Prevalence of mistreatment and disrespect of women during childbirth in the world: a systematic review and meta-analysis

Background

Mistreatment of women during childbirth is a serious violation of women’s rights, which has become a common experience for many women worldwide and is considered a public health challenge because of the negative outcomes it can cause for both mothers and newborns. This systematic review is aimed to estimate the global prevalence of mistreatment and disrespect of women during childbirth.

Methods

The electronic databases PubMed, CINAHL, EMBASE, PsycINFO, Scopus, Web of Science, Google Scholar search engine, and other sources were searched from January 1, 2000, to May 31, 2024, without language restriction, using a pre-specified search strategy. Studies meeting our inclusion criteria were included and assessed for quality using a standardized risk of bias assessment tool. Pooled prevalence was estimated using a random-effects model using Stata software, version 14.0. Heterogeneity was assessed using Cochran’s Q test and I² statistic, and publication bias was assessed using Begg’s funnel plot and Egger’s test.

Results

In total, 117 studies were included, providing 125 datasets and involving 209,175 participants across 37 countries. The prevalence of mistreatment and disrespect during childbirth ranged from 1.9 to 100%, with a pooled estimate of 54.5% (95% CI: 49.1%-59.9%, I² = 100%). The highest prevalence was observed for “not being allowed a birth companion” (51.5%; 95% CI: 3.7%-99.2%) and “poor rapport between women and providers” (48.1%; 95% CI: 32.2%-64.01%), while the lowest prevalence was related to “sexual abuse” (1.2%; 95% CI: -0.14%-2.6%). Risk of bias assessment was the only significant predictor, suggesting that methodological quality influenced the reported prevalence of mistreatment and disrespect.

Conclusion

This study found that more than half (54.5%) of women globally experience mistreatment and disrespect during childbirth- a widespread and alarming issue. The findings highlight an urgent need for targeted interventions, policies, and programs to ensure respectful, safe, and equitable maternity care for all women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-025-02119-6.

Plain language summary

Disrespect and abuse (D&A) or mistreatment during childbirth is a serious global health issue. Despite the reporting of mistreatment and disrespect of women during childbirth in numerous primary studies, to our knowledge, no comprehensive study has been conducted at the global level to quantify the prevalence of mistreatment and disrespect during childbirth. This study is aimed to systematically review the findings of available studies on this issue and estimate its prevalence in the world. Six electronic databases, Google Scholar search engine, and other sources were searched without language restrictions. It included any primary study with an observational design (including cross-sectional or cohort) that reported the prevalence of mistreatment and disrespect of women during labour and childbirth. Overall, 117 studies were included, providing 125 datasets and involving 209,175 participants across 37 countries. We determine that 54.5% of women experienced mistreatment and disrespect during childbirth and maternity care. Results between studies varied widely, ranging from 1.9 to 100% of women experiencing some form of disrespect and abuse. This could be attributed to disparities in socioeconomic development status, cultural conditions, differences in healthcare facilities and systems, sampling techniques, tools, study methods, and how mistreatment and disrespect are defined in studies. Despite these differences, our findings indicate that more than half of women globally experience mistreatment and disrespect during childbirth, highlighting a widespread and concerning problem. The findings highlight an urgent need for targeted interventions, policies, and programs to ensure respectful, safe, and equitable maternity care for all women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-025-02119-6.

Background

In recent years, efforts to improve maternal health, reflected in the Millennium Development Goals (MDGs) and the Sustainable Development Goals (SDGs), have shifted to improving the quality of care, including promoting respectful care and eliminating disrespect and abuse (D&A) during childbirth [1]. However, D&A or mistreatment during childbirth or obstetric violence, is recognized as a serious global health issue and a violation of women’s and newborn fundamental human rights [2], has become a common experience for many women worldwide [3–8]. In 2014, the World Health Organization (WHO) issued a statement calling for urgent attention to this problem, emphasizing that “every woman has the right to the highest attainable standard of health, which includes the right to dignified, respectful health care throughout pregnancy and childbirth, as well as the right to be free from violence and discrimination” [9]. Therefore, advocating facility-based childbirth and upholding respectful maternity care (RMC) have been highlighted as potential strategies not just to reduce maternal and newborn morbidity and mortality but also ensure a dignified person-centered birthing experience, especially in low- and middle-income countries (LMICs) [10].

The alarming prevalence of mistreatment and disrespect during childbirth has been widely documented in previous studies. In Africa the prevalence of mistreatment and disrespect during childbirth is 44.09% and 46.8% [3, 4], in Latin America 43.0% [8], and in Europe 13.5–30.2% [11]. This variation in prevalence may be due to the different subjective natures and concepts of mistreatment and disrespect, based on the cultural and social norms of societies [12]. Furthermore, the use of different terms, tools, and measurement methods to document experiences of mistreatment and disrespect can affect the reported prevalence [12, 13]. Evidence suggests that mistreatment and disrespect are associated with adverse outcomes such as fear of childbirth, increased risk of cesarean section, breakdown of the emotional bond between mother and child, impaired breastfeeding, postpartum depression or post-traumatic stress disorder, poor quality of care, and increased maternal mortality and morbidity [14–17].

