Mistreatment of women during childbirth and its influencing factors in maternity hospitals in Tehran, Iran: a formative qualitative multi-stakeholder study

Abstract

Background Mistreatment during labour and childbirth is a common experience for many women around the world. A picture of the nature and types of mistreatment; and especially its influencing factors has not yet been identified in Iran. This study aimed to explore the manifestations of mistreatment and its influencing factors in maternity hospitals in Tehran. Methods A formative qualitative study was conducted using in-depth face-to-face interviews between October 2021 and May 2022 in five public hospitals. Participants included women, maternity healthcare providers, and managers at hospital and Ministry of Health levels. Participants were selected using purposive sampling. Recorded interviews were transcribed verbatim and thematically analyzed with a combined deductive and inductive approach using MAXQDA 18. Results A total of 60 interviews were conducted. Women experienced various forms of mistreatment during labour and childbirth, including verbal abuse, frequent and painful vaginal examinations, neglect and abandonment, lack of supportive care, denial of mobility and pain relief, and physical abuse. Four main themes were identified as the drivers of mistreatment: (1) individual-level factors (healthcare providers perception about women’s limited knowledge on childbirth process, untrained companions, mismatched expectations of women for care, and discrimination based on ethnicity or low socioeconomic status); (2) healthcare provider-level factors (healthcare provider stress/stressful working conditions, healthcare providers with limited personal experience of pregnancy and childbirth, neglect of midwives' identities by doctors, poor educational contents and curriculum, and low salary and lack of incentive); (3) hospital-level factors (lack of staff, lack of supervision and control, type of hospital, inadequate physical structures); and (4) national health system-level factors (lack of access to pain management during labour and childbirth and perceptions about forced vaginal birth in public hospitals). Conclusions There are multiple level drivers for mistreatment which requires multifaceted interventions. These interventions should emphasize training of pregnant women and their companions, training healthcare providers, encouraging and managing work shifts, strengthening the position of midwives in public hospitals. Moreover, continuous monitoring of the performance of providers, increase staff numbers and improvement of physical space of the maternity wards, as well as implementation of the related guidelines, including painless childbirth, should also be considered.

Challenges to the implementation of a multi-level intervention to reduce mistreatment of women during childbirth in Iran: a qualitative study using the consolidated framework for implementation research

“…The project, which was initiated in October 2021 in ve public teaching hospitals in Tehran, Iran, consists of ve phases: (1) needs assessment (to assess knowledge, attitudes and practices of maternity healthcare providers about mistreatment during labour and childbirth, and the manifestations of mistreatment and its in uencing factors); (2) designing interventions to reduce mistreatment during childbirth; (3) identifying the challenges of implementing the interventions; (4) designing implementation strategies for intervention; and (5) testing implementation strategies in a real-life setting. The ndings of the rst phase of the project are described elsewhere [11,27].…”

“…This was rst initiated to promote vaginal birth. Despite, evidence shows that women have still generally limited knowledge about labour and childbirth process [11,29]; that can provide grounds for mistreatment to them [11,30,31].…”

“…The possibility of presence of birth companions has been provided through redesigning maternity wards to promote vaginal birth. However, most birth facilities do not allow birth companions [11,19].…”

“…The provision of childbirth pain relief methods is another strategy for promoting vaginal childbirth in Iran, which was implemented to make childbirth pleasant and increase satisfaction of women. However, evidence show that in public hospitals, pregnant women do not have access to pain relief interventions during labour [11,32]. We conducted an exploratory qualitative study consisting of individual in-depth and semi-structured interviews between July 2022 and February 2023 in Tehran, Iran.…”

“…The prevalence in Iran was reported 75.7% [9] and 100% [10]. The women have experienced "verbal abuse, frequent and painful vaginal examinations, neglect and abandonment, lack of supportive care, denial of mobility and pain relief, and physical abuse" during labour and childbirth [11].…”