New evidence from a WHO-led study in four countries shows that more than one-third of women experienced mistreatment during childbirth in health facilities. The study, carried out in Ghana, Guinea, Myanmar and Nigeria showed that women were at the highest risk of experiencing physical and verbal abuse between 30 minutes before birth until 15 minutes after birth. Younger, less-educated women were most at risk, suggesting inequalities in how women are treated during childbirth. Addressing these inequalities and promoting respectful maternity care for all women is critical to improve health equity and quality.
How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys - Published: October 08, 2019
The study built on the results from a mixed-methods systematic review conducted in 2015 which developed a typology of what constitutes mistreatment of women during childbirth based on 65 studies conducted in 34 countries. The review identified physical and verbal abuse, stigma and discrimination, failure to meet professional standards of care, poor rapport between women and providers and, health system conditions and constraints as primary manifestations experienced by women during childbirth in health facilities.
Providing high-quality care to the 140 million women giving birth each year is key to improving maternal and newborn health. High-quality maternity care includes not only clinical components, but also ensuring positive care experiences for women. All women have the right to dignified, respectful health care throughout pregnancy and childbirth as well as freedom from violence and discrimination. A growing body of evidence, however, shows that women are being mistreated during childbirth in health facilities across the world.
Women’s rights to dignified and respectful maternity care
In 2014, WHO issued a statement on the prevention and elimination of disrespect and abuse during facility-based childbirth. The WHO statement positioned mistreatment during childbirth as a violation of rights and trust between women and their healthcare providers. It also called for greater action, dialogue, research and advocacy.
The 2018 WHO recommendations on intrapartum care for a positive childbirth experience highlight the importance of woman-centred care to optimize women’s experiences of labour and childbirth through a holistic, human rights-based approach. This includes the provision of respectful maternity care that maintains women’s dignity, privacy and confidentiality, enables informed choice and continuous support throughout labour and childbirth, and ensures freedom from mistreatment.
The impact of mistreatment during childbirth
Mistreatment during childbirth may have both direct and indirect impacts on the woman and her baby. Women and their families may have such low expectations of maternity care that they are accepting of physical and verbal abuse. For example, a WHO qualitative study in Nigeria found that women and healthcare providers justified slapping a woman while she was in labour if it was done to encourage the woman to push.
The role of health systems
A complex range of systemic challenges at both the health facility and health system levels contribute to the mistreatment of women, including poor supervisory structures, insufficient staffing, inadequate supply chains, poor physical conditions, and power dynamics that systematically disempower women.
Health systems must be held accountable for the mistreatment of women during childbirth, and improvements are needed to effectively prevent and respond to these harmful practices. Health systems must have sufficient resources to provide quality, accessible maternal health care and clear policies on women’s rights. Health-care providers at all levels require support and training to ensure that women are treated with compassion and dignity.
The way forward
There has been progress on understanding the different manifestations of mistreatment during childbirth in different contexts. Further research is needed, however, to understand how institutional structures and processes can be reorganized to provide better woman-centred care. Structural dimensions may influence mistreatment during childbirth via historical biases, power inequalities, normalization of poor treatment and communication barriers. Understanding drivers, such as gender and social inequalities, and judgements about women’s sexuality, is critical to ensure that any interventions adequately account for societal context. The depth of these challenges suggests that it is unlikely that interventions that do not address these factors, such as a one-off training, will have a lasting impact on behaviour change.
Preventing mistreatment during childbirth can only be achieved through inclusive and equitable processes that engage both women and healthcare providers. Possible strategies include:
- Redesigning labour wards to allow for privacy and labour companionship
- Providing skills-building exercises for effective communication and on the informed consent process for all procedures
- Teaching providers stress-coping mechanisms
- Ensuring that healthcare providers are empowered and supported through supervisory structures; that workloads are manageable; and that remuneration is adequate.
Professional associations can also play a crucial role in supporting midwives, obstetricians and other maternity providers, and safeguarding their rights. WHO calls upon these entities to collaborate to ensure that mistreatment during childbirth is consistently identified and reported, and that locally appropriate measures are implemented.
The findings of the study should be used to inform policies and programmes to ensure that all women have positive pregnancy and childbirth experiences and, are supported by empowered healthcare providers within well-functioning health systems.
This research was made possible by the support of the American People through the United States Agency for International Development (USAID) 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, WHO.
Related publication
WHO recommendations: intrapartum care for a positive childbirth experience