Various terms have been used to describe poor treatment of women during childbirth [18]. For example, “obstetric violence” was the first term that emerged to describe the dehumanized nature of overmedicalized biomedical care through movements for the humanization of childbirth in the 1990 s in Latin America [19, 20]. In 2010, Bowser and Hill provided an evidence-based definition of “disrespect and abuse” during childbirth, which included physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination, abandonment or denial of care, and detention in facilities [21]. Sen et al. (2018) further expanded the definition by separating disrespect from abuse and presenting it in the Indian context [22]. In 2015, “mistreatment of women during childbirth” was proposed as a more inclusive term by WHO researchers, including physical abuse, sexual abuse, verbal abuse, stigma and discrimination, failure to meet professional standards of care, poor rapport between women and providers, and health system conditions and constraints [23].

Knowing the prevalence of mistreatment during childbirth can provide information to developing effective policies and interventions to prevent associated outcomes. Despite the reporting of disrespect and abuse of women during childbirth in numerous primary studies, to our knowledge, no effort has yet been made at the global level to quantify the prevalence of disrespect and abuse during childbirth. To fill this gap, we conducted this study, aiming to systematically review the findings of available studies on this issue and estimate its prevalence in the world.

Methods

Design and registration

This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [24] (Additional file 1: Table S1). The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) with the registration number CRD42024559861.

Search strategy

A literature search was carried out using the electronic databases PubMed, CINAHL, EMBASE, PsycINFO, Scopus, Web of Science, and Google Scholar search engine from January 1, 2000, to May 31, 2024, using a pre-specified search strategy. Controlled vocabulary and free-text terms were adapted to suit each electronic database, combining the two main search components: (a) maternal health, perinatal health, or childbirth, and (b) mistreatment and disrespect of women (Additional file 1: Table S2). Key journals, reference lists of all included studies, and key references (i.e., relevant systematic reviews) were also hand-searched to identify additional studies. A grey literature search was also conducted using organizational databases such as WHO, White Ribbon Alliance (WRA), U.S. Agency International Development (USAID), and Population Council. The searches were carried out between July and September 2024.

Eligibility criteria

We included any primary study with an observational design (including cross-sectional or cohort) that reported the prevalence of mistreatment and disrespect of women during labour and childbirth. Studies were included regardless of whether they were implemented in the health facility or the community. No language restrictions were applied; however, to focus on contemporary maternity care practices, we included only eligible studies published on or after January 1, 2000. We excluded qualitative studies, conference abstracts, case reports, commentaries, letters to editors, and studies with insufficient data. Systematic reviews were excluded; however, their reference lists were searched to ensure relevant primary studies were included.

Outcomes

Among women who give birth (Population), what is the prevalence of mistreatment and disrespect (Condition) across various countries and healthcare settings (Context)?

Study selection, data extraction and risk of bias (methodological quality) assessment

The search results were first imported into EndNote X9 citation management software (Thomson Reuters, New York, NY, USA). After removing duplicates, remaining studies were imported into Rayyan platform for screening [25], and were selected based on titles and abstracts by two reviewers (MM and MAN). Google Translate was used to translate non-English-language published titles and abstracts. Assessment of the full texts was also conducted independently by two reviewers (MM, MAN, and MD) using the inclusion criteria. If the full texts of the papers were not available or their data were unclear, they were obtained through correspondence with the authors. Any disagreement between the reviewers was resolved through discussion or consultation with a third reviewer (SH and ESh). Data extraction was conducted using a standardised form designed and tested for this review (Additional file 1: Table S3) by two reviewers (MM, MAN, and NK) independently, and disagreements were resolved through discussion and consensus. The extracted information included the title of the paper, name of the first author, publication year, country (according to the regional distribution established by the WHO, including African, Americas, South-East Asia, European, Eastern Mediterranean, and Western Pacific, as well as according to the most recent World Bank classification [26], including high, upper-middle, lower-middle, and low), study design, study setting, type of recruitment (in-facility/community), study population, sampling method, data collection method, data measurement tool, timing of data measurement, sample size, type of mistreatment and disrespect experienced by the women, and results (including mean age, age range, number of victims of mistreatment and disrespect, and prevalence (percentage with confidence intervals). The data were entered into a Microsoft Excel spreadsheet.

The methodological quality of the included studies was assessed by two independent reviewers (MM and MAN or MM and MD) using the 10-item tool developed by Hoy et al. [27], and disagreements were resolved by discussion or by consultation with a third reviewer (SH and ESh). The tool assesses four domains of bias plus a summary risk of bias. Items 1 to 4 assess the external validity of the study (selection and non-response bias domains) and items 5 to 10 assess the internal validity (items 5 to 9 assess the measurement bias domain, and item 10 assesses bias related to the analysis). Item 11, the summary assessment, evaluates the overall risk of study bias. Studies were classified as having a low risk, moderate risk, and high risk of bias when eight or more, six to seven, and five or fewer items were answered as “yes” respectively [27] (Additional files 1: Tables S4 and S5). No studies were excluded as a result of the quality assessment.

