combining information identified in a mixed-methods systematic review. A typology is a systematic classification of objects or behaviors that have characteristics in common. A mixed-methods systematic review identifies all the qualitative and quantitative research on a given topic using predefined criteria. Qualitative research investigates how people feel about a medical intervention; quantitative research provides numerical data about interventions.

          What Did the Researchers Do and Find?

          The researchers identified 65 (mainly qualitative) studies undertaken in 34 countries that investigated the mistreatment of women during childbirth across all geographical and income-level settings. They analyzed the evidence presented in these studies using thematic analysis, an approach that identifies and organizes patterns (themes) within qualitative data. Based on this analysis, the researchers developed a typology of the mistreatment of women during childbirth consisting of seven domains (categories). These domains were physical abuse (for example, slapping or pinching during delivery); sexual abuse; verbal abuse such as harsh or rude language; stigma and discrimination based on age, ethnicity, socioeconomic status, or medical conditions; failure to meet professional standards of care (for example, neglect during delivery); poor rapport between women and providers, including ineffective communication, lack of supportive care, and loss of autonomy; and health system conditions and constraints such as the lack of the resources needed to provide women with privacy.

          What Do These Findings Mean?

          These findings illustrate how women’s experiences of childbirth worldwide are marred by mistreatment. Moreover, they indicate that, although the mistreatment of women during delivery in health facilities often occurs at the level of the interaction between women and healthcare providers, systemic failures at the levels of the health facility and the health system also contribute to its occurrence. Further studies are needed to provide quantitative evidence of the burden of mistreatment of women during delivery and to identify the characteristics of health facilities that facilitate or mitigate the mistreatment of women. For now, though, the researchers call for the adoption of their evidence-based typology as a way to describe the mistreatment of women during childbirth in health facilities. Their typology, they suggest, could also be used to develop measurement tools and to design interventions that ensure that health care providers promote positive birth experiences by providing respectful, dignified, and supportive care to women during childbirth. Hopefully, such interventions will lead to more women deciding to deliver their babies in health facilities, will promote positive birth experiences, and, ultimately, will lead to further reductions in maternal deaths.

          Additional Information

          This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001847.

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          Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis.

          Lay health workers (LHWs) perform functions related to healthcare delivery, receive some level of training, but have no formal professional or paraprofessional certificate or tertiary education degree. They provide care for a range of issues, including maternal and child health. For LHW programmes to be effective, we need a better understanding of the factors that influence their success and sustainability. This review addresses these issues through a synthesis of qualitative evidence and was carried out alongside the Cochrane review of the effectiveness of LHWs for maternal and child health. The overall aim of the review is to explore factors affecting the implementation of LHW programmes for maternal and child health. We searched MEDLINE, OvidSP (searched 21 December 2011); MEDLINE Ovid In-Process & Other Non-Indexed Citations, OvidSP (searched 21 December 2011); CINAHL, EBSCO (searched 21 December 2011); British Nursing Index and Archive, OvidSP (searched 13 May 2011). We searched reference lists of included studies, contacted experts in the field, and included studies that were carried out alongside the trials from the LHW effectiveness review. Studies that used qualitative methods for data collection and analysis and that focused on the experiences and attitudes of stakeholders regarding LHW programmes for maternal or child health in a primary or community healthcare setting. We identified barriers and facilitators to LHW programme implementation using the framework thematic synthesis approach. Two review authors independently assessed study quality using a standard tool. We assessed the certainty of the review findings using the CerQual approach, an approach that we developed alongside this and related qualitative syntheses. We integrated our findings with the outcome measures included in the review of LHW programme effectiveness in a logic model. Finally, we identified hypotheses for subgroup analyses in future updates of the review of effectiveness. We included 53 studies primarily describing the experiences of LHWs, programme recipients, and other health workers. LHWs in high income countries mainly offered promotion, counselling and support. In low and middle income countries, LHWs offered similar services but sometimes also distributed supplements, contraceptives and other products, and diagnosed and treated children with common childhood diseases. Some LHWs were trained to manage uncomplicated labour and to refer women with pregnancy or labour complications.Many of the findings were based on studies from multiple settings, but with some methodological limitations. These findings were assessed as being of moderate certainty. Some findings were based on one or two studies and had some methodological limitations. These were assessed have low certainty.Barriers and facilitators were mainly tied to programme acceptability, appropriateness and credibility; and health system constraints. Programme recipients were generally positive to the programmes, appreciating the LHWs' skills and the similarities they saw between themselves and the LHWs. However, some recipients were concerned about confidentiality when receiving home visits. Others saw LHW services as not relevant or not sufficient, particularly when LHWs only offered promotional services. LHWs and recipients emphasised the importance of trust, respect, kindness and empathy. However, LHWs sometimes found it difficult to manage emotional relationships and boundaries with recipients. Some LHWs feared blame if care was not successful. Others felt demotivated when their services were not appreciated. Support from health systems and community leaders could give LHWs credibility, at least if the health systems and community leaders had authority and respect. Active support from family members was also important.Health professionals often appreciated the LHWs' contributions in reducing their workload and for their communication skills and commitment. However, some health professionals thought that LHWs added to their workload and feared a loss of authority.LHWs were motivated by factors including altruism, social recognition, knowledge gain and career development. Some unsalaried LHWs wanted regular payment, while others were concerned that payment might threaten their social status or lead recipients to question their motives. Some salaried LHWs were dissatisfied with their pay levels. Others were frustrated when payment differed across regions or institutions. Some LHWs stated that they had few opportunities to voice complaints. LHWs described insufficient, poor quality, irrelevant and inflexible training programmes, calling for more training in counselling and communication and in topics outside their current role, including common health problems and domestic problems. LHWs and supervisors complained about supervisors' lack of skills, time and transportation. Some LHWs appreciated the opportunity to share experiences with fellow LHWs.In some studies, LHWs were traditional birth attendants who had received additional training. Some health professionals were concerned that these LHWs were over-confident about their ability to manage danger signs. LHWs and recipients pointed to other problems, including women's reluctance to be referred after bad experiences with health professionals, fear of caesarean sections, lack of transport, and cost. Some LHWs were reluctant to refer women on because of poor co-operation with health professionals.We organised these findings and the outcome measures included in the review of LHW programme effectiveness in a logic model. Here we proposed six chains of events where specific programme components lead to specific intermediate or long-term outcomes, and where specific moderators positively or negatively affect this process. We suggest how future updates of the LHW effectiveness review could explore whether the presence of these components influences programme success. Rather than being seen as a lesser trained health worker, LHWs may represent a different and sometimes preferred type of health worker. The close relationship between LHWs and recipients is a programme strength. However, programme planners must consider how to achieve the benefits of closeness while minimizing the potential drawbacks. Other important facilitators may include the development of services that recipients perceive as relevant; regular and visible support from the health system and the community; and appropriate training, supervision and incentives.
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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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              Low use of rural maternity services in Uganda: impact of women's status, traditional beliefs and limited resources.

