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Table 1 Publications with Quantitative Methodologies for the Measurement of Mistreatment of Women during Childbirth

From: Measuring mistreatment of women during childbirth: a review of terminology and methodological approaches

Author/Year/Location Study Purpose Study Population Methodology Detailed Methodology
Reis et al., 2005, Nigeria [53] To conduct a population-based assessment of health workers’ attitudes and practices of discrimination against people with HIV in clinical settings. 1021 Nigerian health-care professionals (including 324 physicians, 541 nurses, and 133 midwives identified by profession) in 111 health-care facilities in four Nigerian states. Cross-sectional study with two surveys The first included 104 items with questions on respondent demographics; practices regarding informed consent, testing, and disclosure; treatment and care of patients with HIV/AIDS; and attitudes and beliefs about treatment and care of patients with HIV/AIDS including informed consent, testing, and disclosure. Treatment and care practices were assessed using Likert-type scales. Attitudes were assessed by a response of “agree” or “disagree” with statements regarding testing, treatment, and care of patients with HIV/AIDS. The second instrument had 103 items that asked about each facility’s capacity, resources, and policies from facility directors.
De Marco et al., 2008, Oregon, USA [74] To assess women’s perceptions of being discriminated against during prenatal care, labor, and delivery; to assess the relationship between perceived experiences of discrimination and maternal/infant characteristics and frequency of infant checkup appointments. 5672 women living in Oregon who participated in 3 cohorts from the Pregnancy Risk Assessment Monitoring System (PRAMS) study. Analysis of survey data from cohort study The study analyzed data from the 1998–1999, 2000, and 2001 Oregon PRAMS study, which collected information about the attitudes and experiences of women through the continuum of maternal health care. To assess perceived discrimination in health care, the PRAMS asked women if they felt they had ever been treated differently by health care providers during prenatal care, labor, or delivery because of their race, culture, ability to speak or understand English, age, insurance status, neighborhood in which they lived, religious beliefs, sexual orientation or lifestyle, marital status, or desire to have an out-of-hospital birth. Response categories included “yes” and “no.”
Faneite et al., 2012, Venezuela [41] To understand the extent to which health care providers understand national laws on obstetric violence and the mechanisms for reporting it. 500 health workers in three maternity hospitals in different parts of the country recruited through purposive sampling. Cross-sectional study with survey The study was conducted shortly after Venezuela passed legislation defining and outlawing obstetric violence. Participants completed the self-administered questionnaires in the hospitals where they worked. Questions consisted of yes/no questions about different types of obstetric violence and then open questions about the identification of who is responsible for violence and how to report it. Researchers were present while participants completed the survey. The study found little knowledge about details of the law or obstetric violence.
Terán et al., 2013, Venezuela [40] To evaluate the perceptions of women using maternal health care services regarding experiences of obstetric violence. 425 postpartum women still admitted at one national hospital. Cross-sectional study with survey The survey included questions about women’s experiences of acts that would constitute obstetric violence according to the Venezuela Organic Law about the Rights of Women to a Life Free of Violence. Researchers analyzed the absolute frequency, percentages, and standard deviations of different experiences of obstetric violence.
Kruk et al., 2014, Tanzania [43] To assess the frequency of reported disrespect and abuse during childbirth in rural areas of Tanzania. 1779 who had recent given birth at any of two district hospitals, five government health centers, and one government health dispensary and were recruited upon exiting the hospital. Cross-sectional study with exit survey and follow-up survey Questionnaires were administered to 1779 women upon exiting the health facilities, and follow-up surveys were administered to a random subset (593 women) of those initial participants between 5 and 10 weeks after giving birth. Surveys included 14 questions about potential experiences of abuses that were modeled on the categories of disrespect and abuse during childbirth developed by Bowser and Hill [5]. Responses were categorized as “experienced” or “not experienced.” Researchers determined frequencies and logistic regression to analyze associations between abusive treatment and individual and birth experience characteristics.
Abuya et al., 2015, Kenya [58, 59] To assess levels of disrespect and abuse during childbirth as part of a pre and post intervention. Women ages 15–45 who had delivered with 24–48 h at one of the 13 hospitals included in the intervention, regardless of their pregnancy outcome. Cross-sectional study with exit survey, and structured observation checklists Women were administered a questionnaire concerning mistreatment in general as well as typologies based on the categories developed by Bowser and Hill. General questions about mistreatment were constructed using a Likert scale, and questions about specific types of mistreatment were asked in a “yes” or “no” format. Midwife or nurse researchers also conducted structured observations of patient-provider interactions during labor using a checklist of seven categories of mistreatment. Observations measured both process (how patients are treated) and content (what they were told, revealing technical competency, accuracy of information and provision of essential information) of services.