Data analysis

To estimate the pooled prevalence of mistreatment and disrespect during childbirth with 95% confidence interval (CI), a random-effects model was used because of the possibility of heterogeneity among studies. A world map was generated to visualize variations in prevalence by country. Cochran’s Q test and I-squared (I²) statistic were used to assess heterogeneity across different studies [28]. The I² values of 25%, 50%, and 75% were considered as low, moderate, and high heterogeneity, respectively [28, 29]. Influence analysis was conducted to determine the impact of each study on the overall results of the meta-analysis. Meta-regression and subgroup analyses were conducted to identify potential sources of heterogeneity. Subgroup analyses were conducted by year of publication, region, country income level, study setting, type of recruitment, study population, data collection method, tool and timing of data measurement, study risk of bias score, and types of mistreatment and disrespect during childbirth. The Begg’s funnel plot and Egger’s test were used to assess publication bias. Data analysis was conducted using Stata software, version 14.0 (StataCorp LP, College Station, TX, USA); for the statistical tests, the significance level was set at p < 0.05.

Results

Search results

A total of 1,725 citations were identified from the database searches, with 22 studies yielded from additional records identified through other sources. After removal of duplicates, 1,402 unique citations were screened, and 192 citations were identified for full-text review. Reference list screening yielded 30 additional studies. Finally, 117 studies with 209,175 participants published between 2000 and 2024 in English, Spanish, French, Portuguese, and Persian were included (Fig. 1).

Fig. 1.

PRISMA flow diagram for the study selection. * Reasons for exclusion: Other study designs (Qualitative/intervention studies, conference abstracts, case reports, editorials, and commentaries) (n=59). Not focused on mistreatment or disrespect (n=19). Did not report prevalence data (n=8). Duplicates (n=8). Unpublished technical report obtained (n=5). Others (n=6)

Characteristics of the included studies

Table 1 provides a summary of the characteristics of the included studies, and Additional file 1: Table S6 reports more detailed information for each study. In summary, the 117 included studies were conducted in 37 countries. This includes 56 studies in the African region (10 countries: Ethiopia [30–55], Nigeria [56–67], Tanzania [68–74], Kenya [75–79], Ghana [58, 80, 81], Zambia [82], Guinea [58], Mozambique [14], Malawi [83], and Namibia [84]); 19 studies in the Americas region (7 countries: Brazil [2, 85–92], Mexico [93–95], Ecuador [96, 97], Venezuela [98, 99], Peru [100], Chile [101], and the United States of America [102]); 15 studies in the Eastern Mediterranean region (8 countries: Iran [103–105], Palestine [106–108], Sudan [109, 110], Pakistan [111, 112], Saudi Arabia [113, 114], Iraq [115], Egypt [116], and Jordan [117]); 14 studies in the European region (7 countries: Netherlands [118–120], Spain [121–123], France [124, 125], Germany [119, 126], Turkey [127, 128], Italy [129], Poland [130]); and 15 studies in the Southeast Asian region (5 countries: India [131–138], Nepal [139–142], Sri Lanka [143], Bhutan [144], and Myanmar [58] (One multi-country study was conducted in countries in the African and Southeast Asian regions, and one multi-country study in countries in the European region [58, 119]). Most studies were conducted in low- or lower-middle-income countries: 38 studies (32.2%) in low-income, 40 studies (33.9%) in lower-middle income, 25 studies (21.1%) in upper-middle income countries, and 15 studies (12.8%) in high income countries (One multi-country study was conducted in both low- and lower-middle-income countries [58]). A world map to visualize the prevalence variations by country is shown in Fig. 2.

Table 1.

