Table 3 Publications with Mixed Methodologies for the Measurement of Mistreatment of Women during Childbirth

Moore et al., 2002, Kenya and Bangladesh [68]

To discuss the adaptation process and pretest results for Maternity Care Provider Caring Behavior (MCPCB) assessment tools to improve “caring behaviors” of maternal health care providers during labor and delivery.

24 observations of labor and delivery processes, 22 midwives, 13 women who had recently given birth, and another 17 staff midwives and their instructors.

Direct observation tools, self-assessment survey for providers, focus group discussions, patient exit survey

The complete set of tools included four instruments: (1) the Maternity Care Provider Caring Behaviors Observational Assessment Tools; (2) maternity health care providers self-assessment tool; (3) provider focus group discussion guide; and (4) patient exit interview guide. The observational tool was developed to address the gaps between perceived issues and observed behaviors of medical providers. The eight original categories of provider ‘caring’ behaviors are: (1) Attending to human needs, (2) Being accessible to patient (3) Attending to emotional needs, (4) Respecting human rights and dignity, (5) Informing, explaining, and instructing, (6) Involving family members, (6) Incorporating cultural context, and (8) Minimizing negative behaviors. These categories were developed from the results of a literature review. Two hospitals in Kenya (one rural, one urban) and four facilities in Bangladesh (one rural, one urban, one public, one private) were selected to be nationally representative.

Hulton et al., 2007, India [73]

To assess the quality of care in maternity facilities in urban slum areas with a focus on patient experiences of respectful care and clinical practices of care

650 women living near study site health facilities who had given birth between 6 weeks to 8 months previously, hospitals records for all women at 6 hospitals who gave birth between 1996 and 1999, 70 women being discharged at 3 hospitals, 14 staff at 3 facilities.

Quality schedule, exit surveys, review of hospital records, mystery clients, community survey, direct observation, interviews

The study setting was an urban slum area with high poverty but high rates of institutionalized deliveries. Researchers developed a quality of care framework with emphasis on Experience and Provision of care. Subcategories of Experience of Care include: Human and physical resources; Cognition; Respect, dignity, and equity; and Emotional support. Subcategories of Provision of Care included: Human and physical resources; Referral system; maternity information systems; Use of appropriate technologies; and International recognized good practice.

Warren et al., 2013, Kenya [60]

To detail the protocol for study assessing mistreatment against women in childbirth before and after interventions.

Six health facilities and a large maternity hospital, health providers and managers in those facilities, national level managers and policy makers, women in labor and postpartum women and community members in the areas of the six facilities.

Focus group discussions, in-depth interviews, observations, service statistics, exit surveys, reviewing patient records, facility inventory

The evaluations includes 3–5 focus group discussions with women who gave birth at health facilities and at home, their family members, and local health workers that focus on perceptions, attitudes, and experiences of care. Also, researchers will hold in-depth interviews with 25 senior health managers and assess health facility practices through interviews with medical personnel, patient records, structured facility inventory, service statistics, observations of delivery and labor, and exit interviews with women patients ages 15–45. For interviews with medical personnel, Likert scales are used and providers are given the option to self-administer part of the interview. Researchers follow up with some women for case narratives on mistreatment. Using Bowser and Hill’s categories of mistreatment [5], researchers create a Construct Map with measurable elements of mistreatment to assess in study components and interventions.

Sando et al., 2014, Tanzania [49]

To examine if women with HIV experienced increased levels of mistreatment during childbirth at an urban hospital in Tanzania.

2000 postpartum women with and without HIV, 68 health care providers, and 200 observations of labor and delivery.

Direct observations, in-depth interviews, exit surveys, provider surveys

Researchers conducted interviews with women 3–6 h after delivery to capture their experiences of disrespect and abuse and assess their overall perceptions of care. Categories of mistreatment mentioned included in interviews parallels categories documented by Bowser and Hill [49]. Researchers also conducted direct observations of client-provider interactions around the time of childbirth. To understand provider attitudes and opinions, researches administered a structured questionnaire and conducted in-depth interviews. Topics of the surveys and interviews included definitions and perceptions mistreatment, training and practices for managing patients with HIV, and comfort level with women with HIV.

