SummaryBackgroundWomen across the world are mistreated during childbirth. We aimed to develop and implement evidence-informed, validated tools to measure mistreatment during childbirth, and report results from a cross-sectional study in four low-income and middle-income countries.MethodsWe prospectively recruited women aged at least 15 years in twelve health facilities (three per country) in Ghana, Guinea, Myanmar, and Nigeria between Sept 19, 2016, and Jan 18, 2018. Continuous observations of labour and childbirth were done from admission up to 2 h post partum. Surveys were administered by interviewers in the community to women up to 8 weeks post partum. Labour observations were not done in Myanmar. Data were collected on sociodemographics, obstetric history, and experiences of mistreatment.Findings2016 labour observations and 2672 surveys were done. 838 (41·6%) of 2016 observed women and 945 (35·4%) of 2672 surveyed women experienced physical or verbal abuse, or stigma or discrimination. Physical and verbal abuse peaked 30 min before birth until 15 min after birth (observation). Many women did not consent for episiotomy (observation: 190 [75·1%] of 253; survey: 295 [56·1%] of 526) or caesarean section (observation: 35 [13·4%] of 261; survey: 52 [10·8%] of 483), despite receiving these procedures. 133 (5·0%) of 2672 women or their babies were detained in the facility because they were unable to pay the bill (survey). Younger age (15–19 years) and lack of education were the primary determinants of mistreatment (survey). For example, younger women with no education (odds ratio [OR] 3·6, 95% CI 1·6–8·0) and younger women with some education (OR 1·6, 1·1–2·3) were more likely to experience verbal abuse, compared with older women (≥30 years), adjusting for marital status and parity.InterpretationMore than a third of women experienced mistreatment and were particularly vulnerable around the time of birth. Women who were younger and less educated were most at risk, suggesting inequalities in how women are treated during childbirth. Understanding drivers and structural dimensions of mistreatment, including gender and social inequalities, is essential to ensure that interventions adequately account for the broader context.FundingUnited 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.

BackgroundEfforts to improve maternal health are increasingly focused on improving the quality of care provided to women at health facilities, including the promotion of respectful care and eliminating mistreatment of women during childbirth. A WHO-led multi-country research project aims to develop and validate two tools (labor observation and community survey) to measure how women are treated during facility-based childbirth. This paper describes the development process for these measurement tools, and how they were implemented in a multi-country study (Ghana, Guinea, Myanmar and Nigeria).MethodsAn iterative mixed-methods approach was used to develop two measurement tools. Methodological development was conducted in four steps: (1) initial tool development; (2) validity testing, item adjustment and piloting of paper-based tools; (3) conversion to digital, tablet-based tools; and (4) data collection and analysis. These steps included systematic reviews, primary qualitative research, mapping of existing tools, item consolidation, peer review by key stakeholders and piloting.ResultsThe development, structure, administration format, and implementation of the labor observation and community survey tools are described. For the labor observations, a total of 2016 women participated: 408 in Nigeria, 682 in Guinea, and 926 in Ghana. For the community survey, a total of 2672 women participated: 561 in Nigeria, 644 in Guinea, 836 in Ghana, and 631 in Myanmar. Of the 2016 women who participated in the labor observations, 1536 women (76.2%) also participated in the community survey and have linked data: 779 in Ghana, 425 in Guinea, and 332 in Nigeria.ConclusionsAn important step to improve the quality of maternity care is to understand the magnitude and burden of mistreatment across contexts. Researchers and healthcare providers in maternal health are encouraged to use and implement these tools, to inform the development of more women-centered, respectful maternity healthcare services. By measuring the prevalence of mistreatment of women during childbirth, we will be able to design and implement programs and policies to transform maternity services.Electronic supplementary materialThe online version of this article (10.1186/s12874-018-0603-x) contains supplementary material, which is available to authorized users.

BackgroundEvery woman is entitled to respectful care during childbirth; so it is concerning to hear of informal reports of mistreatment during childbirth in Guinea. This study sought to explore the perceptions and experiences of mistreatment during childbirth, from the perspectives of women and service providers, and the analysis presents findings according to a typology of mistreatment during childbirth.MethodsThis study used qualitative methods (in-depth interviews (IDIs) and focus group discussions (FGDs)) and was conducted with four groups of participants: women of reproductive age, midwives, doctors, and administrators. The study took place in two sites in Guinea, an urban area (Mamou) and peri-urban (Pita). Data collection was conducted in two health facilities for providers and administrators, and in the health facility catchment area for women. Data were collected in local languages (Pular and Malinké), then transcribed and analyzed in French. We used a thematic analysis approach and coded transcripts manually.ResultsA total of 64 IDIs and eight FGDs were conducted and are included in this analysis, including 40 IDIs and eight FGDs with women of reproductive age, 5 IDIs with doctors, 13 IDIs with midwives, and 6 IDIs with administrators. Participants described their own personal experiences, experiences of women in their communities and perceptions regarding mistreatment during childbirth. Results were organized according to a typology of mistreatment during childbirth, and included instances of physical abuse, verbal abuse, abandonment and neglect. Women described being slapped by providers, yelled at for noncompliance with provider requests, giving birth on the floor and without skilled attendance in the health facility. Poor physical conditions of health facilities and health workforce constraints contributed to experiences of mistreatment.ConclusionsThese results are important because they demonstrate that the mistreatment of women during childbirth exists in Guinea and occurs in multiple forms. These data should be used by the Ministry of Health and other stakeholders to develop strategies to reduce and prevent the mistreatment of women during childbirth.