Characteristics of the included studies

Characteristic	Number of studies	Studies
Total	117	[2, 14, 30–144]
Year of publication
2000–2020	66	[14, 32–35, 37–40, 43, 44, 46, 48–50, 52, 53, 57, 58, 60, 63, 64, 68–72, 74, 75, 77–80, 82–87, 90, 91, 94–100, 102, 103, 106, 109–112, 114, 117, 122, 125, 130–133, 135, 137, 144]
2021 or later	51	[2, 30, 31, 36, 41, 42, 45, 47, 51, 55, 56, 59, 61, 62, 65–67, 73, 76, 81, 82, 88, 89, 92, 93, 101, 104, 105, 107, 108, 110, 113, 115, 116, 118–121, 123, 124, 126–129, 136, 138–143]
Language
English	110	[2, 14, 30–84, 86–94, 96, 97, 100, 102, 103, 105–124, 126–144]
Spanish	4	[95, 98, 99, 101]
French	1	[125]
Portuguese	1	[85]
Persian	1	[104]
Region 1 (n = 119)
African	56	[14, 30–84]
Americas	19	[2, 85–102]
South-East Asian	15	[58, 131–144]
European	14	[118–130]
Eastern Mediterranean	15	[103–117]
Country-income level 2 (n = 118)
Low	38	[14, 30–55, 58, 68–74, 83, 109, 110]
Lower-middle	40	[56–67, 75–82, 106–108, 111, 112, 116, 131–144]
Upper-middle	25	[2, 84–95, 97–100, 103–105, 115, 117, 127, 128, 130]
High	15	[101, 102, 113, 114, 118–126, 129, 130]
Study design
Cross-sectional	109	[14, 30–93, 95–109, 111–123, 126–132, 134–139, 142–144]
Cohort	8	[2, 94, 110, 124, 125, 133, 140, 141]
Study setting
Urban	94	[2, 14, 30, 32, 33, 35–38, 40–45, 47–50, 52–60, 62–68, 71–73, 76, 77, 79, 80, 82–100, 103–111, 113–119, 121, 124, 125, 127, 128, 130, 132, 135–144]
Rural	7	[34, 51, 69, 70, 78, 131, 134]
Mixed	14	[31, 39, 46, 61, 74, 75, 81, 101, 102, 112, 122, 123, 126, 133]
Not specified	2	[120, 129]
Type of recruitment 3 (n = 119)
Facility-based	91	[2, 14, 30, 32–34, 36–38, 40–44, 46–51, 53–57, 59–67, 69–77, 80–90, 92, 93, 95–100, 103–110, 112–117, 124, 125, 127, 128, 130, 132, 135–137, 139–144]
Community-based	28	[31, 35, 39, 45, 52, 58, 68, 69, 72, 78, 79, 91, 94, 101, 102, 111, 118–123, 126, 129, 131, 133, 134, 138]
Study population
Women	109	[2, 14, 30–32, 34–64, 66–73, 75–81, 83, 85–89, 91–130, 132–136, 138–144]
Healthcare providers	7	[33, 65, 74, 82, 84, 131, 137]
Family members	1	[90]
Data collection method 4 (n = 119)
Self-report questionnaire	111	[2, 14, 30–37, 39–82, 84–89, 91, 92, 94–136, 138–140, 142–144]
Direct observation of labour	7	[38, 58, 83, 93, 132, 137, 141]
Not specified	1	[90]
Data measurement tool 5
Categories of D&A during childbirth by Bowser and Hill	62	[14, 30–37, 39, 40, 42–44, 47, 48, 50–53, 55–57, 61–64, 66, 68–75, 77–83, 86, 93, 94, 100, 103, 105, 109–112, 124, 127, 131, 134, 137–139, 142, 144]
Typology of mistreatment by Bohren et al.	21	[38, 41, 49, 58, 59, 76, 89, 90, 97, 102, 104, 107, 108, 119, 120, 125, 130, 132, 135, 140, 141]
Both categories of D&A during childbirth, and typology of mistreatment	3	[65, 92, 118]
Others	7	[54, 116, 117, 126, 129, 136, 143]
Not specified	24	[2, 45, 46, 60, 67, 84, 85, 87, 88, 91, 95, 98, 99, 101, 106, 113–115, 121–123, 128, 130, 133]
Timing of data measurement 6 (n = 122)
During labour and childbirth care	52	[14, 30, 32–34, 36–38, 40, 42–44, 46–51, 53, 55, 58, 69, 71–73, 75, 77, 82, 83, 85, 89, 90, 93, 95, 96, 98–100, 103–106, 110, 113, 116, 124, 125, 132, 133, 137, 139, 140]
Postpartum within 6 weeks	18	[56–58, 61, 64, 66, 67, 72, 92, 97, 108, 109, 128, 132, 134, 135, 142, 144]
Postpartum ranging outside 6 weeks	42	[2, 31, 35, 39, 41, 45, 52, 59, 60, 62, 68–70, 74, 76, 78, 80, 81, 86–88, 91, 94, 101, 107, 111, 112, 114, 115, 117, 118, 120–124, 126, 127, 130, 131, 138, 141]
Not specified	10	[54, 63, 65, 79, 84, 102, 119, 129, 136, 143]
Methodological quality assessment
Low	71	[30–32, 34–40, 42–47, 49–55, 57–59, 61–63, 66, 68, 69, 72–75, 77–82, 87, 88, 92, 96, 97, 100–105, 107–109, 111, 112, 114, 116, 117, 119, 120, 123, 126, 127, 129, 131, 135, 138, 143]
Moderate	45	[2, 14, 33, 41, 48, 56, 60, 64, 65, 67, 70, 71, 76, 83–86, 89–91, 93–95, 98, 99, 106, 110, 113, 115, 118, 121, 122, 124, 125, 128, 130, 132–134, 136, 137, 139, 141, 142, 144]
High	1	[140]