Vogel et al., 2015, Ghana, Guinea, Myanmar, Nigeria [7]

To explain a study protocol for assessing mistreatment against women in childbirth in four countries.

Medical personnel in maternity centers, facility administrators, and women (15–49) using those facilities recruited through purposive sampling.

Two-phase WHO study with in-depth interviews, focus group discussions, systematic review, exit surveys, direct observation

In the first phase, researchers will conduct a mixed methods systematic review concerning mistreatment during childbirth, and they will conduct focus group discussions as well as in-depth interviews with medical personnel, health facility administrators, and women who have used maternal healthcare facilities. Focus groups will occur with women who have given birth within 5 years, and interviews with women who have given birth within 12 months. These activities will occur in two maternal health facilities in each country (1 rural/peri-urban, 1 urban). Data from the first phase will be used to construct instruments for the second phase, in which the investigators will conduct surveys with postpartum women and observations of delivery room procedures and interactions. Categories of mistreatment addressed in the study are based on typologies outlined by Bohren et al. [3].

Warren et al., 2015, Mali [66]

To explore auxiliary midwives’ perspectives of mistreatment during childbirth in rural Mali.

67 rural auxiliary midwives recruited from a continuing education session at the regional reference hospital.

Survey, semi-structured interviews

The study consisted of a survey with 53 participants, and semi-structured interviews with 33 participants. Study components focused on descriptive norms of mistreatment (“what most people actually do”), as opposed to practices that participants reported doing themselves. Surveys incorporated open ended and Likert scale questions about respectful care practices and mistreatment, with a few questions specific to stage of labor. Semi-structured interviews focused more on participants’ own practices. Analysis considers categories of mistreatment defined by Bowser and Hill [5] and Freedman and Kruk [4].

Ratcliffe et al., 2016, Tanzania [47, 48]

To report the effects of a set of interventions to reduce abusive care during childbirth and measure levels of mistreatment before and after the interventions.

Women using the intervention hospital, medical providers and administrators at the hospitals.

Exit surveys, direct observations, follow up interviews, provider surveys, and provider in-depth interviews

The intervention consisted of an antenatal education program for women and workshops for medical providers. Baseline assessment strategies included: postpartum interviews, direct observations of labor and delivery, follow up interviews with women, provider questionnaires, and provider in-depth interviews. Intervention monitoring included: observations, pre-and-post tests for workshops and education, and post-workshop action plan. Post-intervention evaluation included: direct observation of labor and delivery, follow up interviews, and provider in-depth interviews.

Sheferaw et al., 2016, Ethiopia [62]

To validate a scale that measures women’s perceptions of respectful care.

509 women seeking postnatal care for infants within seven weeks after childbirth at public hospitals in three towns.

Literature reviews, in-depth interviews, survey tool

Items were generated through in-depth interviews with women who give birth in health facilities and a literature review. Face validity and content validity were assessed through expert review. The draft scale included 37 items and two additional measures of global satisfaction items, measured on a five- point Likert scale. The final scale with 15 items was loaded on four components. “The extracted components were labeled as friendly care, abuse-free care, timely care, and discrimination-free care. The final scale correlated strongly with the global satisfaction measures, indicating criterion-related validity of the scale.”

Sudhinaraset et al., 2016, India [75, 76]

To gain a comprehensive understanding of women’s perspectives of mistreatment during childbirth in health facilities.

418 women with a child under the age of 5, whose most recent birth had occurred at one of the local hospitals.

Focus group discussions, surveys

Focus groups were based on an interview guide with questions about migration, social connections with villages of origin and in the study site, experiences of mistreatment, health knowledge, access to health services, and gender norms and beliefs. Surveys asked questions about 11 types of mistreatment: discrimination, verbal abuse, threatening to withhold treatment, patient abandonment, neglect, refusing choice position, restricting birth companions, requesting bribes, and unnecessary separation from the baby. Questions draw from Cultural Health Capital framework.