              In Uganda, lack of resources and skilled staff to improve quality and delivery of maternity services, despite good policies and concerted efforts, have not yielded an increase in utilisation of these services by women or a reduction in the high ratio of maternal deaths. This paper reports a study conducted from November 2000 to October 2001 in Hoima, a rural district in western Uganda, whose aim was to enhance understanding of why, when faced with complications of pregnancy or delivery, women continue to choose high risk options leading to severe morbidity and even their own deaths. The findings demonstrate that adherence to traditional birthing practices and beliefs that pregnancy is a test of endurance and maternal death a sad but normal event, are important factors. The use of primary health units and the referral hospital, including when complications occur, was considered only as a last resort. Lack of skilled staff at primary health care level, complaints of abuse, neglect and poor treatment in hospital and poorly understood reasons for procedures, plus health workers' views that women were ignorant, also explain the unwillingness of women to deliver in health facilities and seek care for complications. Appropriate interventions are needed to address the barriers between rural mothers and the formal health care system, including community education on all aspects of essential obstetric care and sensitisation of service providers to the situation of rural mothers.

                Author and article information

                Role: Academic Editor
                PLoS Med
                PLoS Med
                PLoS Medicine
                Public Library of Science (San Francisco, CA USA )
                30 June 2015
                June 2015
                : 12
                : 6
                : e1001847
                [1 ]Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
                [2 ]Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
                [3 ]Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
                [4 ]Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
                [5 ]Population Services International, Washington, D. C., United States of America
                [6 ]Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
                Medical Research Council, SOUTH AFRICA
                Author notes

                The authors have declared that no competing interests exist.

                Conceived and designed the experiments: MAB JPS AMG. Performed the experiments: MAB ECH OL SKM JPS JPV FSC ALAD CA. Analyzed the data: MAB JPV ECH OL. Wrote the first draft of the manuscript: MAB JPV ECH OL. Contributed to the writing of the manuscript: MAB JPV ECH OL. Conducted the title and abstract screening: MAB ECH OL SKM JPV. Conducted the full text screening and data extraction: MAB ECH OL SKM JPS JPV FSC ALAD. Conducted the quality assessments: MAB ECH OL CA JPV. Assessed the confidence of the review findings: MAB JPV. Agree with the manuscript’s results and conclusions: MAB JPV ECH OL SKM JPS CA FSC ALAD OT DJ OTO RK MJH AMG. All authors have read, and confirm that they meet, ICMJE criteria for authorship.

                Copyright @ 2015

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

                : 18 November 2014
                : 22 May 2015
                Page count
                Figures: 1, Tables: 3, Pages: 32
                The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Funding for this project was received from The United States Agency for International Development (USAID) (USAID Amendment #20, WHO Consolidated Grant GHA-G-00-09-0003) and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization. This article represents the views of the named authors only.
                Research Article
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                All relevant data are within the paper and its Supporting Information files.



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