¹ One multi-country study was conducted in countries in the African and Southeast Asian regions (Bohren, 2019) [58], and one multi-country study in countries in the European region (Reuther, 2021) [119]

² At the time of publication, one multi-country study was conducted in both low- and lower-middle income countries (Bohren, 2019) [58]

³ Two studies provided data for two separate datasets (Kruk, 2018 [69]; Sando, 2016) [72]

 ⁴ Two studies provided data for two separate datasets (Bohren, 2019 [58]; Dey, 2017) [132]

⁵CVANQ Others include Childbirth Verbal Abuse and Neglect Questionnaire, NorAQ NorVold Abuse Questionnaire, Person-Centered Maternity Care Scale, MORI and Mother on Respect Index, Scale, D&A Disrespect and Abuse

⁶ Five studies provided data for two separate datasets (Bohren, 2019 [58]; Dey, 2017 [132]; Kruk, 2018 [69]; Leavy, 2023 [124]; Sando, 2016) [72]

Fig. 2.

World map of prevalence of mistreatment and disrespect of women during childbirth

One hundred and nine studies used a cross-sectional design, and the remaining studies used cohort design (8 studies, 6.8%). Most studies (94 studies, 80.3%) were conducted in urban settings. Ninety-one studies were facility-based (76.4%), and 28 (23.6%) community-based studies. One hundred and nine studies (93.2%) recruited women, seven studies (6.0%) recruited healthcare providers, and one study (0.9%) recruited family members of pregnant women. The data collection method was based on a self-report questionnaire in 111 studies (93.2%), direct observation of women in labor in 7 studies (5.9%), and not specified in one study (0.9%). Various tools were used to measure mistreatment and disrespect during childbirth; 62 studies (53.0%) included Bowser and Hill’s landscape analysis, 21 studies (17.9%) included Bohren et al.‘s typology of mistreatment during childbirth, 3 studies (2.6%) included both landscape analysis and mistreatment typology, and 24 studies (20.5%) did not specify the tool used. Seven studies (6.0%) used other tools (including the Childbirth Verbal Abuse and Neglect Questionnaire (CVANQ), NorVold Abuse Questionnaire (NorAQ), Person-Centered Maternity Care Scale, and Mother on Respect Index (MORI) Scale).

The time periods for measuring mistreatment and disrespect also varied; during labour and childbirth care (52 studies, 42.7%), postpartum within six weeks (18 studies, 14.8%), and postpartum outside six weeks (42 studies, 34.4%). Ten studies (8.1%) did not specify the time period in which women were mistreated. Regarding the methodological quality of the studies, seventy-one studies (60.7%) were judged as having a low risk of bias, 45 studies (38.5%) as having a moderate risk of bias, and one study as having a high risk of bias. Various types of mistreatment and disrespect were reported in studies; physical abuse in 90 studies, non-consented care in 67 studies, non-dignified care in 48 studies, non-confidential care in 63 studies, abandonment or neglect of care in 73 studies, discrimination in 61 studies, detention in facilities in 45 studies, verbal abuse in 44 studies, failure to meet professional standards of care in 12 studies, poor rapport between women and providers in 12 studies, and health system conditions and constraints in 5 studies.

Meta-analysis

Prevalence of mistreatment and disrespect of women during childbirth

At a study level, the reported prevalence of mistreatment and disrespect during childbirth ranged from 1.9 to 100%. The pooled prevalence of mistreatment and disrespect was 54.5% (95% CI: 49.1%−59.9%), with high heterogeneity (I² = 100%; p < 0.001) (Additional file 2: Fig. S1).

Subgroup analysis

Table 2 provides the results of subgroup analyses, and Additional file 2: Figs. S2-S12 reports more detailed information for each subgroup analysis. According to the findings, the highest prevalence of mistreatment and disrespect during childbirth was reported in studies published in 2021 and later, with a pooled prevalence of 57.5 (95% CI: 49.4%−65.6%). Subgroup analysis of prevalence by country-income level did not show a statistically significant difference between groups (p = 0.62). Subgroup analysis of the region showed that the highest prevalence was in the Eastern Mediterranean region (71.5%; 95% CI: 53.07%−90.01%) and the lowest prevalence was in the Americas region (46.5%; 95% CI: 32.4%−60.5%). However, this difference was not statistically significant (p = 0.27). Subgroup analysis to investigate the prevalence based on study design showed a statistically significant difference between groups (p < 0.001). Cross-sectional studies showed a higher prevalence of mistreatment and disrespect during childbirth (56.3%; 95% CI: 50.7%−61.9%) compared with cohort studies (30.8%; 95% CI: 17.3%−44.3%).

Table 2.

