Significant mistreatment of women during childbirth in four countries: WHO & Lancet

New evidence from a WHO-led study, published in the Lancet, shows that more than one-third of women in four lower-income countries — Ghana, Guinea, Myanmar and Nigeria — experienced mistreatment during childbirth in health facilities.

Younger, less-educated women were found to be the most at risk of mistreatment, which can include physical and verbal abuse, stigmatization and discrimination, medical procedures conducted without their consent, use of force during procedures, and abandonment or neglect by health care workers.

The study, carried out in Ghana, Guinea, Myanmar and Nigeria, found that 838 (42%) of 2,016 women experienced physical or verbal abuse, stigma or discrimination. 14% experienced physical abuse – most commonly being slapped, hit or punched. 

There were also high rates of non-consensual caesarean sections, episiotomies (surgical cuts made at the opening of the vagina during childbirth) and vaginal examinations.

WHO guidelines promote respectful maternity care for all women, which is care that maintains ‘dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth’.

High levels of verbal and physical mistreatment

The study observed 2,016 women during labour and childbirth in Ghana, Guinea, Myanmar and Nigeria. Interviews were also conducted with 2,672 women after the birth, finding similar levels of mistreatment to the direct observations.

Among the 2016 women observed by the researchers, 35 (13%) caesarean births were conducted without the woman’s consent, as were 190 of 253 episiotomies (75%). Vaginal examinations occurred without consent in 59% of cases (2611 of 4393 exams).

In addition to physical abuse, 752 (38%) of the 2016 women were observed to experience high levels of verbal abuse – most often, being shouted at, scolded and mocked. 11 women experienced stigma or discrimination, typically regarding their race or ethnicity.

The way forward

To tackle mistreatment during childbirth, health systems must be held accountable, and sufficient resources must be in place to provide quality, accessible maternal health care and clear policies on women’s rights. Health-care providers also require support and training to ensure that women are treated with compassion and dignity.

Possible strategies include:

• Redesigning labour wards to meet the needs of women, including allowing for privacy and labour companionship;
• Improving the informed consent process around all medical interventions;
• Providing sufficient mentoring and support for health workers to help them deliver better quality care;
• Allowing all women who want one to have a companion of their choice with them throughout labour and childbirth;
• Building public demand for high quality maternity services that provide women-centred care and do not tolerate any form of mistreatment.

Professional associations can also play a crucial role in promoting and supporting respectful care among midwives, obstetricians and other maternity providers, and safeguarding their rights. WHO calls upon these entities to collaborate to ensure that mistreatment during childbirth is consistently identified and reported, and that locally appropriate measures are implemented.

The findings of the study should be used to inform policies and programmes to ensure that all women have positive pregnancy and childbirth experiences, supported by empowered healthcare providers within well-functioning health systems.

This research was made possible by the support of the American People through the United States Agency for International Development (USAID) and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, WHO.

In 2014, WHO issued a statement on the prevention and elimination of disrespect and abuse during facility-based childbirth. The WHO statement positioned mistreatment during childbirth as a violation of rights and trust between women and their healthcare providers. It also called for greater action, dialogue, research and advocacy.

The 2018 WHO recommendations on intrapartum care for a positive childbirth experience highlight the importance of woman-centred care to optimize women’s experiences of labour and childbirth through a holistic, human rights-based approach. This includes the provision of respectful maternity care that maintains women’s dignity, privacy and confidentiality, enables informed choice and continuous support throughout labour and childbirth, and ensures freedom from mistreatment.

The report is published here.