Table 2 Publications with Qualitative Methodologies for the Measurement of Mistreatment of Women during Childbirth

Castro & Erviti, 2003, Mexico [15]

To shed light on various sociological factors that contribute to abuse during facility-based childbirth.

200 women who reported abuses in medical facilities in Mexico, and another 64 observations of patient-provider interactions during labor and delivery.

Unstructured birth testimonies and qualitative direct observation

The study consisted of three phases. First, researchers compiled approximately 200 testimonies from women who reported having experienced various types of mistreatment over a five-year period. Many testimonies were collected from other studies that did not directly intend to measure mistreatment. Second, testimonies were assessed using qualitative methodology, looking for patterns that emerge from the testimonies. Third, researched conducted direct observation in labor and delivery rooms in the two largest public hospitals in Cuernavaca.

Beck, 2004, New Zealand, USA, Australia, and United Kingdom [71]

To gain insight on the factors that contribute to reported traumatic experiences during childbirth.

38 women who had given birth within the previous 5 weeks to 14 years and reported emotional trauma from their birth experiences.

Written birth narratives

Participants were recruited online through Trauma and Birth Stress (TABS), a charitable trust based in New Zealand that helps women who have experienced PTSD during their childbirth experiences. Over an 18-month period, participants were asked to write and submit descriptions of their traumatic birth experiences, which were analyzed using Colaizzi’s method of thematic data analysis. Overall study methodology included descriptive phenomenology.

Steele & Chiarotti, 2004, Argentina [42]

To understand experiences of mistreatment for women who access post-abortion care.

300 women who received post-abortion care at public hospitals in Rosario, recruited through women’s community organizations, health workers, and community contacts. 31 women also gave testimonies.

Focus group discussions as part of full day workshops, role play of care scenarios, unstructured testimonies

Researchers organized 13 workshops, in which women participated in discussions about mistreatment and discrimination while seeking post-abortion care and engaged in role-play scenarios of receiving care. Investigators reported that role-play was effective in helping women discuss personal, sensitive, and taboo topics. 31 women gave in-depth testimonies of their experiences. Those interviews were unstructured.

d’Ambruoso et al., 2005, Ghana [57]

To gather women’s perspectives of their interactions with maternal health care providers and assess the acceptability of maternal health services.

Opportunistic sample of 21 women who were participating in another study in Ghana and had accessed maternal health services in the prior five years.

Focus group discussions, in-depth interviews

This study was part of the SAFE initiative, which aimed to increase the knowledge base on skilled birth attendance in various developing countries. The topics of semi-structured interviews and focus group discussions drew from the SAFE study framework and included: (1) Place of delivery, (2) Satisfaction with services, (3) Recommendations of care, (4) Recommendations of services to other women. Investigators first started using focus groups discussions, but abandoned that research strategy in favor of in-depth interviews when it became clear that women were not comfortable sharing personal, emotional experiences in front of a group. Interviews were conducted at a location of the participant’s choosing. The methodology was based on the constructivist paradigm toward enquiry.

Marque et al., 2006, Brazil [35]

To understand nurses’ perspectives of the humanization of childbirth.

12 nurses in obstetric wards recruited from study hospitals with convenience sampling.

Semi-structured interviews

Semi-structured interviews were categorized into (1) the meaning of “humanization” of childbirth, (2) examples of “humanizing” practices, (3) examples of “dehumanizing” practices, (4) role of nurses in humanizing care. Participant interviews were transcribed and analyzed using thematic analysis.

Muñoz, 2008, Spain [69]

To understand the forms of abuse that occurs during facility-based childbirth.

10 women who had just given birth at a hospital.

In-depth interviews and qualitative direct observations

The study consisted of in-depth interviews and participant observations with 10 women who had recently given birth in hospitals. Themes that emerged from the interviews included hierarchal and asymmetric power structures with doctors in hospitals, in which patients are passive, obedient, and submissive to the physicians’ demands. The author used patients’ descriptions of mistreatment as a framework to discuss gender inequalities within society.

Santos & Shimo, 2008, Brazil [36]

To understand women’s knowledge and consent to episiotomies during childbirth.

16 women who received episiotomies during their births at a teaching hospital.

Semi-structured interviews and unstructured observations

Semi-structured interviews asked women about their knowledge of episiotomies, whether someone asked their permission to perform an episiotomy, and information given to them by medical personnel about episiotomies. Interviews took place three days after the woman’s delivery and were audio-recorded and transcribed. Observations were conducted throughout participants’ labor, delivery, and postpartum period at the hospital.

Kruger et al., 2010, South Africa [67]

To understand the psychological experiences of giving birth and working as a nurse in South African maternity wards.

93 low-income, Afrikaans-speaking women who gave birth in maternity wards and 8 of the 12 of the maternity ward nurses.