Subgroup analyses on pooled prevalence of mistreatment and disrespect during childbirth

Subgroup	Number of studies 1	Pooled prevalence % (95% CI)	I2 (%)	p value (between group)
Year of publication
2000–2020	65	52.3 (45.1–59.6)	99.9	0.36
2021 or later	47	57.5 (49.4–65.6)	100
Region
African	58	53.6 (46.4–60.8)	99.9	0.27
Americas	15	46.5 (32.4–60.5)	99.9
South-East Asian	14	58.5 (40.4–76.5)	99.9
European	14	49.4 (35.7–63.2)	99.9
Eastern Mediterranean	11	71.5 (53.07–90.01)	100
Country-income level
Low	40	55.5 (46.6–64.3)	99.9	0.62
Lowermiddle	37	57.05 (46.9–67.1)	99.9
Uppermiddle	19	54.4 (41.2–67.6)	100
High	16	46.4 (33.6–59.3)	99.9
Study design
Cross-sectional	104	56.3 (50.7–61.9)	100	< 0.001
Cohort	8	30.8 (17.3–44.3)	99.6
Study setting
Urban	88	55.3 (49.2–61.3)	100	0.52
Rural	8	43.07 (22.8–63.3)	99.7
Mixed	14	55.9 (39.05–72.8)	99.9
Type of recruitment
Facility-based	84	53.6 (47.3–59.9)	100	0.56
Community-based	28	57.2 (46.8–67.5)	99.9
Study population
Women	104	54.2 (48.6–59.8)	100	0.83
Healthcare providers	7	56.8 (32.7–80.9)	99.5
Data collection method
Self-report questionnaire	106	55.1 (49.6–60.6)	100	0.28
Direct observation of labour	5	37.5 (5.8–69.2)	99.9
Data measurement tool
Categories of D&A during childbirth by Bowser and Hill	65	58.9 (51.5–66.2)	100	0.30
Typology of mistreatment by Bohren et al.	19	47.3 (34.9–59.8)	99.9
Both categories of D&A during childbirth, and typology of mistreatment	3	49.5 (21.05–77.9)	99.9
Others	5	69.7 (43.4-96.04)	99.8
Timing of data measurement
During labour and childbirth care	47	52.3 (43.6-61.07)	100	0.76
Postpartum within 6 weeks	14	58.4 (44.6–72.3)	99.6
Postpartum ranging outside 6 weeks	41	53.7 (44.9–62.6)	99.9
Methodological quality assessment
Low	65	61.09 (54.4–67.7)	100	< 0.001
Moderate	47	45.4 (37.04–53.9)	99.9

D&A Disrespect and Abuse

¹ Studies that did not specify study setting (n = 2), data collection method (n = 1), data measurement tool (n = 24), and timing of data measurement (n = 10) were not included in subgroup analyses. One study that included family members was excluded from the study population subgroup analysis

Subgroup analysis by study setting showed that community-based studies had a higher prevalence of mistreatment and disrespect during childbirth (57.2%; 95% CI: 46.8%−67.5%) than facility-based studies (53.6%; 95% CI: 47.3%−59.9%). The pooled prevalence in urban settings was also 55.3% (95% CI: 49.2%−61.3%), while for rural settings, the pooled prevalence was 43.07% (95% CI: 22.8%−63.3%). Furthermore, the prevalence of mistreatment and disrespect as reported by healthcare providers (56.8%; 95% CI: 32.7%−80.9%) was higher than that reported by women (54.2%; 95% CI: 48.6%−59.8%).

Additional subgroup analyses were conducted to investigate the prevalence by data collection method (p = 0.28), data measurement tool (p = 0.30), and timing of data measurement (p = 0.76) and did not show a statistically significant difference between groups. Subgroup analysis by methodological quality of studies was statistically significant (p < 0.001), with highest prevalence in studies with a low overall risk of bias (61.09%; 95% CI: 54.4%−67.7%) and lowest prevalence in studies with a moderate overall risk of bias (45.4%; 95% CI: 37.04%−53.9%). According to our findings, the highest prevalence of mistreatment and disrespect during childbirth was observed for “not being allowed a birth companion” (51.5%; 95% CI: 3.7%−99.2%) and “poor rapport between women and providers” (48.1%; 95% CI: 32.2%−64.01%), while the lowest prevalence was related to “sexual abuse” (1.2%; 95% CI: −0.14%−2.6%). Heterogeneity (I²) was consistently high across all subgroups, highlighting significant variability among the included studies. However, the sexual abuse was identified as a source of reduced heterogeneity, with I²=0.88% observed in this subgroup.

Sensitivity analysis

To evaluate the impact of each study on the overall results of the meta-analysis, an Influence Analysis was performed. The results indicated that excluding any of the studies had no impact on the level of heterogeneity.

Meta regression

Univariable meta-regression

Each moderator (sample size, year of publication, region, country-income level, study setting, study design, type of recruitment, study population, data collection tool, timing of data measurement, study risk of bias score, and types of mistreatment and disrespect during childbirth) was analyzed separately to assess its effect on the prevalence of mistreatment and disrespect of women during childbirth. The results revealed that study design, study setting, methodological quality assessment, and data measurement tool significantly influenced the effect size (Table 3).

