More than a third of women in four low-income countries experienced mistreatment during childbirth, with younger and less educated women at greater risk.
Physical and verbal abuse during childbirth peaked between 30 minutes before birth until 15 minutes after birth, and mistreatment was more common in younger, less educated women, according to a study in The Lancet which combined observations of 2,016 women during labour and childbirth with surveys of 2,672 women post-childbirth in Ghana, Guinea, Myanmar, and Nigeria.
The study investigated the mistreatment of women during childbirth, which includes physical and verbal abuse, stigma or discrimination, neglect, lack of informed consent and privacy, among others. It identifies gaps in the quality and respectful nature of maternity care that should be addressed, and highlights the importance of effective communication and informed consent.
Evidence suggests that women around the world experience mistreatment during childbirth, including physical and verbal abuse, non-consented procedures and non-supportive care.  WHO guidelines recommend respectful maternity care for all women, which is care that maintains 'dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth'. 
Study author Dr Meghan Bohren, University of Melbourne, Australia, says: "Promoting respectful maternity care for all women is key to improving health equity and is an essential component of quality of care. Moving forwards, we must focus on designing interventions that address complex factors that influence how women are treated during maternity care, including gender biases, structural inequalities, and normalisation of poor treatment. We must advocate for respectful care for all women and empower people to hold health systems accountable." 
The study included 12 health facilities - three per country - which had at least 200 births per month. Observations and surveys noted caesarean sections for which women did not consent, episiotomies and vaginal examinations, and physical abuse and verbal abuse.
Of the 2,016 women whose labour and childbirth was observed, 838 (42%) had observed experiences of physical abuse, verbal abuse, stigma or discrimination. 282 (14%) women experienced physical abuse - most commonly being slapped, hit or punched, with the type of abuse varying between countries. 63 (3%) women experienced forceful downward abdominal pressure, and 38 (2%) were forcefully held down on the bed.
Of 261 caesarean births, 35 (13%) were conducted without the woman's consent, and 190 of 253 episiotomies (75%) were conducted without consent. Vaginal examinations also occurred without consent in 59% of cases (2,611 of 4,393 exams).
Across all four countries' observed births, the most common forms of verbal abuse were being shouted at, scolded and mocked, with 762 (38%) experiencing such abuse. 11 women of the 2,016 had observed experiences of stigma or discrimination, typically regarding their race or ethnicity.
Rates of mistreatment were similar in the surveys conducted with women at up to 8 weeks after birth. Of the 2,672 women surveyed, 945 (35%) reported physical abuse, verbal abuse or discrimination during childbirth, with 287 (11%) of those reporting physical abuse, most commonly forceful downward abdominal pressure (6%) and being slapped (4%). 821 (31%) reported verbal abuse including being shouted at and scolded. 52 of 483 (11%) caesarean sections and 295 of 526 (56%) of episiotomies were conducted without the woman's consent. Almost half of women (50%) - 1,214 of 2,445 - who reported at least one vaginal examination did not consent and many reported that these examinations were not done privately.
Dr Theresa Irinyenikan of the University of Medical Sciences Teaching Hospital, Nigeria says: "We set out to use a systematic, evidence-informed approach to provide comparable data on the burden of mistreatment across different countries and contexts. The results of our study are an eye-opener to what women endure during childbirth. We must now intensify our efforts towards eliminating mistreatment during childbirth, including how we can change institutional structures and processes. For example, we must ensure that midwives and doctors are well supported and mentored to provide high quality, respectful maternity care within well-equipped health facilities." 
The authors highlight several limitations in their study. The presence of an observer may have altered behaviour of the health-care provider, meaning mistreatment may be less likely to happen. However, the authors explored whether this effect was present by calculating the rates of physical and verbal abuse by month of data collection and found no evidence that provider behaviour was altered due to similar rates of mistreatment across time. Some experiences of mistreatment may be more subjective (such as discrimination) and follow up work is planned to explore the differences between the observed and woman-reported experiences of mistreatment among a sub-group of women who participated in both the observation and survey. The time between birth and survey could have affected recall and as the facilities were all public and in urban areas, generalisability may be limited.
Prof Mamadou Balde of Cellule de Recherche en Santé de la Reproduction en Guinea (CERREGUI), says: "More work is needed to explore how reducing mistreatment during childbirth can be integrated into quality improvement initiatives, and these efforts need to be measured and evaluated. Our findings show clear areas for targeted improvements around training for health-care providers on effective communication and informed consent, as well as structural improvements to the birth environment to allow for privacy and companionship during labour. A once-off training is unlikely to create lasting change and we hope our findings will be used to inform policies and programmes to ensure that women have positive pregnancy and childbirth experiences and are supported by empowered health-care providers." 
Writing in a linked Comment, Dr Cheryl A Moyer of the University of Michigan Medical School, USA, says: "Bohren and colleagues' study extends the evidence that many women are mistreated during facility-based childbirth in low resource settings [... and] on disparities in how women are treated on the basis of age and socioeconomic status. [...] Although measurement remains important, we need to move beyond assessing prevalence of mistreatment and begin using the validated tools that have been developed to drive efforts at increasing accountability and tracking change."
NOTES TO EDITORS
This study was funded by the 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. It was conducted by researchers from University of Melbourne, Australia, World Health Organization, Switzerland, University of Ibadan, Nigeria, Department of Medical Research, Myanmar, Cellule de Recherche en Sante de la Reproduction en Guinee, Guinea, University of Ghana, Ghana, Mother and Child Hospital, Nigeria, Burnet Institute, Melbourne, Australia, University of Medical Sciences, Nigeria, University of Medical Sciences Teaching Hospital, Nigeria, Adeoyo Maternity Teaching Hospital, Nigeria
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