Semi-structured interviews

Researchers conducted semi-structured interviews with maternity ward nurses to ask about the psychological experiences of their work. They were never directly questioned about violence or abuse of patients, though that was the topic of interest. Women who had recently delivered with interviewed and asked about experiences in which they did not like nurses’ behaviors. Participants participated in four interviews (during pregnancy, a few days after giving birth, three months after giving birth and six months after giving birth) by the same interviewer. Interviews were analyzed using social constructionist grounded theory and coded. The study helped to shed light on some of the structural drivers of mistreatment as it demonstrated that nurses’ aggressive behaviors might stem from hierarchal power structures within hospitals.

de Aguiar & d’Oliveira, 2011, Brazil [32]

To understand the dynamic between power structures and institutional violence in maternity care from the perspective of women using public services.

21 women who had given birth within three months before the interview.

Semi-structured interviews

Semi-structured interviews were conducted at participants’ homes to allow for participants’ comfort. The number of interviews was determined by when investigators thought saturation was reached. The interview guide contained open-ended questions that asked about access, quality of care, and previous experiences with public maternity hospitals, and women’s perceptions and experiences of mistreatment. Results shed light on how obstetric violence occurs against patients and how patients learn to adapt strategies of acceptance or resistance against mistreatment. Results also indicate that many patients come to trivialize and expect mistreatment as part of the care process.

Janevic et al., 2011, Serbia and Macedonia [70]

To develop a conceptual framework showing how different levels of racism occur in maternal health settings and affect access to maternal health care among Romani women.

71 Romani women who had given birth within the past year recruited through purposive sampling, 8 gynecologists, 11 key informant interviews from NGOs & state institutions recruited through snowball sampling.

Community-based participatory research study with focus groups and semi-structured interviews

Based on community-based participatory research principles, the study included focus group discussions with Romani women with questions on health knowledge and beliefs during pregnancy, what women did after they found out they were pregnant, and experiences during prenatal care and delivery. The study also included semi-structured interviews with gynecologists and key informants. For gynecologists, interview questions focused on the provider practices, their daily challenges, and experiences with Romani patients. For key informants from NGOs, interviews focused on barriers to maternal care for Romani women. Experiences of racism in maternal health care were organized into a framework of three categories: institutional racism, personally-mediated racism, and internalized racism.

de Souza et al., 2011, Brazil [38]

To explore how health care providers perceive the humanization of childbirth.

17 professionals who work in four hospitals, two public, one affiliated with SUS, and one not affiliated with SUS.

Semi-structured interviews

The study used semi-structured interviews to examine perceptions of the humanization of childbirth care process as defined by national legislation. Thematic analysis revealed three principle categories: (1) the meaning of humanization; (2) practice of humanized care, and (3) difficulties in practicing humanized childbirth care. The study showed deficiencies in healthcare infrastructure and medical training that leave personnel not fully equipped to provide humanized care.

Aguiar et al., 2013, São Paolo, Brazil [33]

To understand the dynamic between institutional violence, gender, and power structures in public maternity hospitals.

21 women who had given birth at public hospitals within three months, 18 health care workers recruited through snowball sampling.

Semi-structured interviews

Interview questions focused on participants’ experiences and definition of violence. Interviews were conducted a location of participants’ choosing outside of the hospitals. Transcripts were analyzed using thematic coding and considered the social position of the participants (gender, age, income, race, etc.). The study found that health providers acknowledged violent practices but didn’t see them as violence but as necessary in a ‘difficult’ context and for the patients ‘own good.

Moyer et al., 2013, Ghana [55]

To examine community and health providers attitudes towards mistreatment during delivery incorporating a human rights perspective.

128 community members, including women with their newborn infants, and 13 health care providers recruited purposively at hospitals and health facilities.

Semi-structured interviews and focus group discussions

Community member participants were identified through community key informants in two randomly selected zones of study areas. Topics for interviews and focus group discussions were constructed using the Respectful Maternity Care Charter with an additional category concerning traditional birth practices. Both interviews and FGDs were analyzed using NVIVO thematic analysis.

Mselle et al., 2013, Tanzania [45]

To identify potential weaknesses in acceptable and quality care for women who suffer obstetric fistula.

16 women who suffered obstetric fistula, 5 nurse-midwives, six husbands of affected women, and six community members.

Semi-structured interviews and focus group discussions

Data collection was carried out over two years at a Comprehensive Community Based Rehabilitation Center. Semi-structured interviews were conducted with women about their experiences of care and with nurse-midwives from different levels about their experiences in delivering care. Sample size was determined by when saturation was reached. Focus groups were conducted with community members and described hypothetical situations about women facing challenges in obtaining quality birth care. Focus groups were also conducted with women’s husband about the challenges their wives faced. The study documented poor quality of care and gained insights into why health care personnel do not care well for their patients.