Table 3.

Univariable meta-regression analysis of moderators’ effects on the prevalence of mistreatment and disrespect of women during childbirth

Meta_es	Coefficient	SE	Z	p-value	95% CI
Study design	25.74	10.42	2.47	0.014	5.31	46.18
Study setting	− 7.59	3.51	−2.16	0.031	−14.48	−0.69
Data measurement tool	6.55	2.80	2.34	0.019	1.05	12.04
Methodological quality assessment	−15.77	5.37	−2.94	0.003	−26.30	−5.25

SE Standard Error, CI Confidence Interval

Multivariable meta-regression

Among the tested moderators, the risk of bias assessment was the only significant predictor, suggesting that methodological quality influences reported mistreatment prevalence. A higher risk of bias score is associated with a significantly lower estimated effect size (prevalence of mistreatment and disrespect). Other variables did not show a statistically significant association with the prevalence of mistreatment and disrespect during childbirth (p > 0.05) (Table 4).

Table 4.

Multivariable meta-regression analysis of moderators’ effects on the prevalence of mistreatment and disrespect of women during childbirth

Meta_es	Coefficient	SE	Z	p-value	95% CI
Sample size	−0.001	0.0006	−1.73	0.083	−0.002	0.0001
Year of publication	2.72	5.52	0.49	0.622	−8.10		13.55
Region	2.35	1.58	1.49	0.138	−0.75		5.46
Country-income level	1.89	2.05	0.93	0.354	−2.11		5.91
Study design	18.08	11.00	1.64	0.100	−3.47		39.64
Study setting	−6.05	3.46	−1.75	0.081	−12.84		0.73
Type of recruitment	−3.10	6.89	−0.45	0.653	−16.62		10.42
Study population	−6.25	10.12	−0.62	0.537	−26.09		13.59
Data collection method	2.49	11.08	0.23	0.822	−19.22		24.21
Data measurement tool	3.92	2.89	1.35	0.176	−1.76		9.60
Timing of data measurement	1.25	3.38	0.37	0.711	−5.37		7.88
Methodological quality assessment	−12.25	6.11	−2.00	0.045	−24.24		−0.26

SE Standard Error, CI Confidence Interval

Publication bias

The publication bias was assessed using a funnel plot, as shown in Fig. 3. The observed asymmetry in the plot suggests the potential presence of publication bias or heterogeneity among studies. The clustering of certain studies in areas with high standard error indicates that smaller studies may have overestimated prevalence rates. Additionally, the concentration of data points on the right side of the plot suggests that some studies may have reported higher prevalence estimates, potentially affecting the overall reliability of the pooled estimate. Begg’s test indicated potential small-study effects or publication bias (Kendall’s score = 1390.00, p = 0.0006). These findings should be interpreted alongside Egger’s test and the funnel plot for a comprehensive bias assessment.

Fig. 3.

Funnel plot displaying publication bias of studies reporting the pooled prevalence of mistreatment and disrespect of women during childbirth

Discussion

In the absence of global data about mistreatment and disrespect of women during childbirth and maternity care, we aimed to identify studies that helped to understand the prevalence worldwide. This systematic review and meta-analysis estimated the prevalence of mistreatment and disrespect to be 54.5% for studies from 37 countries. Despite significant heterogeneity, this high prevalence rate confirms that mistreatment and disrespect are a global problem and concern in maternal health care, to the point that RMC is reflected as a top priority of the WHO in a guideline on the prevention and elimination of D&A during facility-based childbirth [9].

Our findings regarding the high prevalence of mistreatment and disrespect during childbirth are supported by previous studies [3–5, 8]. Similarly, in a recent systematic review and meta-analysis study, Hakimi et al. (2025) estimated the global prevalence of obstetric violence as 59% [145]. This review identified and included 26 studies, which were limited to the English language; as a result, some publications may have been excluded. In addition, owing to the low number of studies, the issue of obstetric violence has not been adequately researched in high-income countries, thus highlighting the need for robust prevalence estimates.

Our review shows that the prevalence of mistreatment and disrespect during childbirth ranged from 1.9% in Malawi [83] to 100% in Ethiopia [31], Nepal [139], and Iran [104, 105]. The most common forms of mistreatment and disrespect reported in these countries were non-consented care, non-dignified care, non-confidential care, abandonment of care, discrimination, and physical abuse. We observed the highest prevalence rate in the Eastern Mediterranean region (71.5%) and the lowest prevalence in the Americas region (46.5%). The prevalence rates in countries located in Southeast Asian, African, and European regions were 58.5%, 53.6%, and 49.4%, respectively, indicating considerable variation among WHO-regions and even among studies within the same region. Furthermore, studies on this issue are scarce in countries in the Western Pacific region, highlighting the need for more quantitative studies to generate robust evidence of mistreatment and disrespect during childbirth in this region. Variations in the prevalence rates of mistreatment and disrespect during childbirth among different countries and geographical regions may be attributed to disparities in socioeconomic development status, cultural conditions, differences in healthcare facilities and systems, sampling techniques, tools, study methods, and how mistreatment and disrespect are defined in studies [3, 4].

