© Pawan Kumar

The journal PLOS Medicine published a research review yesterday, "The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Method Systematic Review" (Bohren, et al, 2015). Reading this report was both disturbing and extremely sad to me. Respectful care is a part of the United Nations Millennium Development Goal Target 5A: Improve Maternal Health. - which set a goal of reducing the maternal mortality ratio (the number of deaths among women caused by pregnancy- or childbirth-related complications (maternal deaths) per 100,000 live births) by 75% from 1990 to 2015. The target rate had been 95 pregnancy or childbirth related deaths per 100,000 women but the current rate is sitting at 210/100,000, which is just a 45% drop. 99% of all maternal deaths occur in low-income and middle-income countries, where resources are limited and access to safe, acceptable, good quality sexual and reproductive health care, including maternity care, is not available to many women during their childbearing year. The most common cause of these maternal deaths are postpartum hemorrhage, postpartum infection, obstructed labors and blood pressure issues - all conditions considered very preventable or treatable with access to quality care and trained birth attendants.

Analysis of reports examined in this paper indicate that "many women globally experience poor treatment during childbirth, including abusive, neglectful, or disrespectful care." This treatment can further complicate the situation downstream, by creating a disincentive for women to seek care from these facilities and providers in future pregnancies.

The reports and studies that were reviewed to create this report obtained their information from direct observation, interviews with women under care, and were self-reported by the mothers. Follow-up surveys were also conducted.

From the qualitative research, investigators were able to classify the mistreatment into seven categories:

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
7. health system conditions and constraints

The quantitative research revealed two themes: sexual abuse and the performance of unconsented surgical operations.

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It is no surprise that women's experiences were negatively impacted by the mistreatment they received during their maternity care treatment period. Some of the treatment was one on one - from the care provider to the mother, while other inappropriate treatment was on a facility level.

Investigation of the treatment of women during pregnancy and childbirth was conducted because it is known that care by a qualified attendant can significantly impact maternal mortality, but if women are disinclined to seek out appropriate care due to a fear of mistreatment, help is not available or utilized and mortality rates rise. Removing this obstacle is key to reducing maternal deaths.

Prior experiences and perceptions of mistreatment, low expectations of the care provided at facilities, and poor reputations of facilities in the community have eroded many women's trust in the health system and have impacted their decision to deliver in health facilities in the future, particularly in low- and middle-income countries Some women may consider childbirth in facilities as a last resort, prioritizing the culturally appropriate and supportive care received from traditional providers in their homes over medical intervention. These women may desire home births where they can deliver in a preferred position, are able to cry out without fear of punishment, receive no surgical intervention, and are not physically restrained. - Bohren, et al.

Women who are mistreated during childbirth obviously reflects a quality of care issue, but also a larger scale- a fundamental human rights issue. International standards are clear that this is not acceptable. The researchers encourage the use of their finding to assist in the development of measurement tools that can be used to inform policies, standards and improvement programs.

We must seek to find a process by which women and health care providers engage to promote and protect women's participation in safe and positive childbirth experiences. A woman's autonomy and dignity during childbirth must be respected, and her health care providers should promote positive birth experiences through respectful, dignified, supportive care, as well as by ensuring high-quality clinical care. - Bohren, et al.

I encourage you to read the study for a thorough review of the research findings. The information is difficult to fully take in. Additionally, a companion paper - "Mistreatment of Women in Childbith: Time for Action on this Important Dimension of Violence against Women" provides further information. The New York Times covered this topic in their June 30th Health Section. The World Health Organization also covered this report and has a statement on this issue, endorsed by over 80 organizations, including Lamaze International. The WHO also has a list of videos on the topic of abuse and mistreatment of women during pregnancy and childbirth that can be found here.

References

Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. (2015) The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med 12(6): e1001847. doi:10.1371/journal.pmed.1001847

Jewkes R, Penn-Kekana L (2015) Mistreatment of Women in Childbirth: Time for Action on This Important Dimension of Violence against Women. PLoS Med 12(6): e1001849. doi:10.1371/journal.pmed.1001849

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