Andrade & de Melo Aggio, 2014, Brazil [34]

To gain exploratory data about obstetric violence from the perspectives of women who receive institutional care.

Four women who had given birth in health facilities.

Semi-structured interviews

Semi-structured interviews were conducted at women’s houses until saturation level was reached. The interview guide was developed using principles established in the National Law for the Humanization of Childbirth.

Da Silva et al., 2014, Brazil [37]

To understand obstetric nurses’ perspectives, attitudes, and experiences of obstetric violence.

Obstetric nurses working in public and private health facilities.

“Brainstorming” sessions as part of full day meeting

Investigators conducted a full-day meeting with obstetric nurses. The purpose of the meeting was to “brainstorm” different ways in which obstetric violence occurs in hospitals based on the experiences and perceptions of nurse participants. Participant conversations were audio-recorded, transcribed, and analyzed using thematic analysis. The results were categorized into (1) violent utterances of health professionals to patients, (2) unnecessary and/or iatrogenic experiences procedures performed by health professionals and (3) the institutional unpreparedness with unstructured environment.

McMahon et al., 2014, Tanzania [28]

To gather data on the perspectives of mistreatment during childbirth among women and their male partners in order to inform policy and advance research .

Women who had delivered within the past 14 months at a health facility, their male partners, community leaders and health workers from 16 villages across 4 districts.

In-depth interviews

Community leaders and community health workers were identified purposively from areas that were identified as lacking access to health care. Participant recruitment emphasized women who had normal deliveries. All participants participated in interviews in a location of their choice. Interviews included open questions about perceptions of care and care seeking, and later asked probing questions about experiences of disrespect and abuse. Grounded Theory was used in developing codes from interviews a literature review was conducted based on code results. Results were also compared to categories of mistreatment described by Bowser and Hill [5].

Bohren et al. 2016, 2017, Nigeria [50, 51]

To understand the extent to which mistreatment becomes normalized among health care providers and women accessing health care.

41 women who had given birth within the past year, women who had given birth within the past five years, 17 nurse/midwives, 17 doctors, and 9 heath care administrators.

In-depth interviews and focus group discussions

The study included focus group discussions with women who had given birth within the past five years and in-depth-interviews with women who had given birth within the past year and healthcare providers. Topics included questions about experiences and perceptions of, and perceived factors influencing mistreatment during childbirth. IDI and FGDs were also presented with four scenarios of mistreatment: physical restraint, slapping, verbal abuse, and refusing to help a woman. Thematic analysis of results was conducted based on categories identified in systematic review by Bohren et al. [3]. Combined approach of asking general questions with very specific examples of mistreatment allowed for comparison with other studies and locations.

Rominski et al., 2016, Ghana [56]

To examine perspectives of mistreatment during childbirth among midwifery students in Ghana.

Midwifery students in the final year of training at 15 midwifery schools in all of the country’s regions.

Focus group discussions

Investigators constructed the discussion guide using Bowser and Hill’s categories of mistreatment and participants general perceptions of respectful maternity care [5] and the author’s previous study [55]. Recruitment involved contacting students who had previously participated in a related computer survey. Discussions began with definitions of respectful care. FGDs were transcribed verbatim, coded, and analyzed. The study found that students often tried to justify disrespectful care.

Amroussia et al., 2017, Tunisia [63]

To examine single mothers’ experiences and perceptions of giving birth in medical facilities.

11 single mothers who had given birth a public healthcare facility.

Semi-structured interviews

The study used a semi-structured interview guide. Questions drew from authors’ personal experience and knowledge and focused on four main topics: single women’s experiences of mistreatment, perceptions of the attitudes of health care personnel, barriers to accessing care, and self-perceptions as single mothers. Data was analyzed using feminist intersectional approach.

Balde et al., 2017, Guinea [64, 65]

To examine women’s and health care providers’ perceptions and experiences of mistreatment.

Women of reproductive age who had given birth within the past year and within the past five years, health care providers, and health facility administrators in an urban area and a semi-urban area of the country.

Focus groups and in-depth interviews

Participants were given four scenarios of mistreatment during childbirth including: (1) providers slapping a woman, (2) verbal abuse, (3) providers refusing to help patients, and (4) providers forcing women to give birth on the floor. Participants were also asked questions about the story of childbirth, perceptions and experiences of childbirth, elements of mistreatment, and factors that might influence how women are treated. Researchers used thematic analysis to understand the acceptability of and attitudes towards those instances of mistreatment, as well as the different types of mistreatment that may occur. Typologies of mistreatment drew from the Bohren et al. review [3]. Results found various forms of mistreatment and that both providers and women may accept mistreatment in certain scenarios.