Subtle Abuse Affects Women During Childbirth

Stripping women of dignity and respect during childbirth is not only a violation of human rights. It also affects the health of women and babies. It's time to recognise the urgency of the problem and commit to giving women the care they deserve.

A growing body of research shows that while some women experience physical and verbal abuse, a much larger group experience more subtle forms of disrespectful care. At one of the most vulnerable times in their lives women can be ignored, left in the dark about their treatment and care team, and denied basic comforts that allow for a dignified birth experience.

Several studies have looked at abuse and disrespect in maternity care. But few had explored the range of issues that affect women's experiences in low- and middle-income countries. My colleagues and I set out to understand women's experiences and to create a new way to compare them across different countries.

We talked to about 3,600 women in Kenya, Ghana and India who had recently given birth. They came from a mix of rural and urban areas. We asked them questions to measure what sort of experiences they had had. In particular, whether they'd been afforded dignified and respectful care, whether there had been good communication and whether they felt they could make decisions about their birthing experience.

From in-depth interviews it became clear that the subtler forms of substandard care deeply affected their childbirth experiences. And there is still a great deal of work to be done to give these women the care they deserve.

What women said was missing

We found that communication was the area of care that was most lacking. The vast majority of women in these countries said that their health care providers never introduced themselves. This was true for a shocking 98% of women in the India sample. Many women are not given information about their care and don't understand what is happening to them.

Over half reported that providers did not explain the purpose of exams or procedures and never asked permission before performing them. Leaving women in the dark about their care can be a frightening and alienating experience. One woman told us:

They did not tell me anything, I just saw the vehicle ready and they told me you are going to (the hospital) because you are going for an operation. That is the only thing I was told.

Other simple things that were overlooked included how a woman was received when she arrived at the facility, and the timeliness of her care. It's important to immediately acknowledge her pain and do the best to control it. There is also practical help, like helping her to the bed after delivery, giving her something to drink and warm water to bathe and giving her a bed with clean sheets to rest. One woman said:

The worst thing that I saw was that after giving birth, you should bath but there was no water so I stayed at the hospital and I came back home without bathing which made me to feel bad.

Why it matters

The violations of basic rights would be enough to inspire action to remedy this problem. But it has even bigger implications for women's health.

Negative experiences lead to a lack of trust and poor perceptions of the quality of care in health facilities. This discourages women from seeking health care. It has a ripple effect, as other women hear stories that discourage them from delivering their babies in facilities.

In settings where skilled care is only available in health facilities, this contributes to high maternal mortality: many women die of complications that could have been easily managed in a health facility.

According to the most recent data, about 300,000 women died in 2015 from pregnancy-related and childbirth causes. Almost all of those were in low- and middle-income countries. Kenya's maternal mortality ratio in 2015 was 510 per 100,000 live births. For Ghana and India, it was 319 and 174 per 100,000 live births respectively.

Mistreatment in health care settings has also been linked with poor outcomes for women such as post-traumatic stress disorder.

The good news is that small changes to these behaviour patterns can make an enormous difference in women's experiences. As one woman told us;

Respect to me is like... . maybe how they'd want me to treat them if they were in my shoes.

Simple changes can be made at every level, from interpersonal interactions between women and their providers to the health systems at a national level. Many providers are taught the basics of patient-provider interactions during their training, but lose this quickly. These components should be emphasised in all training and infused in the culture of health facilities.

Women and their families in many settings are disempowered when it comes to demanding respectful care. This is especially true for poorer, less well educated women or those who are hold a low social status for social or cultural reasons. Finding ways to help women know and expect the respectful birth experience that is their right can help every woman have a positive birth experience.

The difference when women experience better treatment is clear. As one woman told us:

You will just feel good that you are welcomed and that you can get help. You can be free with (the doctor).

Researchers, practitioners, advocates and policy makers must continue to work against abuse and more overt forms of disrespect. But making those the sole focus can make many providers and facilities complacent in thinking they are doing well just because they have not been overtly disrespectful. A commitment must be made to hold everyone to a higher standard to guarantee a healthy future for women and babies around the world.

Patience Afulani, Assistant Professor, University of California, San Francisco

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