In this study, “not being allowed a birth companion”, followed by “poor rapport between women and providers” and “non-consented care”, showed the highest prevalence of mistreatment and disrespect during childbirth. Conversely, “sexual abuse” was the least prevalent, suggesting that although this practice is rare in obstetric care, it still occurs in some cases and requires continued monitoring, patient education, and robust reporting systems to ensure a completely safe and respectful birthing environment for all women. The high prevalence of poor rapport between women and providers, as well as non-consented care, can be explained by high workload; low numbers of maternity healthcare providers; poor knowledge, attitudes, and interpersonal communication skills of providers; and normalization of disrespectful or dismissive behaviors. We also found that women who gave birth in urban settings (55.3%) experienced a higher prevalence of mistreatment and disrespect compared to women who gave birth in rural settings (43.07%). This finding is in line with a study conducted in Kano, northwest Nigeria, which showed that D&A was higher in urban healthcare settings than in rural settings [146].

The results of this study have important implications for policy and practice. Considering the increasing global concern about the poor quality of maternity care, the estimated prevalence of mistreatment and disrespect of women during childbirth from this review, as well as understanding the variation in prevalence across regions, will be critical to inform the development and implementation of region-specific interventions to reduce this burden. Our review indicates that mistreatment is more prevalent in community-based births and urban healthcare settings. Therefore, policy makers and practitioners of maternal and child health programs should be given special focus to this issue. The findings of this review also showed that quantitative studies on mistreatment and disrespect of women during childbirth are scarce in the Western Pacific region; hence, future research must focus on countries in the Western Pacific region to gain a more comprehensive picture of the burden of mistreatment and disrespect.

Strengths and limitations

To the best of our knowledge, this is the first comprehensive global systematic review that, by including 117 studies in five languages, was able to estimate the prevalence of mistreatment and disrespect of women during childbirth, thereby increasing the reliability of the estimates. We employed a comprehensive approach, including a broad search strategy across multiple databases and having two reviewers screen each full text and complete data extraction to minimize the possibility of missing eligible studies and errors. However, this study has several limitations. First, the included studies used varying definitions and measurement tools for mistreatment and disrespect during childbirth, which contributed to differences in reported prevalence. Second, since most data are based on women’s self-reported experiences, there is a potential for both overestimation and underestimation of prevalence. Third, some studies were assessed as having low methodological quality, which may have influenced the overall estimates. Additionally, the meta-analysis revealed high heterogeneity, likely reflecting variations in study design, setting, population, data collection methods, and quality. Although a random-effects model was applied and subgroup and meta-regression analyses were performed to investigate these differences, the pooled prevalence should be interpreted cautiously, as it may not represent a universally generalizable estimate.

Conclusion

This systematic review and meta-analysis found that the global prevalence of mistreatment and disrespect of women during childbirth was 54.5%. There were geographical differences, highest in the Eastern Mediterranean and lowest in the Americas. The most commonly reported forms of mistreatment and disrespect during childbirth were “not being allowed a birth companion”, “poor rapport between women and providers”, “non-consented care”, and “not being allowed to eat or drink”. The findings highlight an urgent need for targeted interventions, policies, and programs to ensure respectful, safe, and equitable maternity care for all women.

Abbreviations

MDGs

Millennium Development Goals

SDGs

Sustainable Development Goals

D&A

Disrespect and abuse

WHO

World Health Organization

RMC

Respectful maternity care

LMICs

Low- and middle-income countries

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

PROSPERO

International Prospective Register of Systematic Reviews

WRA

White Ribbon Alliance

USAID

U.S. Agency International Development

CI

Confidence interval

CVANQ

Childbirth Verbal Abuse and Neglect Questionnaire

NorAQ

NorVold Abuse Questionnaire

MORI

Person-Centered Maternity Care Scale, and Mother on Respect Index

SE

Standard error

Authors’ contributions

MM, ESh, SH, and KM conceptualized and designed the study. MAN conducted the search in databases. MM and MAN conducted the title and abstract screening. MM, MAN, and MD conducted the full-text screening and quality assessment. MM, MAN, and NK extracted the relevant information, and AM conducted the meta-analysis. MM wrote the first draft of the manuscript. ESh, SH, AM, and KM critically reviewed the manuscript. All authors have read and approved the final manuscript.

Funding

This study was supported by the Vali-E-Asr Reproductive Health Research Center, Tehran University of Medical Sciences (1403-2-418-73202). The role of the funders was to monitor the planning and progression of the study.

Data availability

All data pertaining to this study have been included in this manuscript and additional files.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Ethics Committee of Vali-E-Asr Reproductive Health Research Center, Tehran University of Medical Sciences, with registration code (IR.TUMS.IKHC.REC.1403.250).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.