The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review

Background 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. Conclusions 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 Background 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. This study is further discussed in a PLOS Medicine Perspective by Rachel Jewkes and Loveday Penn-Kekana The World Health Organization (WHO) has published a statement on promoting the rights of women and access to safe, timely, respectful care during childbirth The White Ribbon Alliance promotes the universal rights of childbearing women The United Nations Children’s Fund (UNICEF) provides information on maternal health and on the recent decline in maternal mortality The World Health Organization provides information on maternal health, including information about Millennium Development Goal 5 (in several languages) and information about the prevention and elimination of disrespect and abuse during childbirth Further information about the Millennium Development Goals and The Millennium Development Goals Report 2014, which details progress on reaching these goals, are available (in several languages) Immpact is a research initiative for the evaluation of safe motherhood intervention strategies Maternal Death: The Avoidable Crisis is a briefing paper that was published by the humanitarian medical aid organization Médecins Sans Frontières in 2012 Veil of Tears contains personal stories from Afghanistan about maternal death More information is available on the CERQual approach for assessing confidence in the evidence from reviews of qualitative research The Cochrane Qualitative and Implementation Methods Group has published supplemental handbook guidance on qualitative evidence syntheses Wikipedia has pages on thematic analysis and on systematic review (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)