Asefa and Bekele, 2015, Ethiopia [61] To quantitatively determine the level and types of disrespect and abuse faced by women during childbirth at four health centers in Ethiopia. 173 who had recently had a vaginal delivery at one of the study sites were recruited via purposive sampling before being discharged from the health centers. Cross-sectional study with exit survey This cross-sectional study administered exit surveys that asked participants about experiences of 23 different types of mistreatment, which were grouped into seven categories. The types of mistreatment were determined through the seven categories of mistreatment defined by Bowser and Hill, and the verification criteria were developed as part of the Maternal and Child Health Integrated Program (MCHIP). Participants’ objective and subjective experiences of mistreatment were taken into consideration.
Kujawski et al., 2015, Tanzania [44] To assess the association between perceived experiences of mistreatment and delivery satisfaction, perceived quality of care, and intention to deliver at the same facility in the future. 1388 postpartum women upon discharge from two hospitals in Tanzania. A subset of women received another survey 5–10 after the initial survey. Cross-sectional study with survey This study drew from a subset of participants in the Kruk et al. study in Tanzania [43]. Multivariable logistic regression models were used to assess the association between mistreatment and (1) satisfaction with delivery, (2) perceived quality of care for delivery, and (3) intent to use the same facility for a future delivery, controlling for confounders. Participants were asked to rate their satisfaction with delivery from four response choices: very satisfied, somewhat satisfied, somewhat dissatisfied and very dissatisfied. Women rated the quality of care they received for their delivery as excellent, very good, good, fair, or poor. Responses were dichotomized into excellent and very good compared to good, fair, and poor – categories based on past research, which indicated potential for courtesy bias among the population. The instrument drew from Bowser and Hill [5] and had “yes” and “no” questions about experiences of various forms of mistreatment.
Lukasse et al., 2015, Belgium, Iceland, Denmark, Estonia, Norway & Sweden [72] To assess the impact of reported experiences of Abuse in Health Care (AHC) on women’s fear of childbirth and desire for a cesarean delivery. 6923 pregnant women attending routine prenatal care who participated in the Belgium, Iceland, Denmark, Estonia, Norway, and Sweden (BIDENS) cohort study. Analysis of survey data from multi-country cohort study The BIDENS study questionnaire included general questions on participants’ demographic and socioeconomic characteristics, mental health, and obstetric history. The questions on abuse were taken from the Norvold Abuse Questionnaire (NorAQ) and included three descriptive questions about experiences of AHC and one scaled-question about frequency of past experiences of AHC. Fear of childbirth (FOC) was assessed by the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) version A. Women were also asked how they would prefer to give birth. Current and past experiences of AHC were associated with the other variables of interested.
Okafor et al., 2015, Nigeria [52] To determine the prevalence of disrespect and abuse of women during childbirth at a large teaching hospital in Nigeria. Convenience sample of 437 women who were accessing immunizations for their newborns within six weeks after delivery. Cross-sectional study with survey This cross-sectional study included a structured questionnaire with questions concerning disrespect and abuse. Mistreatment was grouped into seven categories based on the work of Bowser and Hill [5]. Participants were given yes/no as possible responses.
Rosen et al., 2015, Ethiopia, Kenya, Madagascar, Rwanda, Tanzania [46] To gather the prevalence of mistreatment during childbirth at a diverse array of health centers in five countries in Africa. Direct observations of 2164 labor and delivery processes. Structured clinical observation checklists Observations were part of a larger cross-sectional study called the Maternal and Child Health Integrated Program (MCHIP), conducted between 2009 to 2012. The observation checklist included 10 actions the providers should perform to guarantee that the client received respectful care. Elements of respectful care derived from the rights discussed in the Respectful Maternity Care Charter. For each country, percentage of women receiving these practices and delivery room privacy conditions were calculated. Observers’ open-ended comments were also analyzed to identify examples of mistreatment. Researchers tried to minimize the Hawthorne effect by letting health care providers know that the observations were anonymous and would not be reported if they did anything wrong. Obstetric professionals were trained as observers, used paper checklists or smartphones.
Valdez-Santiago, 2015, Mexico [39] To characterize the types of abuse that occur in obstetric facilities in three hospitals of Morelos, Mexico. 512 women recruited immediately after giving birth in the postpartum areas of the study sites. Cross-sectional study with survey The study consisted of a structured questionnaire about experiences of abuse during labor, delivery, or postpartum care from the perspective of women. Questionnaire asked mostly yes/no questions.
Moyer et al., 2016, Ghana [54] To examine what midwifery students learn and witness concerning respectful labor and delivery care. 853 students in the final year of their studies at 15 midwifery schools. Cross-sectional study with computer-based survey The cross-sectional study consisted of a computer-based self-administered survey. In addition to questions about demographics, the survey included questions about working in underserved areas, observations of respectful and disrespectful care during training, and perceptions of working conditions in the clinical settings where students train. For questions about witness events, participants had three choices of responses: “rarely or never,” “sometimes,” or “most of the time.” Surveys took between 30 and 45 min to complete, and participants received small monetary incentives.